CARDIOVASCULAR Pathology:

ACUTE CARDIOGENIC PULMONARY OEDEMA

ACUTE CARDIOGENIC PULMONARY OEDEMA

- Aetiology:
o Severe Decompensated LV-Failure (CCF)
- Pathophysiology:
o Severe Decompensated LV-Failure (CCF) Fluid Accumulation in Alveoli & Interstitium Dyspnoea
Impaired Gas Exchange & Respiratory Failure
- Clinical Features:
o Symptoms:
Tachycardia
Tachypnoea
Diaphoresis
Wet Cough w. Frothy Sputum
o Signs:
Respiratory Distress ( SpO2)
Bi-Basilar Crackles
Splitting of S2
Dullness to Percussion
(+/- Signs of RV-Failure [↑JVP, Peripheral Oedema, Ascites])
- Investigations:
o CXR – (Pulmonary Congestion/Oedema, Cardiomegaly, Effusions)
o ECG – (Dx Previous/Current IHD, Rule out Arrythmias)
o Echo (TTE) – (Assess Ventricular Function [Ejection Fraction])
o +(FBC [ Hb/Infection], UEC, eLFT [Alcohol], TSH [↑Thyroid], Lipids [IHD], BSL/HbA1c [Diabetes])
- Management:
o Pt will most likely already be on CCF Regime. Ie:
ACEi (Perindopril) / ARB (Candesartan)
B-Blocker (Carvedilol)
Diuretics (Frusemide / Spirinolactone)
Fluid Balance (Daily weights/Fluid restriction/ Na diet)
o “LMNOP” Protocol:
L – Lasix (↑Diuresis & Fluid Restriction) – [Frusemide / Spirinolactone]
M – Morphine (Anxiolytic & Vasodilation)
N – Nitrates (GTN)
O – Oxygen
P – Positive Pressure Ventilation (CPAP / BiPAP)

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 HEART FAILURE . . . CONT.

❏ other agents
• ß blockers - recommended for functional class (FC) II-III patients
• should be used cautiously, titrate slowly because may initially worsen CHF
• postulated that these agents interfere with neurohormonal activation
• carvedilol confers survival benefit in FC II-III CHF
• metoprolol has been shown to delay time to transplant, decreased hospitalizations in dilated
cardiomyopathy and to decrease mortality (MERIT study)
• CCB (have equivocal effect on survival)
• antiarrhythmic drugs
• if required, amiodarone is drug of choice
• class I anti-arrhythmics associated with increased mortality in CHF
ACUTE CARDIOGENIC PULMONARY EDEMA
Definition
❏ left-sided backward heart failure leading to severe pulmonary congestion with extravasation of capillary fluid
into the pulmonary interstitium and alveolar space
Clinical Manifestations
❏ tachycardia, tachypnea, diaphoresis
❏ severe left-sided venous congestion
Management, use mnemonic "LMNOP"
❏ make sure to treat any acute precipitating factors (e.g. ischemia, arrhythmias)
❏ sit patient up with legs hanging down if blood pressure is adequate
❏ L - Lasix - furosemide 40 mg IV, double dose q1h as necessary
❏ M - Morphine 2-4 mg IV q5-10 minutes
• decreased anxiety
• vasodilation
❏ N - Nitroglycerine topical 2 inches q2h (or IV)
❏ O - Oxygen
❏ P - Positive airway pressure
• (CPAP or BiPAP) decreased need for ventilation and decreased preload
❏ other vasodilators as necessary in ICU setting
• nitroprusside (IV)
• hydralazine (PO)
• sympathomimetics
• potent agents used in ICU/CCU settings
• dopamine
• agonist at dopamine D1 (high potency), ß1-adrenergic (medium potency),
and α1-adrenergic receptors (low potency)
• "low-dose" causes selective renal vasodilation (D1 agonism)
• "medium-dose" provides inotropic support (ß1 agonism)
• "high-dose" increase systemic vascular resistance (SVR),
which in most cases is undesirable (α1 agonism)
• dobutamine
• acts at ß1 and α1 adrenoceptors
• selective inotropic agent (ß1 agonism)
• also produces arterial vasodilation (α1 antagonism)
• phosphodiesterase inhibitors (amrinone, Inocor)
• effects similar to dobutamine (inhibits PDE ––> cAMP ––>
inotropic effect and vascular smooth muscle relaxation (decrease SVR)
• adverse effect on survival when used as long-term oral agent
❏ inotropic support (dopamine, dobutamine) if necessary
❏ consider PA line to monitor capillary wedge pressure
❏ consider mechanical ventilation if needed
❏ rarely used but potentially life-saving measures
• rotating tourniquets
• phlebotomy
CARDIAC TRANSPLANTATION
❏ indications - end stage cardiac disease (CAD, DCM, etc.)
• failure of maximal medical/surgical therapy
• poor 6 month prognosis
• absence of contraindications
• ability to comprehend and comply with therapy
❏ 1 year survival 85%, 5 year survival 70%
❏ complications: rejection, infection, graft vascular disease, malignancy

MCCQE 2002 Review Notes Cardiology – C31

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 CVS Pathology:
Aneurysms & Dissections

Aneurysms (General Info):

- Definition:
o Dr. Martin A Increase in the Si e of an Artery Above its Normal Si e
Eg. Normal Infra-Renal Aorta = 2cm :. An Aneurysm would be >3cm.
(90% of AAAs are Infra-Renal)
o Robbins a Localised abnormal dilation of a BLOOD VESSEL OR THE HEART
- True Vs. Pseudo- Aneurysms:
o True Aneurysms – (Full Thickness Aneurysms)
o False/Pseudo Aneurysms – (Partial Thickness Aneurysms)
- Classification (Size/Shape):
o “Saccular Aneurysms”: Hemispherical Outpouchings involving ONLY PART of the vessel wall
o “Fusiform Aneurysms”: CIRCUMFERENTIAL Dilation of a vascular segment
o “Dissecting Aneurysms”:Blood within the Arterial wall itself.

- Aetiologies:
o Atherosclerosis - (Typically AAAs)
o Hypertension - (Typically Thoracic Aortic Aneurysms)
o Myocardial Infarction - (Typically Ventricular Aneurysms)
o (Others: Congenital – Eg. Downs/Marfan’s/Ehlers-Danlos Syndrome/Conn.Tissue Disorders/Etc)
- Risk Factors:
o Age >65
o Male
o Atherosclerosis
o ↑Cholesterol
o HTN
o Smoking
o FamHx

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- ABDOMINAL AORTIC ANEURYSM:
o Aetiology:
Atherosclerosis
o Pathogenesis:
Atherosclerotic Plaque Weakening of Vessel Wall Aneurysm
o Morphology:
90% of AAAs are INFRA-RENAL
Saccular OR Fusiform
o Clinical Features:
Presentation:
Typically Asymptomatic (Hence Sudden Death”)
But Symptoms Include:
1. Pulsatile Abdo Mass.
2. Pain - Back/Flank/Abdo/Groin
3. DVT (From Venous Compression)
4. “Trash Foot” – from Thrombo-Emboli
o Investigations:
Clinical Suspicion + Examination
**Abdo USS – (100% Sensitive)
CT/MRI
o Complications:
#AAA – (NB: SIZE = #1 Predictor of Rupture):
Classic Triad of Rupture:
1. Sudden Pain – (Abdo/Back)
2. Shock – (Hypotension/ALOC)
3. Pulsatile Mass
+ Acute Abdomen
+ Grey Turners Sign
Occlusion of a Branch-Vessel:
Eg. Pre-Renal Failure
Eg. Mesenteric Ischaemia
Thromboemboli:
Renal Infarction
Mesenteric Infarction
“Trash Foot” – Focal Gangrene.
o Management:
AAAs <5cm Diameter Watchful Waiting (6mthly)
+ Risk Factor Modification
AAAs >5cm Diameter Surgical Repair (Due to ↑ Rupture Risk)
(Open Vs. Endovascular Repair)
#AAA EMERGENCY SURGERY:
+ 2x Large Bore Cannulas
+ Fluid Resuscitation (Bolus + Maintenance; Target BP 80 Systolic)
+ Group & Hold + X-Match for Transfusion
o Prognosis:
Pre-Rupture: Good Prognosis
Post Rupture: 95% Mortality – (Only 30% Make it to Hospital; 20% of those Survive).

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- THORACIC AORTIC ANEURYSMS:
o Aetiology:
Hypertension
o Clinical Features:
Complications:
Mediastinal Compression (Heart & Lungs)
Dysphagia
Cardiac Disease (Eg. Aortic Regurgitation, Myocardial Ischaemia/Infarction)
Rupture

- AORTIC DISSECTION:
o Aetiology:
Hypertension
M:F = 4:1
o Pathogenesis:
Hypertension Intimal Tear Blood Enters False Lumen Dissection Continues
o Morphology:
#1. Ascending Type (Ascending Aorta):
Bad because can Occlude Brachiocephalic Trunk/Internal Carotid/Subclavian.
Descending Type (Descending Aorta):
Bad because can Dissect all the way to legs GI/Renal/Limb Ischaemia
o Clinical Features:
Sudden Excruciating Chest Pain Radiating to the Back between Scapulae
Radio-Radial Delay
+/- Signs of Complications:
Rupture Cardiac Tamponade & Shock
Valvular Aortic Regurgitation Diastolic Murmur (Due to Dilation)
Vessel Occlusion MI, Stroke, Limb Ischaemia, Mesenteric Ischaemia, Renal Fail
o Investigations:
CXR – Wide Mediastinum, L-Pleural Effusion
CT – 100% Sensitive
TOE (Echo) – 100% Sensitive, but slow.
o Management:
1. Aggressive BP-Reduction (Nitrates + B-Blocker) Slows Progression
If Ascending: EMERGENCY SURGERY
If Descending: Initial Medical Mx

CEREBRAL ANEURYSM (Congenital Berry Anerysms – See Sub-Arachnoid Haemorrhage Notes):

o Symptoms for an aneurysm that has not yet ruptured –
Fatigue
Loss of perception
Loss of balance
Speech problems
o Symptoms for a ruptured aneurysm –
Severe headaches
Loss of vision
Double vision
Neck and and/or stiffness
Pain above and/or behind the eyes.

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 VASCULAR - ARTERIAL DISEASES . . . CONT.

CRITICAL ISCHEMIA
❏ arterial compromise eventually leading to necrosis
❏ signs and symptoms (see Colour Atlas PL5)
• rest pain, night pain
• ulcerations, gangrene of toes
• pallor on elevation, dependent rubor, slow capillary refill
• decreased or absent pulses
• significant bruits may be heard (at 50% occlusion) – if stenosis severe, no bruit will be heard
• ABI < 0.5
❏ investigations
• as above
❏ management
• needs immediate surgery due to risk of limb loss
• initial procedures: transluminal angioplasty, laser, atherectomy and stents
❏ operations include
• inflow procedures for aortoiliac disease
• endarterectomy
• reconstructive procedures for superficial femoral artery occlusion
• profundoplasty
• femoropopliteal bypass
• aortoiliac or aortofemoral bypass
• axillofemoral bypass (uncommon)
ABDOMINAL AORTIC ANEURYSM (AAA)
❏ aneurysm: localized dilatation of an artery that is 2x normal diameter
• true aneurysm: wall is made up of all 3 layers of the artery
• false aneurysm: defect in arterial with aneurysmal sac composed of fibrous tissue or graft
❏ classification
• etiology: congenital
• Marfan syndrome, berry aneurysms acquired
• metabolic / endocrine
• degenerative
• inflammation / infection - syphilis
• neoplastic
• dissection
• shape:Fusiform (true aneurysms)
Saccular (false aneurysms)
• location: aortic
peripheral arteries
splanchnic
renal
❏ structure true or false
❏ inflammatory
❏ infected
❏ 95% of AAA’s are infrarenal
❏ incidence 4.7 to 31.9 per 100,000 person from 1951-1980
❏ the average expansion rate (80% of aneurysms) is 0.2cm/yr for smaller aneurysms (< 4 cm)
and 0.3-0.5 cm/yr for larger aneurysms (> 4-5 cm)
❏ may be associated with other peripheral aneurysms
❏ etiology
• cystic medial necrosis – likely due to enzymatic abnormalities in the aortic wall
• atherosclerosis
❏ high risk groups
• 65 years and older
• male:female = 3.8:1
• peripheral vascular disease, CAD, CVD
• family history AAA
❏ clinical presentation
• common
• 75% asymptomatic (often discovered incidentally)
❏ symptoms due to acute expansion or disruption of wall
• syncope, pain (abdominal, flank, back)
• uncommon
• partial bowel obstruction
• suodenal mucosal hemorrhage ––> GI bleed
• erosion of aortic and duodenal walls ––> aortoduodenal fistula
• erosion into IVC ––> aortocaval fistula
• distal embolization
❏ signs
• hypotension
• palpable mass felt at/above umbilicus
• pulsatile mass, in 2 directions
• bounding femoral pulses
• distal pulses may be intact

CVS24 – Cardiac and Vascular Surgery MCCQE 2002 Review Notes

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 VASCULAR - ARTERIAL DISEASES . . . CONT.

❏ investigations
• U/S (100% sensitive, able to measure up to +/– 0.6 cm accuracy); however, operator dependent, and
may not be possible with obese patients, excessive bowel gas or periaortic disease
• Aortogram (not useful because lumen may not change in size due to thrombus formation)
• CT (accurate visualization, determines size)
• MRI (very good imaging, but limited access)
• Doppler/Duplex (to rule out aneurysmal disease elsewhere in the vascular tree)
❏ treatment and prognosis
• decision to treat is based on weighing the risk of OR to disease complications (such as rupture)
• risk of rupture depends on
• size %/yr
• 4-5 cm – 2-3%
• 5-6 cm – 5-8%
• > 7 cm – 25-40%
• > 10 cm – 100%
• rate of growth (> 0.4 cm/yr)
• presence of symptoms, hypertension, COPD
• consider operate at > 5 cm since risk of rupture greater than or equal to risk of surgery
• mortality of elective repair = 2-3% (mostly due to MI)
• consider revascularization for patients with CAD before elective repair of CAD
• conservative
• reduce risk factors
• smoking
• HTN
• DM
• hyperlipidemia
• exercise
• watchful waiting if <4-5cm re-U/S q6mo
❏ surgery
•procedure
• laporotomy performed firm xyphoid process to symphis pubis
• aorta is dissected out
• distal clamp is placed onto aorta
• proximal clamp is placed onto aorta or common iliacs
• aneurysm opened
• removal of thrombis
• graft put into place: tube/bifurcation
• graft sewn into proximal site
• graft suture site tested
• graft sewn into distal site - last stitch not closed until integrity of anastomosis tested
• aorta wall sewn over graft
• indications for surgery
• ruptured
• symptomatic or rapidly expanding aneurysms
• asymptomatic aneurysms >5cm
• contraindications
• less than 1 year to live
• terminal underlying condition (cancer)
• overwhelming medical conditions
• recent MI, unstable angina, decreased mental acruity, advanced age
• early post-op complications
• myocardial ischemia
• arrhythmias
• CHF
• pulmonary insufficiency
• renal damage
• bleeding
• infection
• cord injury
• impotence
• late complications
• graft infection/thrombosis
• aortoenteric fistula
• anastomotic aneurysm
• infection

MCCQE 2002 Review Notes Cardiac and Vascular Surgery – CVS25

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 VASCULAR - ARTERIAL DISEASES . . . CONT.

• post-op orders
• bedrest (24-48 hr)
• NPO
• NG ––> straight drainage, record drainage q12h +/– NG losses 1:1 q shift Ns with 10 mEq KCl/L
• Foley ––> straight drainage
• +/– PA line
• +/– arterial line
• routine post-op vitals q15min until stable then q1h
• routine CU ICU admission blood work
(includes CBC, lytes, BUN, Cr, PLT, PT, PTT, glucose)
• CXR on CUICU admission and daily until extubated
• ECG on admission q8h x 24 hrs and PRN after
• ABI’s/pedal pulses q1h x 4 h then q shift
• chest physiotherapy assessment and treatment
• weaning protocol as per CUICU portocol
• titrate FiO2 to keep PO2 > 90 mmHg or O2 sat > 95% c/c
• ventilation (if required) Vt 700 mL, FiO2 > 50% c/c, rate 12/min, PEEP 5 cm/H2)
to keep PaCo2 35-45 mmHg
• incentive spirometry when extubated
• epidural proticol if required
• IV’s: N/S or RL at 150 cc/hr x 24 hr; reassess at 24 hrs
• morphine 2-10 mg IV q1h PRN
• midazolam 2-4 mg IV q1h PRN max 20 mg/24hr
• dimenhydrinate 12.5-25 mg IV q4h PRN
• heparin 5,000U SC q12h for DVT prophylaxis start post-op
• sulcrote 1 gm NG q4h
• may require inotropic agents
• may require antiphypertensive agents
ABDOMINAL AORTIC DISSECTION
❏ Stanford Surgical Classification
• Type A: involves the ascending and aortic arch; requires emergency surgery
• Type B: involves the aorta distal to subclavian artery; emergency surgery only if
complications of dissection (require long-term follow-up to assess aneurysm size)
❏ male:female = 3-4:1
❏ predominantly older patients
❏ etiologic factors
• hypertension
• cystic medial necrosis (not atherosclerosis)
❏ associated factors
• Marfan's Syndrome
• coarctation of aorta
• congenital bicuspid aortic valve
❏ pathogenesis (usually in thoracic aorta)
• intimal tear ––> entry of blood separates media ––> false lumen
created ––> dissection often continues to aortic bifurcation
❏ symptoms and signs
• sudden searing chest pain that radiates to back
• asymmetric BPs and pulses between arms
• branch vessel "sheared off" – ischemic syndromes
• MI with proximal extension to coronary arteries
• "unseating" of aortic valve cusps
• new diastolic murmur in 20-30%
• neurologic injury - stroke (10%), paraplegia (3-5%)
• renal insufficiency
• lower limb ischemia
• cardiac tamponade - false lumen ruptures into pericardium
• hypertension (75-85% of patients)
❏ diagnosis and investigations
• CXR
• Pleural cap
• Widened mediastinum
• Left pleural effusion with extravasation of blood
• ECG - most common abnormality is LVH (90%)
• TEE, CT, aortography
❏ management
• sodium nitroprusside and B-blocker to lower BP and decrease cardiac contractility
• ascending aortic dissections operated on emergently
• descending aortic dissections initially managed medically
• 10-20% require urgent operation for complications

CVS26 – Cardiac and Vascular Surgery MCCQE 2002 Review Notes

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 VASCULAR - ARTERIAL DISEASES . . . CONT.

RUPTURED ABDOMINAL AORTIC ANEURYSM (RAAA)

❏ narrow window of opportunity
❏ usually present with classical diagnostic triad (50% cases)
• sudden abdominal or back pain
• SHOCKY (Hypotensive, faintness, cool, mottled extremities)
• pulsatile mass
❏ may be confused with renal colic
❏ ECG confusing - may show cardiac ischemia
❏ diagnosis by history and physical
❏ do not waste time in radiology if RAAA strongly suspected
❏ if patient stable without classic triad ––> consider CT
❏ management
• initial resuscitation including vascular access, notify OR,
• ensure availability of blood products, invasive monitoring
• emergency laparotomy as soon as IV and cross-match sent
• upon opening - gain centre of aorta proximal to rupture with cross clamp
❏ prognosis
• 50% survival for patients who make it to OR
• 100% mortality if untreated
• overall mortality 90%
CAROTID SURGERY (see Neurosurgery Chapter)

VASCULAR – VENOUS DISEASE

ANATOMY
❏ the venous system is divided into 4 general areas
• superficial venous system (subcutaneous veins and the greater and lesser saphenous veins)
• communicating venous system (perforating veins)
• deep venous system (tibial, popliteal, femoral and iliac veins)
• venous valves (in all infra-inguinal veins)
DEEP VENOUS THROMBOSIS (DVT) (ACUTE)
❏ occlusion of the deep venous system, typically of the lower extremity that can extend up to the right atrium.
❏ pathogenesis (Virchow's Triad)
❏ flow stasis
❏ postulated that stasis protects activated pro-coagulants from circulating inhibitors,
fibrinolysis and inactivation in the liver
❏ surgery
❏ trauma and subsequent immobilization
❏ immobilization due to: acute MI, stroke, CHF
❏ compression of veins by tumours
❏ shock (decreased arterial blood flow)
❏ hypercoagulability
❏ states that increase coagulability of the blood (ex. Increased fibrinogen or prothrombin) in which there is a
deficiency of anti-coagulants (anti-thrombin III, Protein C+S), e.g.
• pregnancy
• estrogen use
• neoplasms: diagnosed, occult, undergoing chemotherapy
• tissue trauma: activation of coagulation
• nephrotic syndrome
• deficiency of anti-thrombin III, protein C or S
• endothelial damage
❏ exposure of the underlying collagen in a breach of the intimal layer of the vessel wall leads to
platelet aggregation, degranulation and thrombus formation. There also appears to be a
decrease endothelial production of plasminogen and plasminogen activators, e.g.
• endothelial damage: venulitis, trauma
• varicose veins
• previous thrombophlebitis

MCCQE 2002 Review Notes Cardiac and Vascular Surgery – CVS27

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 Week 13
CardioVascular Medicine Notes
Arrhythmias

Characteristics of a Normal ECG:

- Sinus Rhythm/Rate:
o Between 60-100 bpm.
o Initiated by SA-Node
o NB: it’s intrinsic rate is higher, but is suppressed by constant Parasympathetic-NS Influence
- P-Wave:
o Rounded
o Between 0.5-2.5 mm Tall
o Less than 0.1 Seconds Duration
- PR-Interval:
o Fixed
o Between 0.12-0.20 Seconds
- QRS-Complex:
o Clean & Sharp
o Normally Less Than 25mm Tall
o QRS Interval: Between 0.06-0.12 Seconds Duration
- Q-T Interval:
o Between 0.35-0.45 Seconds Duration
- S-T Segment:
o Normally ≈0.08 Seconds Duration
- T-Wave:
o Prominent
o Rounded
o Less Than 5mm Tall (Limb) or Less Than 10mm Tall (Precordial)
o Between 0.1-0.25 Seconds Duration
- U-Wave

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 Week 13
CardioVascular Medicine Notes
Arrhythmias

Characteristics of a Normal ECG:

- Sinus Rhythm/Rate:
o Between 60-100 bpm.
o Initiated by SA-Node
o NB: it’s intrinsic rate is higher, but is suppressed by constant Parasympathetic-NS Influence
- P-Wave:
o Rounded
o Between 0.5-2.5 mm Tall
o Less than 0.1 Seconds Duration
- PR-Interval:
o Fixed
o Between 0.12-0.20 Seconds
- QRS-Complex:
o Clean & Sharp
o Normally Less Than 25mm Tall
o QRS Interval: Between 0.06-0.12 Seconds Duration
- Q-T Interval:
o Between 0.35-0.45 Seconds Duration
- S-T Segment:
o Normally ≈0.08 Seconds Duration
- T-Wave:
o Prominent
o Rounded
o Less Than 5mm Tall (Limb) or Less Than 10mm Tall (Precordial)
o Between 0.1-0.25 Seconds Duration
- U-Wave

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 CVS Pathology:
Arrhythmias

BACKGROUND INFO:
- Working knowledge of ECG and Cardiac Cycle is Essential:
o P Wave = Atrial Depolarisation
o QRS Complex = Ventricular Depolarisation
o T Wave= Ventricular Repolarisation
o Normal Rate 70bpm
o Tachycardia = >100bpm
o Bradycardia = <60bpm

- Revision of the Cardiac Cycle:

o P-Wave = Atrial Systole
o QRS-Complex = Start of Ventricular Systole
o T-Wave = Ventricular Filling
o First & Second Heart Sounds:
1. Lubb (AV Valve Closure)
2. Dupp (Semilunar Valve Closure)

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 Mechanisms of TachyArrhythmias

Mechanism of Re-Entry:
- Accounts for ≈75% of Tachycardias
- Causes of Re-Entry:
o Ischaemic Heart Disease
o Ion-Channel Mutations
o Electrolyte Disturbances
- Results in an “Ectopic Focus”:
o = An area in the heart that initiates abnormal beats. (Aka: An Ectopic Pacemaker)
o Ectopic foci may occur in both healthy and diseased hearts
o Usually associated with irritation of a small area of myocardial tissue.
o Creates a Single Additional Beat, OR a Full Rhythm.
- How It Occurs:
o Normally, an Impulse from Conductile Tissue transmits into Myocytes (Contractile Cells), then
spreads amongst the myocytes. All Myocytes receive the Impulse and Contract.
o NB: Once a cell receives a signal, it won’t receive another.

àààààààààààààààààààààààààààààààààààààààààààààààà

o However, for Re-Entry to occur, an initial momentary/transient Block is required. See Below:

àààààààààààààààààààààààààààààààààààààààààààààààà

àààààààààààààààààààààààààààààààààààààààààààààààà

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Early After-Depolarisations:
- Occur During Repolarisation Phase
o (Where K+ is Flowing OUT)
o (Where Ca+ has STOPPED Flowing IN)
- More Likely to occur when Action-Potential Duration is Increased...WHY?
o The Absolute Refractory Period for the Na+ Channels (those responsible for depol) only lasts for a
small period of time. Usually this period is enough for repolarisation to occur.
o However, if the AP-Duration is increased, the membrane will still be in Plateau when the Na+
Channels enter the Relative Refractory Period, meaning a further stimulus will cause another action
potential.
- Early After-Depolarisations can result in:
o Torsades de pointes (Twisting of the Points)
o Tachycardia
o Other Arrhythmias

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Delayed After-Depolarisations:
- Depolarisation during phase 4 (after repolarization is completed, but before another action potential would
normally occur)
- Due to High Intracellular Ca2+ Concentrations Caused by TOO MUCH DIGOXIN.
o NB: Digoxin is a drug used to treat Atrial Flutter & Atrial Fibrillation by Decreasing Conduction
Through the AV-Node. Ie. DIGOXIN à DECREASED HEART RATE

- Digoxin – Mechanism of Action:

o 1. Blocks the Na+/K+-ATPase on the cell.
§ à Accumulation of Na+ inside the cell
§ à Deficit of K+ inside the cell
o 2. The Secondary Active Na/Ca-Exchanger (That normally relies on the High Extracellular Na+
Gradient to remove Ca+ from the cell) ceases to work.
§ à Accumulation of Ca+ inside the cell à ↓Rate of Depol & Repol of Pacemaker Action
Potentials à Stops Atrial Flutter/Fibrillation/other atrial tachycardia.

- NB: This accumulation of Na+ & Ca+ in the cell makes the Resting Membrane More Positive.
o à Action Potentials are easier to stimulate
o Can Lead to A Series of Rapid Depolarisations.

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LOOKING AT ECGs:
- Check Pt ID
- Check Voltage & timing
o 25mm/sec
o 1large square = 0.2s (1/5sec)
o 1small square = 0.04s
- What is the rate?
o 300/number of large squares between QRS Complexes
Tachycardia
>100bpm
Bradycardia
<60bpm
- What is the Rhythm?
o Sinus? (are there P-Waves before each QRS complex)
o If Not Sinus?
Is it regular
Irregular?
Irregularly Irregular (AF)
Brady/Tachy
- Atrial Fibrillation:
o Irregularly Irregular
o P-Waves @ 300/min
- QRS:
o Is there one QRS for each Pwave?
o Long PR Interval? (1st degree heart block)
o Missed Beats? (Second degree block)
o No relationship? Complete heart block
- Look for QRS Complexes:
o How wide should be < 3 squares
o If wide It is most likely Ventricular
o (Sometimes atrial with aberrant conduction (LBBB/RBBB)
o IF Tachycardia, & Wide Complex VT is most likely. (If hypotensive Shock; if Normotensive
IV Drugs)
- Look for TWaves:
o Upright or Inverted
- Look at ST-Segment
o Raised, depressed or inverted
o ST Distribution Tells you which of the coronaries are blocked/damaged
Inferior ischaemia (II, III, AVF)
Lateral ischaemia (I, II, AVL, V5, V6)
Anterior ischaemia (V, leads 2-6)
o NB Normal ECG Doesn e cl de infarc
o ST Depression Ischaemia
o ST Elevation Infarction
o If LBBB or Paced, you CANNOT comment on ST-Segment

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 COMMON TACHYCARDIAS:

DDX #1 SUPRAVENTRICULAR TACHYCARDIAS:

- SINUS TACHYCARDIA:
o = Sinus Rhythm of 100+Beats/min
Shortened T-P Interval (But All Waves Visible)
o Management:
Carotid Massage
(B-Blocker if Symptomatic)

- ATRIAL PREMATURE BEATS (APBs):

o = Single Ectopic P-Wave QRS
o Management:
Nil
(If Symptomatic B-Blocker or Ca-Ch-Blocker)

- ATRIAL FLUTTER:
o = Atrial Rate of 300bpm; But NOT Sinus Rhythm!
Sa oo h P-Waves
Ventricular Conduction Variable (Eg. 2:1 / 3:1 / 4:1 Block etc)
o Mechanism: Re-Entry (See End)
o Treatment:
Rate Control (B-Blocker, Ca-Ch-Blocker [Verapamil], Digoxin)
Electrical Cardioversion (NB: Different to Defibrillation)

- ATRIAL FIBRILLATION (AF):

o = Sinus Rate of -600Beats/min; Irregular QRSs.
NB: Poor Atrial Contraction Thromboemboli Common. (Requires Warfarin)
o Causes PIRATE SHIV
PE, IHD, Rh-Heart Disease, Anaemia, Thyroid, ETOH, Sepsis, HTN, Iatrogenic, Valvular
o Treatment:
Vent-Rate Control (B-Blocker / Ca-Ch-Blocker [Verapamil] / Digozin)
Anticoagulation (Warfarin)
Cardioversion (Medical [Sotalol/Amiodarone] or Electrical)

- PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (PSVT):

o = Sudden Onset Regular Tachycardias (Typically Atrial Re-Entry)
+
Ra e bpm (Regular)
o Diagnosis:
ECG
Adenosine Trial (Dromotropic Slows SA-Node) :. If Rate slows = SVT.
(If not, consider ventricular cause)
o Management:
Rate Control (B-Blocker / Ca-Ch-Blocker [Verapamil] / Dogoxin)
(Definitive Catheter Ablation.)

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DDX #2 VENTRICULAR TACHYCARDIAS:
- PREMATURE VENTRICULAR COMPLEXES (PVCs):
o = Additional QRS s with No Preceding P-Wave.
Wide QRS & Bizarre Shape
o Complication Consecutive PVCs = VENTRICULAR TACHYCARDIA.
o Management:
Nil Necessary
B-Blocker (if Symptomatic)

- VENTRICULAR TACHYCARDIAS:
o = 3 or more Consecutive PVCs.
>30sec = Sustained VT
<30sec = Non-Sustained VT
o Mechanism: Re-Entry (Typically due to IHD)
o Treatment If Sustained (>30s):
Cardioversion
+/- Anti-Arrhythmic Drugs (Type 1a Antiarrhythmics [Eg. Procainamide])

- VENTRICULAR FIBRILLATION:
o = Disordered, Rapid Ventricular Depolarisation with NO Coordinated Contraction.
No Coordinated Contraction No Cardiac Output
A Ca se of S dden Death
o Mechanism: Often Preceded by PVCs or Ventricular Tachycardia.
o Treatment:
Defibrillation (Much Stronger than Cardioversion & isn imed
+/- CPR
+/- Anti-Arrhythmic Drugs.

- TORSADES DE POINTES ( TWISTING OF THE POINTS ):

o = Polymorphic VT with QRS-Complexes of Changing Amplitude
o Ra e -250bpm
o Causes:
Long-QT-Syndrome (An inherited ion channel mutation)
(Drugs) eg. K+ Channel Blockers
Electrolyte Disturbances (Hypokalaemia / Hypomagnasaemia)
o Management:
IV Magnesium
Temporary Pacing
DC Cardioversion - (If Haemodynamic Compromise)

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 COMMON BRADYCARDIAS:

SINUS BRADYCARDIA:
- = Sinus Rhythm of <60 Beats/min (SA-Node is still the pacemaker)
o Prolonged TP-Interval; All Waves Visible
- Normal (At rest/Sleeping/In Elite Athletes)
- Pathological ( SA-Node Firing (Eg. IHD/Old Age), Cardiomyopathy).
- Management:
o Atropine (If symptomatic) (+/- Pacing)

ESCAPE RHYTHMS (SINUS ARREST/EXIT BLOCK):

- = SA-Node Failure (No P-Wave) AV-Nodal E ca e Rh hm .
o AV-Node Rate -60bpm (Compared to the SA-Node s -100bpm)
- Management:
o Cease Dromotropic Drugs (B-Blockers / Ca-Ch-Blockers / Digoxin)

Conduction Blocks:
- = Impaired AV-Conduction
o Often due to IHD
o Often Escape Rhythm.
- Types of Conduction Blocks:
o Vertical - Between Atria & Ventricles
o Lateral - Between L-Heart & R-Heart
- AV-Conduction Blocks 1 of 3 Degrees:
o 1. FIRST-DEGREE HEART BLOCK:
= Prolonged AV-Delay (Greater than 0.2sec)
Ie. Prolonged PR-Interval (But P:QRS ratio = 1:1)
Management:
Nil.

o 2. SECOND-DEGREE HEART BLOCK:

MOBITZ TYPE-I (WENCKEBACH):
= Gradual Lengthening of PR-Interval until a QRS is lost.
Management:
o Nil; (Atropine if Symptomatic)

MOBITZ TYPE-II:
= Intermittent Loss of AV-Conduction with FIXED PR-Interval
o Block may last for 2/more beats.
Management:
o Pacemaker

o 3. THIRD-DEGREE HEART BLOCK (AKA: COMPLETE HEART BLOCK):

= Complete AV-Conduction Failure.
No P:QRS Relationship
Cardiac Output (Disordered Contraction of Atria & Ventricles)
Management:
Pacemaker.

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- Bundle Branch (Lateral) Blocks (Ie. @ L/R Bundle-Branches):
o LEFT BUNDLE-BRANCH BLOCK:
= When Left Bundle-Branch is unable to conduct impulses to L-Ventricle.
Therefore, R-Bundle-Branch depolarizes R-Ventricle First, then the impulse travels
to L-Ventricle causing it to depolarize.
Ie. Ventricles depolarize Consecutively rather than Simultaneously.
Widened & Split QRS-Complex
o RIGHT BUNDLE-BRANCH BLOCK:
= When Right Bundle-Branch is unable to conduct impulses to R-Ventricle.
Therefore, L-Bundle-Branch depolarizes L-Ventricle First, then the impulse travels
to R-Ventricle causing it to depolarize.
Ie. Ventricles depolarize Consecutively rather than Simultaneously.
Widened & Split QRS-Complex

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DRUGS FOR ARRHYTHMIAS:
Therapeutic Management of Dysrhythmias (Arrhythmias) (Anti-Arrhythmics):
- Class-I Antiarrhythmics (VG-Na+ Channel Blockers):
o General Info:
Indication:
Ie. Typically Re-Entrant Tachycardias (But Not 1st line)
Mechanism of Action:
Selective VG-Na+ Channel Blockade (in Contractile Cells):
o Slows down Re-Entrant Foci Restores SA-Nodal Control of HR.
Typical Agents:
1a Quinidine, Procainamide (Intermediate Association/Dissociation)
1b Lidocaine, Tocainide (Fast Association/Dissociation)
1c Flecainide, Encainide (Slow Association/Dissociation)

- Class-II Antiarrh thmics 1-Blockers):

o Classical Agents:
**Propanolol
Atenolol
o Mechanism of Action:
-Adrenergic Receptor Blockade Inhibit Sympathetic NS
Conductile System HR
Contractile Cells Contractilit
o Indications:
Atrial Fibrillation (Or other Sinus Tachycardia)
SVT
(Hypertension.)
Ischaemic Heart Disease Cardiac Workload (Ie. Metabolic Demands)
o Contraindications:
Asthma Can cause Bronchoconstriction.
Ca+ Channel Blockers (Verapamil/Nifedipine) Can cause Fatal Bradycardia.
o Side Effects:
Sinus Bradycardia.
Bronchoconstriction in Asthmatic Patients.
(Rebound Tachycardia if stopped abruptly; Must be weaned off)

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- Class-III Antiarrhythmics (VG-K+ Channel Blockers):
o Classical Agents:
**Amiodarone
o Mechanism of Action:
VG-K+ Channel Blockers Prolongs Plateau Phase of AP HR
o Indications:
*1st Line in Re-Entrant Tachycardias. V-Tac, V-Fib, A-Fib & A-Flutter.
o KEY Side Effect/s:
Bradycardia
Early-After-Depolarisation (PVCs/Ectopic Beats)

- Class-IV Antiarrhythmics (VG-Ca+ Channel Blockers):

o Classical Agents:
**Verapamil (Selective for the Heart)
Nifedipine (Selective for Vessels) (Used in Angina & Heart Failure)
o Mechanism of Action:
**Heart:
VG-Ca+ Channel Blockade
o @ SA/AV Nodes HR
o @ Myocytes Ca Infl Contractility)
(Vessels Used in Angina):
VG-Ca+ Channel Blockade
o @ Vascular Smooth Muscle Vasodilation BP & Afterload
o Indications:
SVT (Supraventricular Tachycardias)
Variant Angina
o Contraindications:
-Blockers (Since Ca+ Channel Blockers also Inhibit Ca+ Influx) Fatal Bradycardia.
o KEY Side Effect/s:
Heart Block
Bradycardia.
Also H po ension Di iness d e o Con rac ili

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- Other Agents:
o Digoxin:
2x Clinical Uses:
1. Heart Failure (Especially Pts with coincident Atrial Fib. Kill birds
2. Long Term SVT (Eg. AF) Management
2x Mechanisms of Action:
1. Inotropic: Myocytes: Na/K-ATPase Inhibitor Contractility.
o Use: Heart Failure
o Side Effect: Earl Af er Depolarisa ions (Ectopic Beats/SVT)
2. Dromotropic: AV Node: K+ Channel Agonist Slows AV Conduction.
o Use: SVT (Supraventricular Tachycardia)
o Side Effect: Heart Block (if HR <60bpm)
Summary of Actions & Potential Side Effects:
NB: Not to be given if HR less than 60bpm Brady/Heart Block.
NB: Also, Dosage is very important for reducing side effects.
*(NB: Also require K+ Monitoring - & Supplements if on K+ Wasting Diuretic)

o Adenosine:
Clinical Use:
Diagnostically to distinguish V-Tac from SVT.
NB: Extremely short T1/2 - Only Effective in Emergency Situations to stop SVT.
o (Digoxin is used for long-term SVT Management)
Mechanism of Action:
Adenosine Receptor Agonist @ SA & AV Nodes Delays AV-Node Conduction.
(HR will slow if it is an SVT) / (If HR is unchanged, then it is V-Tac)
Side Effect/s:
IMPENDING DOOM!!! P s li erall feel like he re d ing

o Atropine:
Clinical Use:
Acute Bradycardias/Asystole HR. (However can cause V-Tac).
Mechanism of Action:
Chronotropic: Anti-Muscaranic (Blocks Parasympathetic NS) HR
KEY Side Effect/s:
Overdose Ventricular Tachycardia

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 CVS Pathology:
Atherosclerosis

TERMINOLOGY:
Arteriosclerosis Hardening of Any Artery:
o **Macroangiopathy = A he o cle o i - Hardening of Large & Medium Arteries
o Microangiopathy = A e iolo cle o i Hardening of Small Arteries
Hyperplastic
Hyaline
Arteritis Inflammation of Any Artery. (Next Week)

**ATHEROSCLEROSIS:
- = A Progressive Chronic Inflammation of Arteries characterised by:
o 1. Inflammation, (Macrophages engulf LDLs Foam Cell
o 2. Fibrosis, (Conn. Tissue Matrix/Collagen/Elastin)
o 3. & Lipid Deposition (Cholesterol Esters & Cholesterol in Cells)
o A he o Fa Scle o i Ha dening
- Aetiology:
o BEGINS with Endothelial Injury
o BIG Inflammatory Component
o Risk Factors:
Non Modifiable: Age (40-60), Male, FamHx, Indigenous
Modifiable: Cholesterol, HTN, Smoking, Diabetes, Obesity, Metabolic Syndrome
- Pathogenesis
o 1. Endothelial Injury & Activation (HTN/Smoking/DM/Turbulence/Toxins/Infection/Immune).
o 2. Endothelial Inflammation (Macrophage & Smooth Muscle Migration)
o 3. Accumulation of Lipoproteins Fatty Streak Formation.
o 4. Proliferation & Fibrosis (Conversion of Fatty Streak into a Mature Atheroma)
o 5. Complicated plaque formation (Thin Fibrous Cap Rupture Thrombus ACS)
- Clinical Features/Complications:
o Multi-Organ Disease:
Heart IHD (Angina, MI).
Brain Cerebral Infarction (Stroke)
Kidneys Renal Infarction
GIT GI-Ischaemia/Infarction
Lower Extremities PVD (Eg. Claudication, Gangrene of Legs, Arterial Leg Ulcers)
- Investigations:
o Coronary Angiogram
- Management:
o Risk Factor Modification:
Statins - ( Cholesterol)
ACE-I/B-Blocker - (HTN)
Control DM
Die Physical Exercise (For Obesity)
Smoking, Alcohol
o Prevent Thrombosis:
Aspirin/Clopidogrel
o Surgical Intervention:
Balloon Angioplasty/Stent AngioplastyBypass Surgery:

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 Week 7
CardioVascular Medicine Notes
Atherosclerosis

Atherosclerosis: A General Overview:

- “Athero” = Gruel/Porridge (ie. The fat in the blood)
- “Sclerosis” = Hardening

- A Progressive Chronic Inflammatory Disease of the Blood Vessel Wall

o Due to Vessel Injury à Fatty Plaque Formation à Occlusion of Blood Vessel
§ Reduced blood flow to local area à Imbalance of Supply & Demand.

- Occurs Silently Over Many Decades

- Advanced Plaque & Thrombus:

o If ‘Apical Cap’ becomes unstable à Ruptures à Massive Thrombus (Clot) à
o Thrombus Completely Occludes Vessel

- Characterised By Accumulation of:

o 1. Lipids (Cholesterol Esters & Cholesterol in Cells)
o 2. Fibrous Elements (Conn. Tissue Matrix/Collagen/Elastin) &
o 3. Local Inflammatory Response (Macrophages engulf LDLs à “Foam Cells”)

- Principle cause of Heart Disease & Stroke

o Cause of 90% Myocardial Ischaemia
§ Due to Occlusion of Coronary Circulation
o Cause ≈50% of deaths in Western Society.

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Lipids: The Main Culprits! (A Review)
- 3 Types of Lipids in Plasma:
o 1. Cholesterol + Ch. Esters
o 2. Phospholipids
o 3. Triglycerides (Fatty Acids + Glycerol)
- Lipid Transport:
o Insoluble In Water à Must be Packaged to be suspended in plasma.
o Fats Absorbed in GI à Packaged into Chylomicrons (in S.I.) à Lymphatics à
§ Lymphatics à Circulation (Left Sub-Clavian Vein) àLiver.
o Liver Repackages Chylomicron Remnants à Lipoproteins à Circulation

NB: LDLs Attribute to Atherosclerosis

NB: HDLs Help Prevent Atherosclerosis

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What Is The Process?:
1. Vessel Injury – Endothelial Damage:
a. Risk Factors:
i. High Cholesterol
ii. Hypertension – High Pressure can split arteries (Particularly where they branch)
iii. Smoking – Toxins from cigarettes.
iv. Toxins/Poisons
v. Virus
vi. Bacteria
vii. Immune Reactions
viii. Diabetes
b. Endothelium Becomes Activated:
i. Increased Vessel Permeability – Become ‘Leaky’
ii. Platelets Adhere
iii. Monocytes Adhere à Transform to Macrophages
iv. Blood LDLs Enters à Bind to their Apolipoprotein ‘Receptors’ à Activated & Oxidised à
v. Oxidised LDL Presence à Causes Inflammation:
c. Local Inflammation:
i. Oxidised LDLs – Attract Immune Cells/Cytokines/Platelets/Smooth Muscle/Conn. Tissue
ii. Macrophages Engulf Oxidised LDL à Transform to Lipid-Laiden Foam Cells.
iii. Plaque Building Slowly Begins.

2. Fatty Streak Formation:

a. Fat Deposition Under the Tunica-Intima Vessel-layer.
b. The Typical Early Atherosclerotic Lesion.
i. Majority Are Clinically Silent
ii. Are Reversible – eg. If Diet Changes
c. Yellow Colour Reflects:
i. Oxidized Lipids
ii. Presence of ‘Foam Cells’

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3. Lipid Plaque:
a. Fatty Streak gets more profound
b. ‘Foam Cells’ Unable to Digest Lipid Contents à Die
i. à Extracellular Lipids
ii. à Cell Debris
c. Oxidised LDLs – Attract Immune Cells/Cytokines/Platelets/Smooth Muscle/Conn. Tissue
i. Positive Feedback.
d. Plaque Builds.

4. Complicated Plaques:
a. ‘Cap’ forms on plaque à Becomes more ‘Unstable’ à May rupture à Thrombus à Occlusion
b. Clinical Manifestations (Different Types of ‘Complicated Plaques’):
i. **Plaque Rupture à Thrombosis (Responsible for 90+% of MI’s)
ii. Narrowing/Calcification à Vessel Rigidity & Fragility
iii. Haemorrhage Into Plaque à Narrowing of Lumen
iv. Fragmentation of Plaque à Distal Emboli
v. Weakening of Vessel Wall à Aneurysms

Simplified Summary Of Process Of Atherosclerosis:

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 Whole Process

Diagnosis Of Atherosclerosis:
- (Old) Invasive Method:
o Catheter via Femoral Artery à Coronary Artery à X-Ray Angiogram.
- (Current) Non-Invasive Method:
o Contrast-Enhanced CT-Scan
o Takes 15sec.

Preventing Atherosclerosis:
- Drugs:

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Reparative Surgery:
- Balloon Angioplasty:
o Balloon-tipped tube inserted in coronary artery
o Balloon Expanded multiple times – Stretches lumen.

- Balloon Stent Angioplasty:

o Stent-Tipped Balloon-Tipped Tube inserted in coronary artery
o Balloon (+ Stent) expanded
o Balloon deflated & withdrawn
o Stent stays in & open.

- Bypass Surgery:
o The use of a distal vessel as a substitute for Blocked Artery.
o Eg. Radial Artery Bypass
o Eg. Saphenous Vein Bypass

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SS Questions:
1. What is the difference between Arteriosclerosis & Atherosclerosis?
a. Arteriosclerosis is a general term describing any hardening (and loss of elasticity) of medium or large
arteries, whereas...
b. Atherosclerosis is the hardening of an artery specifically due to an atheromatous (atherosclerotic)
plaque.

2. What are the 3 Types of Arteriosclerosis?

1. Atherosclerosis - 2. Arteriosclerosis Obliterans - 3. Medial Calcific Sclerosis - mostly in elderly -
Atheroma Plaque Fibrosis of intima _ Calcification Calcification of Internal Elastic Lamina, but without
of Media. thickening of intima or narrowing of vessel.

3. What is the effect of Diabetes on the Vascular System?

a. Chronic elevation of blood glucose level leads to damage of blood vessels (angiopathy). The
endothelial cells lining the blood vessels take in more glucose than normal, since they don't depend
on insulin. They then form more surface glycoproteins than normal, and cause the basement
membrane to grow thicker and weaker.

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 CVS Pathology:
Carcinoid Heart Disease

CARCINOID HEART DISEASE:

- Aeitology:
o Cardiac Manifestation of the Systemic Syndrome caused by Carcinoid Tumours.
- Pathogenesis:
o Carcinoid Tumour Releases Vasoactive Hormones into Venous Circulation
Serotonin / Bradykinin / Histamine / Prostaglandins
o Venous Drainage of these Hormones R-Heart R-Heart Endocardial & Valvular Fibrosis.
(Generally Fibrosis of R-Heart Valves (Tricuspid/Pulmonary))
- Clinical Signs:
o “Carcinoid Syndrome”:
Episodic flushing of skin
Cramps
Nausea/Vom/Diarr.
o Heart Manifestations (RV-Failure due to..):
*Tricuspid Regurgitation (Most Common)
Hepatomegaly/Pain
Pulsatile Liver
↑JVP with Prominent V-Waves
Systolic Murmur @ 4th ICS, L-Sternal Border, Louder on Inspiration
*Pulmonary Regurgitation
Dyspnoea
Diastolic Murmur @ 2nd ICS, L-Sternal Border, Louder on Inspiration
(+ Features of RV-F):
Peripheral Oedema
Organomegaly
Portal HTN (Caput Medusa, Spider Naevi)
↑JVP
- Investigations:
o 24hr Urinary 5-HIAA (A Serotonin Metabolite)
o Abdo CT + Somatostatin Receptor Scintigraphy (SRS) – (Tumour Localisation)
o Abdo MRI + Contrast
o Cardiac Ix (ECG, CXR, ECHO)
- Management:
o Medical Somatostatin Analogues (Octreotide)
+/- Interferon-A in Palliative Pts.
o Surgery Tumour Resection + Valuloplasty
- Prognosis:
o Can Metastasize :. Early Removal is Essential

(A, Characteristic endocardial fibrotic lesion involving the right ventricle and tricuspid valve. B, Microscopic
appearance of carcinoid heart disease with intimal thickening.)

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 CVS Pathology:
CARDIOMYOPATHIES

CARDIOMYOPATHIES (“Heart Muscle Diseases”):

- 1. DILATED CARDIOMYOPATHY (Most Common):
o Aetiology:
***Idiopathic
**Chronic Alcoholism
*Post-Viral (Myocarditis)
Genetic
Chemotherapy
Chronic Anaemia
o Pathogenesis:
Progressive Dilation & Hypertrophy Systolic Dysfunction.
Enlarged, Flabby Heart
Mural Thrombi (Can embolise)
AV-Valve Regurgitation (Due to Chamber Dilation)
o Clinical Features:
Any Age (Incl. Childhood).
Presentation: Congestive Heart Failure:
Dyspnoea/Orthopnoea/PND
Exercise Tolerance
Fatigue
Wet Cough
o Complications:
Mitral Regurgitation
Arrhythmias
Possible Thrombotic Embolism
o Investigations:
ECG
CXR (Globular Heart)
Echo (Assess Vent Function)
o Management:
ETOH
CCF Triple Therapy:
ACEi (Perindopril) / ARB (Candesartan)
B-Blocker (Carvedilol)
Diuretic (Frusemide)
Warfarin (Prevent Thromboembolism)
FluVax & PneumoVax
** Heart Transplant
o Prognosis:
50% 5yr Mortality Unless Heart Transplant.

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- 2. HYPERTROPHIC CARDIOMYOPATHY (AKA: HOCM – Hypertrophic Obstructive Cardiomyopathy)
o Aetiology:
**Genetic
o Pathogenesis:
Genetic Mutation Hypertrophy Diastolic Dysfunction ( Filling Chamber Size
NB: End Stage can Focal Ischaemia (Even in absence of Coronary Artery Disease)
o Clinical Features & Complications:
CCF (Dyspnoea, Orthopnoea, PND, Cough)
Ventricular Outflow Obstruction Syncope + Harsh Systolic Murmur
Angina
Arrhythmias
Mural Thrombus Embolisation (eg. Stroke)
Sudden Death
o Investigations:
ECG (LVH, Path Q Waves)
Echo (LVH, Diastolic Dysfunction, Poor EF)
o Management:
Medical β-Blockers Heart Rate Contractility
Surgical Septal Myomectomy (Relieves the outflow tract obstruction)
+/- ICD (If Arrhythmias)

A, The septal muscle bulges into the left ventricule, left atrium is enlarged.
B, Extreme hypertrophy, branching of Myocytes, and the characteristic interstitial fibrosis (collagen is blue).

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- 3. RESTRICTIVE CARDIOMYOPATHY
o Aetiology:
**Amyloidosis/Sarcoidosis/Scleroderma/Haemochromatosis
o Pathogenesis:
Stiffening of Myocardium Diastolic Dysfunction ( Filling) Heart Failure
Ventricles Normal Size Volume
Myocardium is Firm & Non-Compliant
o Clinical Features & Complications:
Heat Failure Symptoms:
Cough, Dyspnoea, PND, Orthopnea
Fatigue
Chest Pain, Palpitations
Signs:
Elevated JVP
Lung Crepitations
Peripheral Oedema
Arrhythmias
o Investigations:
ECG (Low Voltage)
CXR – (CCF Signs)
Echo – (Diastolic Failure, Poor EF)
Myocardial Biopsy (To Determine Aetiology)
o Management:
Medical:
CCF Triple Therapy (ACEi/ARB + B-Blocker + Diuretics)
Warfarin
+/- Anti-Arrhythmics
Definitive: Requires Heart Transplant.

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- (4. “COR PULMONALE”):
o RV Hypertrophy AND Dilation. (Secondary to COPD/Chronic Pulmonary Hypertension)

- (5. “STRESS CARDIOMYOPATHY”):

o AKA:
Broken Heart Syndrome
Takotsubo Cardiomyopathy
Apical Ballooning Cardiomyopathy
o Aetiology:
(NON-ischaemic)
Stress-Related (High Catecholamines)
o Pathogenesis:
Stress High Catecholamines Coronary Vasospasm Myocardial Stunning
Bulging of the LV-Apex with Hypercontractile LV-Base. Octopus Trap Shape
o Clinical Presentation & Complications:
Acute, Reversible LV Systolic Dysfunction
Sudden Onset CCF
Chest Pain
Dyspnoea
Lethal Ventricular Arrhythmias + Other ECG Changes (Similar to MI)
Ventricular Rupture
o Investigations:
ECG – (ST-Elevation)
Troponins – (Elevated)
CXR
Echo – (Characteristic Regional Wall Motion Abnormalities)
Serum Catecholamines
o Management:
Supportive Therapy
CCF Triple Therapy:
ACEi (Perindopril)
B-Blocker (Carvedilol)
Diuresis
Inotropes (If Hypotensive) (Dopamine)
Aspirin
+/- Warfarin

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 Week 8 & 9
Preventative Medicine & Addiction Studies Notes
CARDIOVASCULAR DISEASE & OBESITY; NUTRITION & PHYSICAL EXERCISE

CARDIOVASCULAR DISEASE:

What is CVD?
- Heart Disease
- Stroke
- Blood-Vessel Disease
- NB: The Leading Cause of Death.
- NB: Signs & Symptoms are often Silent until Acute Event.

Epidemiology:
- CVD Mortality Has Declined Significantly:
o Better Drugs
o Better Surgery
o Falling Smoking Rates
- However, CVD Rates are Increasing due to:
o Ageing Population
o ↑Overweight/Obesity (Doubled since ‘80s)
o ↑Diabetes (Doubled since ‘90s)
o ↑Sedentary Behaviour
o NB: Hypercholesterolaemia Hasn’t Changed.
- ATSI Populations Suffer Most:
o 3x Rate of Major Coronary Events (incl. Heart Attack)
o 3x as likely to Die from CVD
o 15-25% More Likely to die from Acute Rheumatic Fever & Chronic Rheumatic Heart Disease.
o Why? – Tend to have multiple CV Risk Factors & more of them.

THE 3 MAJOR RISK FACTORS FOR CVD:

- Smoking
- Hypertension
- Hypercholesterolaemia

Other Risk Factors for CVD:

- Unavoidable Factors:
o Sex
o Age
o Family history
o Personality type
- Avoidable/Changeable Factors:
o Nutrition & Inactivity /Sedentary Lifestyle
§ Obesity
§ Hypertriglyceridaemia
§ Hypertension
o Diabetes
o Psychosocial factors (depression, social isolation, poor social support)
o NB: All of the above can be improved by 2 things: - NUTRITION & PHYSICAL EXERCISE.

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Lifestyle Measures to Reduce Risk Factors for Chronic Disease:
- *Control Blood Pressure:
o Lose Weight
o Regular Physical Activity
o Nutrition
- *Maintain a healthy Weight:
o Regular Physical Activity
o Nutrition
- *Physical Activity:
o ↑Activity; ↓Sedentary Behaviour
- *Nutrition:
o Adequate Fruit/Veg
o 2x Fish/Week – (Omegas - Essential Fats)
o Limit Alcohol
o Limit Saturated Fats
o Calcium (At least 800mg/day) à Helps reduced BP in Hypertension.

Role of the National Heart Foundation in CVD:

- Aim: To reduce Suffering & Death from Heart/Stroke/Vessel Disease in Australia.
- How?:
o Fund Scientific Research
o Public Education Resources
§ Public Awareness Programs
§ Assist in Making Healthier Choices
§ Educate Community about Recognising Warning Signs of Heart Attack:
• Jaw Pain
• Neck Pain
• Back Pain
• Shoulder Pain
§ Especially Women – Leading cause of death in Women (4x Breast Cancer)
o Guidelines for Health Professionals:
§ Lipid Management
§ Acute Coronary Syndrome Management
§ Heart Failure Management
§ Hypertension Management
§ Guidelines for Physical Activity (For healthy people & with CVD)
§ Guidelines on Diagnosis/Management of Acute Rheumatic Fever & Rheumatic Heart Disease.
§ Guidelines for Reducing risk of Coronary Heart Disease.
§ ‘Cardiovascular Risk Calculator’
o National Programs:
§ “Tick Program” – (The Heart-Foundation Approved “Tick” on foods.)
§ “Time for Action”
o Advocates of Anti-Tobacco Legislation.
o Advocates of Physical Activity for CVD & Obesity Prevention:
§ Walking Groups – Encourage more people to walk.
o Advocate & Actively Contribute to Improving ATSI Health:
§ Projects to Improve Smoking Cessation.
§ Promoting Physical Activity
§ Promoting Good Nutrition
§ Guidelines on Diagnosis/Management of Acute Rheumatic Fever & Rheumatic Heart Disease.

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- Cardiac Rehabilitation
o Assist CVD Patients by promoting Treatment & Rehabilitation:
§ “Heartmoves” – Safe exercise program for Stable CVD Pts/High-Risk Pts/Chronic Disease.
§ Walking Groups – Encourage more people to walk.
§ “My Heart My Life” – Cardiac Rehabilitation:
• (An education booklet resource)
• Phase 1 – Counselling & Education of Cardiac Patients:
o Basic Understanding of Heart Disease
o Angina Recognition & Home-Management.
o Medication Education à ↑Compliance
o Recognition & Modification of Risk Factors
• Phase 2 – Improving Condition & Education of Patient:
o Regain Pre-Hospital Activities.
o Action Plans to Modify Risk Factors.
o Psychological Recovery
o Regular Physical Exercise.
• Physical Activity Guidelines:
o Walk 5-10mins Twice Daily (Post- Surgery/Cardiac-Event)
o Avoid Upper Body Activity (Sternotomy)
o Sleep on back (not side) for 4-6weeks post-op.
o Post-Discharge walking program:

o NB: Shouldn’t do Too Much Physical Activity:

§ Walk & Talk test – (Tests breathlessness)
§ If Previous Day’s Exercise has left you Tired or Sore, have a day off.
o Stairs?:
§ Increase Gradually Within Your Own Limits.
§ (If you can walk normally, you should be fine with 2 Flights of Stairs)
o Sport?:
§ Most sports are fine After 6 Weeks.
§ However, must check with Cardiologist.
o Sex?:
§ Same as 2 flights of stairs.
§ (If you can walk normally, you should be fine with sex)

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 OVERWEIGHT & OBESITY:

Obesity is due to:

- ↑Processed (High GI) Foods & Drinks
- ↑Fatty foods
- ↑Sedentary Behaviour
- ↑Effort-saving inventions
- Possibly genetically determined (and Epigenetics)
- Epigenetics – events during childhood can change the expression of certain genes which predispose patient
to Obesity (Changes are Permanent & Heritable)
- Leptin Deficiency & Obesity:
o Leptin Deficiency causes Hyperphagia à Obesity
o However, there have only ever been 12 cases worldwide

The General Effect of Fat on the Body:

- ↑Fat Mass à ↑Blood Vessels à↑Peripheral Vascular Resistance à ↑Strain on the Heart à↑CVD
- ↑Fat Mass à ↑Body Weight à ↑Wear & Tear on Joints (Particular weight-bearing)à Arthritis
- ↑Fat Mass à Endocrine Imbalances à Glucose Tolerance .... à Diabetes.
- Many More – Ie. The Whole Body has to work harder to compensate.

What is a Healthy Weight?

- BMI:
o Normal = 18.5-24.99
o Overweight = >25.00
o Obese = 30.00à
- Waist Circumference:
o Better than BMI
o Abdominal Adiposity, Regardless of BMI, Increases Risk of Certain Obesity-Related Conditions.
o NB: Fat deposited elsewhere (hips/buttocks) seems to be less of a risk.
o Healthy Measurements:
§ Women: Waist Circumference of 88cm or Less.
§ Men: Waist Circumference 94cm or Less.

Regulation of Appetite:
- Central Signals:
o Appetite Stimulating
§ Neuropeptide Y
§ Agouti Related Peptide
o Appetite Inhibiting
§ Α-MSH
§ 5HT
§ NE
- Peripheral Signals:
o Positive Feedback:
§ Ghrelin
§ Cortisol
o Negative feedback:
§ Leptin
§ Insulin

- NB. The CNS Appetite-Centre has evolved around the idea that “there is not enough”.
o Ie. There are several Safeguards Against Weight Loss.
o Ie. There is NO Safeguard Against Weight Gain.

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↑Mortality increases exponentially with ↑BMI:
- Almost all body organs are affected

Managing Obese Patients:

- Weight loss improves all of:
o Cholesterol
o Glucose tolerance
o HBA1C
o Blood lipids
- Obesity Treatment Pyramid:
o Lifestyle Mods at the foundation (Nutrition/Dieting & Physical Exercise)
o Pharmacotherapy
o Surgery (at the top)

- Nutritional Advice & Food Diaries:

o Useful for recording what/how much/where/ate too much?/calories etc.
o Also useful for monitoring alcohol intake
o NB: There is NO particular Diet that is proven to cause weight loss:
§ Instead, it is an Energy Balance.
§ If by eating low-energy density foods, you create an energy deficit in your body, which is
supplemented by burning fats.
§ Summary:
• Low energy density, calorie controlled style of eating
o Increased fruit & veg
o Reduce sat fat
o Reduce portion size
o Regular meals especially breakfast
o Eat slowly
o Self-Monitoring (food diary)
§ NB: Plateaus in weight loss charts are normal & predictable:
• Patients plateau after losing an amount of weight because their energy intake (which
was previously creating an energy deficit) is now neutral since his body uses less
energy to move the increased body mass. (which is now not there)

- Physical Activity:
o ↑Incidental Movement (Movt is an opportunity rather than inconvenience)
o Increase aerobic capacity
o Resistance training
o NB: Aerobic fitness almost halves risk of cardiovascular disease mortality.
o NB: Increased body fat increases CVD
o However, even a fit, obese person has a lower risk of CVD than an unfit, thin person.
o Benefits of regular physical activity:
§ ↓loss of fat-free mass associated with weight loss
§ Improves maintenance of weight loss
§ Improves cardiovascular risk regardless of weight loss.

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 - Psychological Component of weight Loss:
o Self monitoring
o Systematic approach to solving problems
o Contingency plans for times of overeating
o Stimulus control (identify triggers for overeating)
o Stress management
o Social Support (important for both exercise & maintaining dietary change) – eg. Wife
o Cognitive Restructuring
§ Changing style of thinking
§ Changing Dichotomous thinking (all or nothing; passed or failed; good or bad)
§ Reassessing Unrealistic Goal Setting
§ Body image issues.

- Bariatric Surgery:
o Indications:
§ BMI over 40
§ Or life-threatening CVD/diabetes/lifestyle impairment
§ Failure to achieve adequate weight loss with non0surgical treatment
o Contraindications:
§ High Risk Heart Disease
§ Uncontrolled Depression/Psychotic Illness
§ Active Substance Abuse

BRUCE:
- 55yrs
- 84kg à 110kg due to sedentary job, too much food & alcohol. (BMI 35)
- Waist 110cm
- Tried many times to diet/exercise etc, but largely ineffective.
- Motivation – excercise intolerance, uncomfortable, avoid medication, avoid premature death, poor body
image.
- Goal – to be under 90kg.
- Med Hx:
o Impaired glucose tolerance (Elevated fasting BSL)
o Unfavourable lipid profile
o Recently hypertensive 155/90
o Mild osteoarthritis of knees.
- Fam Hx:
o Bowel Cancer
o Myocardial Infarction
o Ischaemic Heart Disease
- Social Hx:
o Poor sleep
o Late to bed, & tired in morning
- Treatment (Physical Exercise):
o Bike riding
o Walked to and from work
o Pedometer
o Supervised resistance training with Exercise Physiologist
o Decreased screen time (Sedentary time)

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 LIFESTYLE FACTORS & CHRONIC DISEASE

NB: Lifestyle Measures in Treatment of Chronic Disease is INDIVIDUAL:

- Ie. Not one size fits all – (Ie. The same ‘lifestyle prescription’ doesn’t suit everyone.)
- Dietary Advice should be Adapted Depending on the Patient’s Situation:
o Eg. Obese with CVD
o Eg. Normal weight with CVD
o Eg. Diabetes and obese
o Eg. Diabetes and normal weight

Lifestyle Measures to Reduce Risk Factors for Chronic Disease:

- *Control Blood Pressure:
o Lose Weight
o Regular Physical Activity
o Nutrition
- *Maintain a healthy Weight:
o Regular Physical Activity
o Nutrition
- *Physical Activity:
o ↑Activity; ↓Sedentary Behaviour
- *Nutrition:
o 2x Fruits/Day
o 5x Vegs/Day
o 2x Fish/Week – (Omegas - Essential Fats)
o Legumes
o Limit Alcohol
o Limit Alcohol
o Limit Saturated Fats
o Calcium (At least 800mg/day) à Helps reduced BP in Hypertension.

- NB: Notice how all of the above tie in with each other?
- Therefore, the 2 MOST IMPORTANT Lifestyle Measures that cover all the bases in reducing Chronic Disease
are Nutrition & Physical Activity.

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NUTRITION:

- The Role of Nutrition in Promoting Health & Preventing Chronic Disease:

o Helps Control Blood Pressure
o Helps Control Hypercholesterolaemia
o Helps Maintain/Achieve a Healthy Body Weight
o Good Diet Promotes Good Health – by supplying the body with all essential vitamins/minerals.

- The Role of Nutrition in Management of Chronic Disease:

o Nutrition & Obesity – An Energy Balance:
§ Losing/Maintaining Weight is a simple Energy Balance:
• Ie. Energy Input (Caloric Intake) </= Energy Expenditure (Physical Activity).
• NB: There are certain Energy-Dense foods to avoid (Sweets/Cheese/Butter/Etc),
However, you can still get fat if you eat LOTS of “Healthy” foods.

o Nutrition & Cholesterol – A Problem of SAT-FATs:

§ Apparently Saturated Fats à ↑LDL Levels:
• Don’t know how, Just Know that it Does. (Possible Controversy)
• (NB: LDLs – Low density lipoproteins – are “Bad Cholesterol”)
§ SOURCES OF SATURATED FAT
• ANIMAL PRODUCTS
o Fat on meat
o Skin on chicken
o Dairy fats
o Some “deli meats”
• • VEGETABLE PRODUCTS
o Coconut (milk/cream/oil)
o Palm oil
o Tropical oil
o Vegetable oil (unspecified) eg fish shops
o Many roasted nuts
§ REPLACING SATURATED FAT:
• If Pt. Is Fat: Carbohydrates
• If Pt. Is Thin: Poly- or mono-unsaturated fats
• (Decision depends on BMI)

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- Role of Dieticians in Managing Patients with Chronic Disease - Giving Nutritional Advice:
o *Tell them what to eat, rather than what not to eat:
§ 2x Fruits/Day
§ 5x Vegs/Day
§ 2x Fish/Week – (Omegas - Essential Fats)
§ Legumes
§ Limit Alcohol
§ Limit Alcohol
§ Limit Saturated Fats
§ Calcium (At least 800mg/day) à Helps reduced BP in Hypertension
o IF you tell them what to avoid:
§ Many will starve themselves
§ Others will find it too hard & give up

o Nutrition knowledge quiz - Hawkes and Nowak 1998

§ 1. To reduce your cholesterol level do you think you should eat less:
• Cakes/biscuits - yes
• Ice cream - yes - (No if made with Skim Milk)
• Fat on meat - yes
• Peanuts - yes – (Salted Peanuts require oil for the salt to stick)
• Coconut - yes
• Skim milk - (Has NO fat – so makes no difference)
• Sugar – (Sugar will make you fat, but doesn’t affect cholesterol)
• Bread – (It’s what you put on the bread)
• Avocados – (Contains Good Cholesterol)
§ 2. Cholesterol is only found in animal products?
• True – Plants don’t have sat-fats)
• (NB: Saturated Fats apparently increases Bad (LDL) Cholesterol Levels)
§ 3. To reduce your blood cholesterol level is it more important to eat less saturated fat or
less cholesterol?
• Saturated fat
• (NB: Dietary Cholesterol has little/no effect)
§ 4. Which has LESS fat (pick one)
• Butter
• Margarine
• They are equal – (Fat content goes by Weight, therefore 1g of Marg = 1g of Butter)
o (The Only difference is Margarine contains Poly-Unsaturated Fats)
§ 5. Which has LESS fat (pick one)
• Olive oil
• Vegetable oil
• They are equal
§ 6. The correct way to lose weight is to eat LESS:
• Cheese - yes
• Butter - yes
• Cakes - yes
• Margarine - yes
• Bread – (It’s what you put on the bread)
• Bananas – (Depends how much you eat)
• Potatoes - (Depends how much you eat)
• Grapes - (Depends how much you eat)
• Rice yes - (Depends how much you eat)
• NB: While there are some things to avoid to lose weight Faster, it still comes down
to HOW MUCH you eat – (Energy Balance)

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§ 7. Are these foods HIGH in fat?
• Toasted muesli - yes – (Muesli is Toasted in Oil. NB: NON-Toasted is fine)
• Nuts - yes – (50% Oil, 50% Protein; Where do you think they get peanut oil from?)
• Margarine - yes – (Even though it contains poly-unsaturated fats, it still has fat)
• Olive oil - yes – (Oil IS Fat in Liquid Form)
• Carob bar - yes – (Requires oil to form it into Bars & Resemble the Texture of Choc)
• Spaghetti – (No – Just carbs)
• Rice – (No – Just carbs)
• Bread – (No – Just carbs)
§ 8. The Main Ingredient in a food is listed FIRST on a food label:
• True
§ 9. Does one teaspoon of fat weigh:
• 0.1 gram
• 1 gram
• 4 grams
• 10 grams
• not sure
§ 10. Which of these foods contain fibre?
• Oranges - yes
• Bread - yes – (NB: White Bread has very little; unless fortified with fibre)
• Baked beans – yes
• Steak – (NO – Just Protein)
• apple juice – (NO – unless freshly squeezed with pulp)
• fish - (NO – Just Protein)

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PHYSICAL ACTIVITY:
- The Role of Physical Activity in Promoting Health & Preventing Chronic Disease:
o NB: DECREASING Sedentary Behaviour is MORE EFFECTIVE than INCREASING Exercise.
§ Both are good, but doing exercise is pointless if you lead a Sedentary Lifestyle.
§ What you WANT to do is ↑PHYSICAL ACTIVITY.
§ Ie. Exercise ≠ Physical Activity:
• Exercise = Dedicated Physical Exertion
• Physical Activity = Miscellaneous Day-to-Day Activity.

- The Perils of Sedentary Behaviour:

o Sedentary Behaviour is DIRECTLY LINKED to:
§ ** CVD (NB: All of the below further contribute to CVD)
§ *Obesity
§ *Depression
§ *Diabetes (Typically type 2)
§ Osteoporosis
§ Stroke
§ Hypertension
§ High Cholesterol
o Exercise is known to a) Reduce the Risk of these conditions, but b) Also Decrease their Severity.
§ Ie. Any Increase in Physical Activity (be it small/large) is immensely beneficial, Even in
patients who already have these diseases.

- The Rewards of ↑Physical Activity:

o ↑Lean body mass
o ↑Bone density
o ↑Cardiac output
o ↑Oxygen carrying capacity & exchange
o ↑Metabolism
o Improved neurotransmitter regulation
o Improved mood, self-efficacy
o Improved QOL

- Physical Activity Guidelines:

§ (NB: Moderate Activities = Brisk walk, a Bike ride or Active Play)
§ (NB: Vigorous Activities = Anything that makes the kid “huff and puff” (Ie. Sports))
o 5-12 year olds:
§ Combination of Moderate and Vigorous Activities for At Least 60mins/day.
§ NB: Children & Adolescents require almost Double.
o 12-18 year olds:
§ At least 60mins of Moderate to Vigorous Physical Activity Every Day.
§ NB: Children & Adolescents require almost Double.
o Adults:
§ Step 1 – Think of movement as an opportunity, not an inconvenience
§ Step 2 – Be active every day in as many ways as you can
§ Step 3 – At least 30mins of Moderate Physical Activity per day. (At least 5 days a week)
§ Step 4 – Some Regular, Vigorous Activity for extra health and fitness.
§ NB: If Exercise is being used as a disease Intervention, the recommendations are Doubled.
o Elderly/Completely Sedentary:
§ ANY Physical Activity is Beneficial.

- Rate of Perceived Exertion – RPE – “Borg’s RPE Scale”:

o Measures Perceived Exertion on a scale of 0-20:
§ 0 = Falling Asleep; 6 = Very Very Light Exertion; 20 = Maximal Exertion
o Why? – Because HR alone is an unreliable measure of exertion in patients on Cardio-Drugs.

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- How do we Ensure the Exercise is Safe for the Patient?:
o NB: Low-Risk Patients can start exercise Immediately.
§ However, Moderate-High-Risk Patients should undergo medical testing before undertaking
any exercise.
o Risk Stratification Flow-Chart:

NB: I Doubt you’ll have to memorise this. For your interest & understanding only.

- The Role of Physical Activity in Management of Chronic Disease:

o PA & Management of Cardiovascular Disease (Post Myocardial Infarction):
§ Post-MI Exercise is Immediate:
• Ie. Within days after the MI.
• NB: However, It is only LOW INTENSITY.
• NB: Cardiac Rehab is usually done as an INPATIENT under close supervision.
§ Recommendations (MI)
• Begin ASAP
• 3days/wk
• 20-60 min (cardiac rehab) PLUS home-based
• Start @ 40-60% Heart-Rate Reserve; progress to 85%
• (HR Reserve = 220 – Age – Resting HR.)
§ Benefits (MI):
• Improved cardio-respiratory function
• Protection against exertional MI trigger
• Reduced HR, BP, LDL, TC
§ Contraindications (CVD):
• Change in Resting ECG Indicating Ischemia/MI/Unstable Angina/Uncontrolled
Dysrhythmias.
• Symptomatic Aortic Stenosis
• Uncontrolled Heart Failure
• Pulmonary Embolus/infarction
• Myo-/Pericarditis

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o PA & Management of Diabetes:
§ Diabetics are advised to Cycle/Swim instead of Running:
• Because Peripheral Vasculopathy & Neuropathy in Diabetes à Repetitive Trauma to
feet + Little Sensation à Formation of Ulcers.
§ Benefits:
• Improved Action of Insulin (Insulin Sensitivity)
o NB: Exercise + Normal dose of Insulin = Additive Effect; can cause
hypoglycaemic shock. Therefore Necessary to ↓Insulin dose with Exercise.
o NB: Can even Reverse Type-2 Diabetes.
• Improved Glucose tolerance
• Improved weight management
• Improved BP à Decreased CVD Risk
• Improved Lipid profiles àDecreased CVD risk
§ Recommendations:
• Aerobic Exercise: (20-60min @ Heavy Exertion (High RPE) At least 4 Times/wk)
• Strength: (Low Resistance @ Moderate Exertion (RPE 11-16) 2-3 Times/wk.)
• Flexibility, balance & coordination: (2-3xwk)
§ Precautions:
• Effects of insulin & exercise are ADDITIVE - (Adjust insulin dose accordingly)
• If BG <4 or >17 mmol/L, delay exercise until stable
• Always have glucose handy (honey, jelly beans) in case of Insulin Overdose.
• Illness, infection, retinal haemorrhage, peripheral neuropathy.

o PA & Management of Depression:

§ Benefits:
• Improved Self-esteem
• Improved Mood
• Opportunity for participation in community/family events/tasks
§ Recommendations:
• HIGH Intensity, FUN Exercise is recommended à Mental Distraction.
o NB: The opposite (Anxiety), requires long, slow, exercise à Calming.
• The longer the duration, the greater the benefit
• Exercise is As Effective as psychotherapy
§ Precautions:
• CVD risk factors
• Stage of change & motivation
• Must vary exercises, repetition leads to boredom.

o PA & Management of Cancers:

§ Benefits:
• Preservation/Improvement in Muscle Mass & Strength
• Preservation/Improvement of CV fitness
• Preservation/Improvement of Immune Function
• Preservation/Improvement Self-Esteem
• Decrease in side-effects & symptoms
• Decreased hospitalisation length, depression & anxiety
§ Recommendations:
• Large muscle groups (Moderate Daily Aerobic Exercise ≈ 20-30 min total)
§ Precautions:
• Swimming (Infection/catheters/wounds)
• Limited Balance/Coordination (eg. Treadmill, Yoga) when sensory neuropathy, dizzy.
§ Contraindications:
• On days of IV Chemotherapy.
• Platelets<50,000; WBC<3,000
• Unusual weakness/malaise, dehydration, nausea

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- Allied Health Professionals & Physical Activity:
o Exercise Scientists (3Yr Degree):
§ Mainly Involved in Disease PREVENTION in Healthy Patients:
• Kids/teenagers:
o • active after school program
o • sporting groups
• • Adults:
o • community projects (healthy hearts, 10,000 steps)
o • workplace health promotion (corporate challenges)
• • Elderly:
o • group exercise (aqua)
o Accredited Exercise Physiologists (4Yr Degree):
§ Mainly Involved in Management & Rehabilitation of Chronic Disease Patients:
• Musculoskeletal conditions
o Athletic/Workplace injury
o Osteoarthritis/Osteoporosis/Back pain
• Neurological conditions:
o Multiple Sclerosis, stroke, ABI, SCI, Epilepsy, Cerebral Palsy, Parkinsons
Disease
• Cardio-respiratory conditions:
o CVD, asthma, COPD, emphysema, cystic fibrosis
• Metabolic conditions:
o Obesity, diabetes
• Cancers
§ NB: AEPs Have Medicare Provider Numbers – Pts are covered.

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 CVS Pathology:
Congenital Heart Defects

Review of Foetal Circulation:

B passes Sh n s of foe al circ la or s s em
o Ductus Venosus
Shunts O2-Blood from Placental Vein IVC R-Atrium
Bypasses the Liver
o Foramen Ovale
Shunts O2-Blood from R-Atrium L-Atrium.
Bypasses the Lungs.
o Ductus Arteriosus
Shunts O2-Blood from Pul-Artery Aorta
Bypasses the Lungs
o ( All of these “shunts” are should close after birth due to pressure changes)
NB: The Foramen Ovale can take up to 6 months to close.

CONGENITAL HEART DEFECTS:

NB: 50- of Children ha e Innocen Hear M rm rs Red Flag = Murmur + Cyanosis/ Perfusion.
L R (Non-Cyanotic) Shunts (ASD, VSD, PDA)
o VSD = Commonest
R L (Cyanotic) Shunts (TETRALOGY & TRANSPOSITION)
Obstructive Defects (COARCTATION, Valvular Stenoses)

Genetic Associations:
- MARFAN S SYNDROME
o Autosomal Dominant Disorder
o CV-Defects: - (Mitral Prolapse / Tricuspid Prolapse / ASD / Others)
- DOWN S SYNDROME
o Trisomy 21
o CV-Defects: - (Valvular Malformations / ASD / VSD)

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Left Right (NON-Cyanotic) Shunts.
- PATENT DUCTUS ARTERIOSUS (PDA):
o = Malocclusion of Ductus Arteriosus after birth.
L R Shunt from Aorta Pulmonary Artery
Pulmonary Hypertension
o Clinical Features:
Murmur (Continuous, Harsh “Machinery-like” Murmur).
o Complications:
Soon After Irreversible Obstructive Pulmonary Vascular Disease (Pulmonary Vessel
Hypertrophy & Vasoconstriction Resistance SHUNT REVERSAL Cyanosis
o Investigations:
CXR (Pulmonary Congestion, Cardiomegaly)
ECG (LVH, RVH)
ECHO (Definitive)
o Management:
(*PDAs should be closed as early in life as possible)
Medical: Indomethacin (Prostaglandin Inhibitor)
(NB: In Cyanotic Heart Defects, Prostaglandin is actually Given to maintain a PDA)
Surgical: Surgical Ligation

- ATRIAL SEPTAL DEFECT (ASD):

o = Hole in the Interatrial Septum. (NB: NOT a patent Foramen Ovale)
Shunt from L-Atria R-Atria:
RV-Hypertrophy & Pulmonary HTN.
o Clinical Features:
Asymptomatic in Childhood (Symptom onset yrs).
Murmurs:
Diastolic ASD Murmur (During Atrial Contraction)
(Systolic Pulmonary Flow-Murmur (Hyperdynamic))
(Splitting of S2 (Delayed P2))
RV-Hypertrophy Parasternal Heave
o Complications are Rare, but Include:
CCF Pulmonary Oedema (Dyspnoea) + Peripheral Oedema, Ascites, etc.
Parado ical Embolisa ion (DVT Stroke)
o Investigations:
ECG (RV-Hypertrophy, RAxDev)
CXR (Pulmonary Congestion & Oedema)
ECHO (Definitive)
o Management:
Surgical Endovascular Closure of Defect

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- VENTRICULAR SEPTAL DEFECT (VSD):
o (*The Most Common Congenital Heart Disease)
o = Hole in the Interventricular Septum.
Shunt from L-Vent. R-Vent.
LV-Failure (CCF, Pulm.HTN, RV-Hypertrophy).
o Clinical Features:
Asymptomatic if Small (& Close Spontaneously)
Failure to Thrive if Large (& Requires Surgical Closure)
Murmurs:
Pansystolic VSD Murmur (+/- L-Sternal Thrill)
Pulmonary Valve Flow Murmur
CCF (Dyspnoea, Cough, Peripheral Oedema)
o Complications:
Initially a L-R-Shunt Pulmonary HTN RV-Hypertrophy
Later Irreversible Obstructive Pulmonary Vascular Disease SHUNT REVERSAL:
R-L Shunt ( O2 Blood Systemic Circulation Cyanosis/Death)
o Investigations:
CXR (Pulmonary Congestion, Cardiomegaly)
ECG (LVH & RVH)
ECHO (Definitive)
o Management:
Early surgical intervention is Critical for normal lifespan

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Right Left (CYANOTIC SpO2 <75%) Shunts
- TETRALOGY OF FALLOT C ano ic Hear Bl e Bab S ndrome
o 4 Features:
1. VSD
2. Overriding Aorta:
Aortic Valve sits above the VSD :. Connected to both the R & L-Ventricle.
3. Subvalvular Pulmonic Stenosis:
RV-Outflow Obstruction R-L-Shunt Hyopxemia/Cyanosis
4. R-Ventricular Hypertrophy:
Due to R-Vent. Worlkload
(5. Sometimes Patent Ductus Arteriosus)
o Clinical Features:
If Mild Pulm. Stenosis Resembles an isolated VSD. (L-R-Shunt) [Non Cyanotic]
If Severe Pulm. Stenosis R-L-Shunt
Chronic Cyanosis SpO2 <75%
Fingernail Clubbing
Polycythaemia RBC
Symptoms:
Blue Baby
Paroxysmal Tachypnoea
Irritability/Crying
o Complications:
“Paradoxical Embolism – (DVT Stroke)
Seizures
o Investigations:
ECG (RV-Hypertrophy)
CXR (Boot-Shaped Heart)
ECHO (Definitive)
o Management:
Medical:
Supp O2
B-Blocker
Surgical:
Definitive Repair

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- TRANSPOSITION OF GREAT VESSELS:
o = Aorta & Pulmonary Artery are switched.
(NB: Atrioventricular Connections are correct)
(NB: Venous Return is correct – IVC/SVC & Pulmonary Veins)
Hence, the Pulmonary & Systemic Circuits run in Parallel, rather than Series.
o NB: Incompatible with Post-Natal Life Unless a Shunt exists for Mixing of Blood:
Eg. TGV + VSD = Stable Shunt. (Adequate mixing)
Eg. TGV + Patent Foramen Ovale = Unstable Shunt (Tends to close).
o Clinical Features:
Severe Hypoxemia & Cyanosis
Blueness of skin & mucous membranes
Fingernail Clubbing
Polycythaemia RBC
o Complications
Prominent R-Ventricular Hypertrophy (R-V Pressure overload)
Atrophy/Thinning of L-Ventricle
o Investigations:
ECG (RAxDev, RVH)
CXR (Egg-Shaped Heart w. Narrow Mediastinum – “Egg on a string heart”)
ECHO (Definitive Dx)
o Management:
Prostaglandin Infusion (To maintain PDA & allow mixing of blood)
Surgical repositioning of Great Vessels
o Prognosis:
90% 1yr Mortality without Surgery.

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Obstructive Defects:
- COARCTATION OF AORTA
o = Narrowing/Constriction of the Aorta.
2M:1F
50% have Bicuspid Aortic Valve
o Pathophysiology 2 Types:
Preductal:
Proximal to Ductus Arteriosus
• R-L-Shunt (Pulm.Artery Aorta).
• Cyanosis of Lower Half of body.
Postductal:
Distal to Ductus Arteriosus.
• L-R-Shunt from Aorta Pulm.Artery
• Pulmonary HTN & CCF
o Clinical Features:
Symptoms:
Leg Claudication
NB: Presentation may take up to 10 years – As the Coarctation doesn’t grow with
the rest of the body Only symptomatic when peripheral demand > Aortic Flow.
Signs:
Upper limb BP > Lower limb BP.
RF-Delay
Cold Legs & CRT
Systolic Murmur
LV-Hypertrophy
o Investigations:
ABI - (Asymmetrical)
ECG (LV-Hypertrophy)
o Management:
Surgery – (Balloon Angioplasty & Stenting).

- AORTIC STENOSIS:
o = Narrowing/Obstruction of the Aortic Valve.
LV-Afterload Cardiac Output LV-Failure (Pul.HTN, Dyspnoea)
- PULMONIC STENOSIS:
o = Narrowing/Obstruction of the Pulmonary Valve OR Artery.
RV-Afterload Pulmonary Output RV-Failure (Peripheral Oedema)

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 Week 11
CardioVascular Medicine Notes
Congenital Heart Defects

Basics of Foetal Development of the Heart:

- Begins at Wk 3 of Gestation
- Why? Because by this stage, the foetus is too large for nutrient/gas exchange to be via simple diffusion.
o Therefore, an active nutrient/gas distribution system is needed for continual growth of Foetus.
- Beating occurs @ week 4/5

- The “Cardiac Tube”:

o The primordial tubular heart in the embryo, before its division into chambers.

o This cardiac tube begins to fold & twist on itself until it is laid out in the basic heart-like structure.

- Septation:
o Between 4-6 weeks

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Foetal Circulation:
• Foetal circulation is different from neonatal circulation.
o Has to integrate circulation of placenta.
o Blood flow to non-functional lungs & liver are partially bypassed.
• “Bypasses” / “Shunts” of foetal circulatory system:
o Ductus Venosus
§ Directs the oxygenated blood from the placental vein into inferior vena cavaàheart
§ Partially bypasses the liver sinusoids
o Foramen Ovale
§ An opening in the interatrial septum loosely closed by a flap of tissue.
§ Directs some of blood entering the right atrium into the left atrium à Aorta.
§ Partially bypasses the lungs.
o Ductus Arteriosus
§ Directs most blood from right atrium of the heart directly into aorta
§ Partially bypasses the lungs
o **All of these “shunts” are occluded at birth due to pressure changes.
§ NB: The Foramen Ovale can take up to 6 months to close.
• NB: At Birth, the Pulmonary Vascular Resistance Falls Due to:
o 1. Mechanical Inflation à Increased Radial Traction of Vessels
o 2. Vasodilation – due to ↑Oxygen-Tension in the Lungs

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 Types of Congenital Heart Defects:

Septal Defects:
- A hole in the septum (Either Atrial/Ventricular) Leading to the Mixing of Blood from one side to the other.
o This ‘mixing’ (shunt) typically occurs from Left to Right (Due to Higher L-Heart Pressure)
o However, the shunt may reverse to RightàLeft (If Pulmonary Blood Volume Reaches a Critical Level)
- Treatment: Direct suture closure with a pericardial/synthetic patch.

• Atrial Septal Defects:

o Opening in the Inter-Atrial Septum – Usually at the level of the Foramen Ovale.
o NB: This is different from a ‘patent foramen ovale’ (Normal for up to 6-12 months old) in that an
‘Atrial Septal Defect’ is just a hole, not a flap.
o Leads to: Oxygenated Blood is shunted from the L-Atrium to the R-Atrium.

• Ventricular Septal Defects:

o Opening in the Inter-Ventricular Septum – Vary greatly in size.
§ Most smaller shunts close spontaneously by 2 yrs.
§ Larger shunts tend to remain open
o Leads to: Blood shunted from L-Ventricle to R-Ventricle àIncreased output to Pulmonary Circulation
§ Can result in Pulmonary Hypertension à R-Heart failure & Hypertrophy
à The Shunt may Reverse à Causing Deox. Blood to
flow into L-Ventricle (Therefore Systemic Circulation) à Systemic Cyanosis.
(Eisenmenger Syndrome)

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Patent Ductus Arteriosus:
- Where the Foetal Shunt that connects the Pulmonary Artery to the Aorta Doesn’t Close off.
o Normally, Rising O2 Tension & Decreasing Prostaglandins cause it to Close.
- Leads to: Shunting of Oxygenated (Aortic) Blood back into the Pulmonary Artery (Deox) à Lungs.
o NB: In Utero, Blood flows the other way (From the Pulmonary Artery to the Aorta)

Valvular Stenosis:
- Aortic Stenosis:
o Narrowing/Obstruction of the Aortic Valve.
o Typically presents as a Bi-Leaflet, instead of the normal Tri-Leaflet Formation.
o Most common in males.
o Leads to: Increased Afterload à ↑L-Ven. End Systolic Volume à ↓Cardiac Output à Hypotension
(↓Cardiac Output à Backup of Blood in Lungs à Pul.Congestion)
à L-Ventricular Hypertrophy à Possibly Left Heart Failure

- Pulmonic Stenosis:
o Narrowing/Obstruction of the Pulmonary Valve OR Artery.
§ 90% = Valvular
§ 10% = Elsewhere in the Pulmonary Artery
o Leads to: Increased Afterload à ↑R-Ven. End Systolic Volume à ↓Pulmonary Output
(↓Pulmonary Output à Backup of Blood in Body à Syst.Oedema)
à R-Ventricular Hypertrophy à Possibly Right Heart Failure

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Coarctation of the Aorta:
- Narrowing of the Aortic Lumen Either Before or After the Ductus Arteriosus.
o “Preductal” Coarctation of the Aorta
o “Postductal” Coarctation of the Aorta
- Leads to: Increased Afterload à ↑L-Ven. End Systolic Volume à ↓Cardiac Output à Hypotension
(↓Cardiac Output à Backup of Blood in Lungs à Pul.Congestion)
à L-Ventricular Hypertrophy à Possibly Left Heart Failure
àDecreased Perfusion to Abdominal Organs & Lower Limbs.
- NB: Clinical Presentation may take up to 10 years – Due to the fact that the Coarctic bit doesn’t grow, while
the rest of the heart grows around it. Hence, it only presents itself when the body’s demand for increased
cardiac output exceeds the flow rate of the Aorta.
- Treated By: Surgery or Balloon Angioplasty & Stenting.

Preductal Coarctation Postductal Coarctation

Tetrology of Fallot:.
- Consists of 4 Abnormalities:
o 1. Ventricular Septal Defect
o 2. Subvalvular Pulmonic Stenosis
o 3. R-Ventricle Hypertrophy (Due to Pulmonic Stenosis)
o 4. Overriding Aorta (Valve sits over the Vent.Septal Defect – ie. Receives Blood from Both Ventricles)
- Most Common Cause of CYANOSIS after Infancy.
- Symptoms:
o Cyanosis
o Irritability
o Hyperventilation (Due to Cyanosis–low [O2] stimulates peripheral chemoreceptors à ↑Respirations)
o Occasional Syncope (Fainting)
o Occasional Convulsion
- Symptoms Alleviated by Increasing Systemic Vascular Resistance:
o Eg. By squatting (kinking femoral artery)
o à Means more blood being ejected via the Pulmonary Artery à Better Oxygenation.

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Transposition of the Great Vessels:
- Where the Aorta comes off the R-Ventricle & the Pulmonary Artery comes off the L-Ventricle.
- Hence, the 2 Circuits (Pulmonary & Systemic) are running in Parallel, rather than Series.
o Pulmonary Circuit:
§ L-Vent. Blood à Pulmonary Artery à Lungs à Pulmonary Vein à L-Atrium à L-Vent.
o Systemic Circuit:
§ R-Vent. Blood à Aorta à Systemic Circulation à Vena Cavae à R-Atrium à R-Vent.

- The Most Common Cause of Cyanosis (“Blue Babies”) during Infancy

- Leads to:
o Severe Hypoxia & Cyanosis
- Typically Incompatible with Life:
o 30% die within a week
o 90% die within a year
- The Baby May Survive If:
o 1. The Foramen Ovale Remains Patent...and
o 2. The Ductus Arteriosus Remains Patent
o – These shunts maintain some communication between the parallel circuits à may prolong life.
o – Therefore the doctor may give Prostaglandins to Maintain Patency of the Ductus Arteriosus as a
short-term treatment until surgery is available.
- Treatment (Surgery):
o Atrial Switch (Mustard/Senning Procedure):
§ Where the Systemic Venous Blood is diverted to the Left Atrium à L-Ventricle à Lungs.
§ And the Pulm-Venous (Oxy) Blood is diverted to the R-Atrium à R-Ventricle à Aorta
§ - The Disadvantage = The R-Heart becomes responsible for Systemic Circulation (which it is
not designed to do)
o Arterial Switch:
§ Where the Pulmonary Artery & Aorta are switched.

Atrial Swich Operation Arterial Switch Operation

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 Marfan’s Syndrome:

- Autosomal Dominant Disorder

- Common CV Abnormalities
o Mitral Valve Prolapse - (L-AV Valve) this can lead to a mitral valve regurgitation. (blood will flow back
from the ventricle to the atrium)
o Tricuspid prolapse
o ASD
o Many More.....

Down’s Syndrome:

- 40% of Down’s Syndrome Patients have congenital Heart Defects

- Common CV Abnormalities:
o Atrio-Ventricular Canal - (Incomplete formation of AV Valves)
o Atrial Septal Defects
o Ventricular Septal Defects

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 CVS Pathology:
DVT & PE

DEEP VEIN THROMBOSIS “PHLEBOTHROMBOSIS” “THROMBOPHLEBITIS” :

- Aetiology:
o **Deep Venous Valve Incompetence of Lower Limbs:
Blood Stasis Thrombosis
o + **Prolonged Immobilisation:
Blood Stasis Thrombosis
o +Risk Factors:
“Virchow’s Triad”
1. Vessel Damage:
o Surgery/Smoking/Hypertension
2. **Stasis
o Flight/Long Travel/Prolonged Bedrest/Surgery
o Obesity/Pregnancy/Congestive Heart Failure
o Post Operative
3. Hypercoagulabiltiy
o Cancer (Eg. Adenocarcinoma Paraneoplastic Syndrome)
o Congenital: Eg. Antithrombin III Def./Factor 5 leiden
o Drugs: Eg. Oral Contraceptive/HRT
o Hyperviscosity: Eg. Pregnancy/Polycythaemia
- Pathogenesis:
o Failure/Inactivity of the Venous Calf Pump (Immobility/Valve Insufficiency)
Blood Stasis & Pooling in Leg Veins Coagulation Thrombosis
- Clinical Features:
o Symptoms:
Localized Symptoms (Typically in Calf):
Tenderness (Elicited by Pressure/Passive Dorsiflexion)
Heat, Redness, Swelling
Distal Oedema
Distal Cyanosis
Superficial Venous Dilation
**Pulmonary Embolism – May be the 1st Manifestation:
Thromboembolism into Pulmonary Artery Biventricular Heart Failure
o Sudden Chest pain, Dyspnoea, Haemoptysis, Collapse, Death.
- Investigations:
o Duplex Doppler USS (93% Sensitive; 98% Specific)
- Management:
o **Heparinization (LMW-Heparin) 1wk
Then Convert to Warfarin 6mths
o +/- Thrombectomy
o +/- IVC Filter (To Prevent Pulmonary Embolus)

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PULMONARY EMBOLISM
- Aetiology:
o 95% = DVT Thrombo-Emboli
- Pathogenesis:
o DVT Thrombo-Emboli Lodges in Pulmonary Arteries
1. VQ-Mismatch Respiratory Compromise (Respiratory Failure)
2. ↑Pulm.Vas.Resistance Haemodynamic Compromise (Heart Failure).
- Clinical Features:
o Severity Depends on Size/Number of Emboli (Extent of Obstruction)
o If Severe Instant Death!! (Due to sudden Cardiac Failure)
o Symptoms
Pleuritic Chest Pain (+ Pleural Rub)
Dyspnoea/Tachypnoea
Cough/Haemoptysis
(+ DVT Symptoms)
o Signs:
RV-Failure (↑JVP, Tricuspid Regurg)
Shock/Syncope
Fever
- Diagnosis:
o **CTPA (CT-Pulmonary Angiogram): Shows Large Emboli lodged in Major Pulmonary Artery
o ECG: Classical S1Q3T3 Pattern
o VQ Scan: Shows VQ Mismatch
o CXR (Later >1day): Shows Wedge-Shaped Pulmonary Infarct
- Treatment:
o Give Oxygen
o **Heparinization (LMW-Heparin) 1wk
Then Convert to Warfarin 6mths
o TPA-Thrombolysis (If Haemodynamic Compromise)
o (+/- Trombectomy & IVC Filter)
- Prevention (in High Risk Individuals):
o Elastic/Compression Stockings
o Anticoagulation
o If Severe Risk, Insertion of a IVC-Filter

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 VASCULAR - ARTERIAL DISEASES . . . CONT.

RUPTURED ABDOMINAL AORTIC ANEURYSM (RAAA)

❏ narrow window of opportunity
❏ usually present with classical diagnostic triad (50% cases)
• sudden abdominal or back pain
• SHOCKY (Hypotensive, faintness, cool, mottled extremities)
• pulsatile mass
❏ may be confused with renal colic
❏ ECG confusing - may show cardiac ischemia
❏ diagnosis by history and physical
❏ do not waste time in radiology if RAAA strongly suspected
❏ if patient stable without classic triad ––> consider CT
❏ management
• initial resuscitation including vascular access, notify OR,
• ensure availability of blood products, invasive monitoring
• emergency laparotomy as soon as IV and cross-match sent
• upon opening - gain centre of aorta proximal to rupture with cross clamp
❏ prognosis
• 50% survival for patients who make it to OR
• 100% mortality if untreated
• overall mortality 90%
CAROTID SURGERY (see Neurosurgery Chapter)

VASCULAR – VENOUS DISEASE

ANATOMY
❏ the venous system is divided into 4 general areas
• superficial venous system (subcutaneous veins and the greater and lesser saphenous veins)
• communicating venous system (perforating veins)
• deep venous system (tibial, popliteal, femoral and iliac veins)
• venous valves (in all infra-inguinal veins)
DEEP VENOUS THROMBOSIS (DVT) (ACUTE)
❏ occlusion of the deep venous system, typically of the lower extremity that can extend up to the right atrium.
❏ pathogenesis (Virchow's Triad)
❏ flow stasis
❏ postulated that stasis protects activated pro-coagulants from circulating inhibitors,
fibrinolysis and inactivation in the liver
❏ surgery
❏ trauma and subsequent immobilization
❏ immobilization due to: acute MI, stroke, CHF
❏ compression of veins by tumours
❏ shock (decreased arterial blood flow)
❏ hypercoagulability
❏ states that increase coagulability of the blood (ex. Increased fibrinogen or prothrombin) in which there is a
deficiency of anti-coagulants (anti-thrombin III, Protein C+S), e.g.
• pregnancy
• estrogen use
• neoplasms: diagnosed, occult, undergoing chemotherapy
• tissue trauma: activation of coagulation
• nephrotic syndrome
• deficiency of anti-thrombin III, protein C or S
• endothelial damage
❏ exposure of the underlying collagen in a breach of the intimal layer of the vessel wall leads to
platelet aggregation, degranulation and thrombus formation. There also appears to be a
decrease endothelial production of plasminogen and plasminogen activators, e.g.
• endothelial damage: venulitis, trauma
• varicose veins
• previous thrombophlebitis

MCCQE 2002 Review Notes Cardiac and Vascular Surgery – CVS27

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 VASCULAR - VENOUS DISEASE . . . CONT.

❏ signs and symptoms

• most frequent site of thrombus formation is calf
• isolated calf thrombi often asymptomatic
• 30-50% are asymptomatic or minimal symptoms
• 20-30% extend proximally and account for most clinically significant emboli
• classic presentation < 1/3
• calf/thigh discomfort, edema, venous distension
• investigations (refer to PIOPED study for details)
• history and physical
• calf tenderness (if elicited on ankle dorsiflexion = Homan’s sign)
• wider circumference of affected leg
• fever POD #7-10
• clinical assessment incorrect 50% time, therefore must confirm by objective method
• non-invasive tests
• duplex doppler U/S
• 93% sensitive and 98% specific for symptomatic patients, decreased for asymptomatic patients
• detects proximal thrombi
• initial negative exam should be repeated 6-7 days later to detect proximal extension
• invasive testing
• ascending phlebography (venogram)
• the gold standard but costly
• detects distal and proximal thrombi
• complicated by contrast-induced thrombosis of peripheral veins (2-3%)
❏ management
• goals of treatment
• prevent formation of additional thrombi
• inhibit propagation of existing thrombi
• minimize damage to venous valves
• prevent pulmonary emboli (PE)
• 25% develop PE if untreated; 5% if treated
• aggressive medical management
❏ treated as outpatient
❏ fragment / low molecular weight heparin (LMWH)
❏ coumadin
❏ advantage: avoid hospitalization
• conservative medical management
• IV heparin, 5,000 U bolus + 1,000 U/hr to keep aPTT 2-2.5x control
• convert to warfarin 3-7 days after full heparinization; warfarin for 3-6 months
• risks of therapy - bleeding, heparin-induced thrombocytopenia, warfarin is teratogenic
• surgical
• venous thrombectomy - if arterial insufficiency with extensive iliofemoral thrombosis,
+/– venous gangrene
• inferior vena cava (IVC) (Greenfield) filter- inserted percutaneously, indications:
• recurrent PE despite anticoagulation
• contraindication to anticoagulation e.g. intra-cranial trauma
• certain operations for cancer, pulmonary embolectomy
• septic emboli refractory to combination antibiotic and anticoagulation
• "free-floating" thrombus loosely adherent to wall of IVC or pelvic veins
• IVC ligation, surgical clips - increases risk of venous insufficiency; rarely used
❏ DVT prophylaxis
• conservative
• minimize risk factors
• early ambulation, passive range of motion
• anti-embolism stockings
• pneumatic sequential compression devices
• elevation of limb
• medical prophylaxis
• optimize hydration to prevent hemoconcentration
• ECASA, warfarin, minidose heparin(5,000 U SC q8-12h) in high risk situations
❏ complications
• pulmonary embolus (PE)
• varicose veins
• chronic venous insufficiency
• venous gangrene
• phlegmasia cerulea dolens (PCD) - massive DVT with clot extension to iliofemoral
system and massive venous obstruction resulting in a cyanotic, immensely swollen,
painful and critically ischemic leg
• risk venous gangrene
• phlegmasia alba dolens (PAD) - as above with additional reflex arterial spasm
resulting in less swelling than PCD
• cool leg and decreased pulses
CVS28 – Cardiac and Vascular Surgery MCCQE 2002 Review Notes

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 CVS Pathology:
Dyslipidaemia

DYSLIPIDAEMIA:
- Dyslipidaemia = a blanket term for Elevated Blood levels of Fats (cholesterol and/or triglycerides).
- Review of physiology of cholesterol and other lipids:
o Five Lipid Transporters:
1. Chylomicrons Made by Small Intestine:
Transport Dietary Fats from SI Liver (Via Lymph).
Ver Lo Densit Lipoproteins VLDL s Made by Liver:
Transports Fats from Liver Tissues.
Intermediate Densit Lipoproteins IDL s Made by Liver:
Essentially a VLDL with some lipid and protein removed.
4. Low Density Lipoproteins (LDL s) BAD
Delivers Cholesterol to Liver and Tissues.
NB: Fat Consumption [LDL] ATHEROSCLEROSIS.
5. High Density Lipoproteins GOOD
Cholesterol Re-Uptake from Tissues Liver
- Aetiologies:
o Primary Hyperlipidaemias (Genetic):
Eg. Familial Hyperlipidaemia
Eg. Lipoprotein lipase deficiency
o Secondary Hyperlipidaemia (Acquired):
Eg. Obesity
Eg. Hypothyroidism
Eg. Diabetes mellitus
Eg. Nephrotic syndrome
Eg. Liver Failure
Eg. Drugs: (eg. Oral contraceptives/Retinoids/thiazide diuretics)
- Diagnosis & Screening (for high risk Pts):
o FamHx of CVD/IHD/MI/ Cholesterol
o Physical Signs (Xanthomata, Xanthelasma)
o Comorbidities (Eg. Obesity, Diabetes, HTN, Hypothyroid).
- Investigations:
o Serum TGLs - (Normal = <2mmol/L):
*>6mmol/L Requires Intervention - (<6mths Lifestyle Modification Statin Therapy).
o Cholesterol - (Normal = <4mmol/L):
*>6.5mmol/L Requires Intervention - (<6mths Lifestyle Modification Statin Therapy).
(Target = <4mmol/L total cholesterol or LDL-CK less than 1.8mmol/L)
- Management:
o **1. Lifestyle Modification:
Diet ( Sat.Fat/Cholesterol Intake, Fibre intake, Alcohol, Smoking, Weight Loss)
Exercise
o **2. Pharmacological:
**Statins (HMG-CoA Reductase Inhibitors):
Classical Agents: (Simvastatin, Atorvastatin)
MOA: HMG-CoA Reductase Inhibitor Cholesterol Synthesis
Side Effects:
o Statin-Induced Myopathy/Myositis/Rhabdomyelosis Muscle
Pain/Weakness + CK-Levels
o (Other Lipid-Lowering Agents (Only Recommended If CHD or Intolerant to Statins)):
*Fibrates: (Fenofibrate)
Bile Acid-Binding Resins (Ion Exchange Resins): (Cholestyramine)
Ezetimibe: (Ezetimibe)
Fish Oil (Omega-3) Prophylactic?

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 CVS Pathology:
HEART FAILURE
HEART FAILURE:
- Insufficient Cardiac Output to meet the demands of the body Organ Perfusion
- NB: 30% die within 1yr of Dx.
Where is the Failure?:
- Myocardial Failure (Ie. Systolic/Diastolic Dysfunction (Heart Muscle Itself) Pumping Function):
o (Eg. Ischaemic Heart Disease, Myocarditis, Cardiomyopathies, etc.)
- Valvular Heart Failure (Ie. A problem with the Heart-Valves Pumping Function):
o (Eg. Stenosis/Regurgitation)
- Circulatory Failure - (Ie. Defect in the Peripheral Circulation Vascular System Dysfunction):
o (Eg. Haemorrhage/Shock)

What side is the Failure?

- Left Heart Failure (LSHF):
o = L-Ventricle CO into Systemic Circulation
o Common Causes:
Systolic Failure: Weak LV (IHD, Dilated Cardiomyopathy, Alcoholism, Myocarditis)
Diastolic Failure: Stiff LV (Eg. Amyloidosis, Sarcoidosis, Hypertrophic Cardiomyopathy).
Valve Dysfunction: (Aortic Stenosis/Regurg, Mitral Stenosis/Regurg)
Excessive Afterload: (Eg. HTN, Coactation of Aorta, Dissecting AAA)
o Consequences & Clinical Features:
Pulmonary Congestion CCF Cough/Dyspnoea/Or hopneoa P can lie fla /PND.
CO (Kidneys Pre-Renal Failure), (Brain Irritability, ALOC)
LV-Hypertrophy Initially Adaptive, then Weakens Worse LV-Failure
- Right Heart Failure (RSHF):
o = R-Ventricle CO into Pulmonary Circulation
o Common Causes:
Isolated RHF is Rare (Typically caused by LSHF, Aka. “Cor Pulmonale )
“Cor Pulmonale : LSHF Pulmonary Hypertension RSHF.
o Consequences & Clinical Symptoms:
Pulmonary Congestion CCF Cough/Dyspnoea/Orthopneoa P can lie fla /PND.
PLUS Systemic Congestion Peripheral Oedema/Organomegaly/Pleural Effusion/Ascites
Signs of Cardiac Output:
- Thready Pulse (Due to Low Arterial Pressure)
- Tachycardia (A Compensatory Mechanism)
- Exercise Intolerance (Due to Ti e Perf ion & Pulmonary Congestion)
- Dyspnoea (Due to In Pulmonary Congestion)
- Peripheral Oedema (Venous Overload)
The Body’s Responses to Heart Failure:
- Short Term (Adaptive):
o Peripheral Shutdown (To maintain BP of Vital Organs. Af erload
o Salt & H2O Retention To Blood Vol me Preload
o Preload To S roke Vol me
o Sympathetic Tone To Hear Ra e Ejec ion
o Hypertrophy To M cle Ma o Con rac ile S reng h
- Long Term (Maladaptive):
o Peripheral Shutdown Afterload L-Heart Failure
o Salt & H2O Retention Fluid Overload Pulmonary & Peripheral Oedema
o Hypertrophy Myocardial Ischaemia + Diastolic Failure
Investigations:
- B-Natriuretic Peptide (BNP) (If >500 = Heart Failure)
- CXR (Pulmonary Congestion/Oedema, Cardiomegaly, Effusions)
- ECG (Dx Previous/Current IHD, Rule out Arrythmias)
- Echocardiogram (TOE/TTE) (Assess Ventricular Function [Ejection Fraction])
- +(FBC [Anaemia/Infection], UEC, eLFT [Alcohol], TSH [Hyperthyroid], Lipids [IHD], BSL/HbA1c [Diabetes])

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 Week 9
CardioVascular Medicine Notes
Heart Failure

Heart Failure:
- Where an abnormality in cardiac function à poor cardiac output à isn’t enough to supply the demands of
the body à low perfusion of organs à hypoxia etc.
- Ie. The heart can’t maintain circulation to tissues for normal metabolism.

Revision of Cardiac Output

- Cardiac Output = Heart Rate x Stroke Volume
§ = End Diastolic Volume – End Systolic Volume
§ ≈ 70mL/min
o Heart Rate Determined by:
§ Chronotropic Factors
§ Autonomic Nervous System
o Stroke Volume Determined by:
§ Contractility (NB: a direct effect of Ca+ at the cellular level.)
§ Preload (Degree of Ventricular Filling During Diastole. High à ↑SV)
§ Afterload (ie. Resistance to Ventricular Ejection (ie. Due to ↑Aortic Blood Pressure)
- ‘Ejection Fraction’: % of the End Diastolic Volume that is Ejected in Systole.
o Stroke Volume/End Diastolic Volume
o ≈60%

Types of Failure:
- Heart Failure:
o Failure of the Heart as an organ to pump enough blood to satisfy the Periphery.
o Myocyte Function May Be Normal.
§ Eg. Heart Valve Failure:
• Ie. A problem with the Heart-Valves
• Eg. Valve Incompetence/Regurgitation
• Eg. Valve Stenosis (Narrowing)
• Result = Changes in Preload/Afterload à Altered Cardiac Output
- Myocardial Failure:
o Ie. Defect in Myocardial Contration (Heart Muscle Itself)à Leads to deficit in Pump Function
o Eg. Myocyte Death Due to Infarction à↓Myocyte Mass
o Result = Decreased/Altered Pump Function
- Circulatory Failure:
o Ie. Defect in the Peripheral Circulation
o Eg. Haemorrhage/Shock/Cardiogenic Shock/Hypoxia
o Result = Reduced Peripheral Perfusion
- Congestion:
o Peripheral or Pulmonary Oedema - Due to:
§ Inadequate Pumping of the Heart
§ High Heart-‘Filling’
§ High Venous Pressures à Backlog
§ Ie. When one side of the heart isn’t ‘pulling its weight’àBackglog

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Forward/Backward Heart Failure:
- Forward Heart Failure:
o Reduced Output due to Inadequate Discharge of Blood into Arterial System.
- Backward Heart Failure:
o Where One/Both Ventricle
§ 1. Fails to Discharge its Contents OR
§ 2. Fails to Fill Normally
o Results in ↑Atrial Pressure + ↑Pressure in Venous System Behind the Failing Ventricle.
- NB: Most Patients Have Both (Because Blood Flows in a Circle)
o Eg. Forward Heart Failure à Low Cardiac Output à Less Venous Return à Backward Heart Failure.

Left/Right Heart Failure:

- Left Heart Failure:
o Inability of L-Heart to Pump into Systemic Circulation
o What Happens:
§ Heart Tries to Compensate by Pumping Harder
§ àL- Heart Becomes Weaker
§ à ↑L-Ventricular End Systolic Volumes
§ à ↑L-Ventricular End Diastolic Volumes
§ à ↑L-Atrial Pressure
§ à ↑Pulmonary-Vein Pressure
§ à Shortness of Breath (Dyspnoea) & Pulmonary Oedema
§ à Fatigue

- Right Heart Failure:

o Inability of R-Heart to Pump into Pulmonary Circulation
o What Happens:
§ Blood Backs-Up in Peripheral Circulation
§ à ↑Venous Pressure
§ à Peripheral Oedema (Especially Legs & Abdominal Organs (Mainly Liver))
• & Renal Insufficiency (Due to ↓Perfusion of Kidneys) – Hence Renal & Heart Failure
go hand in hand.
§ Ie. A Congestive Heart Failure

- NB: L-Failure can lead to R-Failure:

o Eg. L-Failure à Pulmonary Hypertension à ↑Afterload on R-Ventricle à R-Ventricular Failure.

Signs of ↓Cardiac Output:

- Low Arterial Pressure (Due to weaker heart muscle)
- Tachycardia (A Compensatory Mechanism)
(Due to [Carotid/Aortic] BaroReceptor-Reflex In Response to ↓BP)
(Also due to the ↑Venous Pressure of Systemic Backlog (↑Systemic Blood Volume)
àAtrial Stretchà Bainbridge Reflex à Vagal (Parasympathetic) Withdrawal à↑HR)
- Exercise Intolerance (From ↓Tissue Perfusion)
- Difficulty Breathing (eg. In Pulmonary Congestion)
- Peripheral Oedema (eg. Due to R-Sided Heart Failure)

New York Heart Association – Grading of Heart-Failure Symptoms:

- 5 Classes

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The Body’s Responses to Heart Failure:
- Short Term (ie. Acute Heart Failure):
o Mainly Adaptive:
§ Vasoconstriction (To maintain BP of Vital Organs. à ↑Afterload)
§ Salt & H2O Retention (To ↑Blood Volume à ↑Preload)
§ Increased Preload (To ↑ Stroke Volume)
§ ↓Parasympathetic (To ↑ Heart Rate & Ejection)
+ ↑ Sympathetic
§ Increased HR (To ↑ Cardiac Output)
§ Hypertrophy (To ↑ Muscle Mass to ↑ Contractile Strength)

- Long Term (ie. Chronic Heart Failure/Congestive Heart Failure):

o Mainly Maladaptive:
Over a long period, the Heart simply Can’t maintain the compensatory mechanisms of increasing CO.
§ Vasoconstriction à L-Heart Failure + ↑Myocardial Oxygen Consumption (MVO2)
§ Salt & H2O Retention à Pulmonary / Peripheral Oedema
§ Increased HR à ↑Energy Demand
§ Hypertrophy à Myocyte Energy Starvation + Impaired Relaxation

3 Compensatory Mechanisms:
- 1. Frank-Starling Law/Mechanism:
o “↑Preload à ↑Stroke Volume”
o Incomplete Chamber Emptying à↑PRELOAD à ↑Cardiac Output BY ↑STROKE-VOLUME.
o BENEFICIAL in Short-Term
o DETRIMENTAL in Long-Term
§ Ie. In Severe Heart Failure, Starling Curve is Flatter than normal.
§ àEven large Increase in End-Diastolic Volume has Little Effect on Stroke Volume & CO.
§ Also, ↑Vent-EDV à ↑Atrial Pressure à ↑Pulmonary Pressure

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- 2. Myocardial Hypertrophy:
o Pressure Overloaded Hypertrophy:
§ In response to ↓Cardiac Output: When↓CO is due to ↑↑Afterload (↑Arterial Pressure)
§ “Concentric Hypertrophy”: Muscle Thickens – Due to Synthesis of Sarcomeres in PARALLEL.
o Volume Overloaded Hypertrophy:
§ In response to ↑Volumes:
§ Ie. ↑EDV à Ventricle Stretches (Dilates) à Cannot Generate Enough Force to Pump Blood.
§ “Eccentric Hypertrophy”: Heart Balloons Out – Due to Synthesis of Sarcomeres in SERIES.

o Increased Ventricular Mass = Cell Hypertrophy (↑Size) & Hyperplasia (↑Numbers).

§ Helps Maintain CO
§ Helps Reduce Wall Stress (By Increasing Thickness & Radius of Ventricle)
§ To Increase Contractility BUT Doesn’t Work!
• Heart becomes Rounder & Larger
• Muscles Thicken, Lose Elasticity & Stiffen à Hard to relax.
o àDecreased Compliance à ↑ESV à ↑Atrial Pressure à ↑Pul.Pressure.
• Ventricle Stretches (Dilates) à Cannot Generate Enough Force to Pump Blood.
• Cells Actually Become WEAKER!

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- 3. Neurohormonal Systems:
o Nor-Adrenaline/Epinephrine:
§ Baroreceptors sense ↓CO as ↓Perfusion-Pressure àStimulates Sympathetic:
• à↑ Heart Rate
• à↑ Contractility
• à↑ Vessel Tone à To Increase Venous Return
• à↑Preload (àSV àCO)

o Renin-Angiotensin-Aldosterone System (RAAS)/Anti-Diuretic-Hormone Release:

§ Due to ↓Renal Perfusion-Pressure à Stimulates Renin Secretion from Juxtaglomerular Cells.
• àVasoconstriction (Angiotensin-II = Potent Vasoconstrictor)
• à↑Fluid Retention (Increases Intravascular Volume)
• à↑Blood Pressure
• à↑Preload (àSV àCO)

o Atrial Natriuretic Peptide:

§ Produced by Heart – But has NEGATIVE effects.
§ Released due to High Filling Pressures (within heart) – Via L-Atrial & Arterial Baroreceptors.
§ Important INDICATOR of Heart Failure
§ Function: à Reduce Fluid Retention (ie. Diuretic)
• àVasorelaxation
• à↓BP Therefore Inhibits RAAS.
• à↑Renal Excretion (Na+ & H2O)

o NB: The Neurohormonal Compensatory Mech = Viscious Cycle:

§ Strain on heart à Activation of Neurohormonal Mechanisms à↑Preload & BP à Extra
Strain on the heart.
§ Heart Responds by Remodelling à Larger & Rounder à Weaker.

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Management of Chronic CCF:
- 1. Correct Systemic Factors & Comorbidities (Eg. Thyroid, Infection, Diabetes, COPD)
- 2. Lifestyle Mods ( Smoking/Alcohol, Weight Loss)
- 3. Fluid Restriction - Sal In ake Fl id Restriction, Daily Weights)
- 4. Antihypertensives ( Preload & :. CO :
o ACE Inhibitors (Perindopril)/ARBs (Candesartan):
MOA: AT-II Va odila ion Fl id Re en ion SNS Preload Afterload
Dose: Start Low &Go Slow.
(Side Effects: Persistent Dry Cough, Postural Hypotension, K+, Renal Impairment)
o β-Blockers (Carvedilol, Metoprolol, Bisoprolol):
MOA: Workload of Heart (+ Preload Cardiac Output) & Triggers Remodelling.
(Side Effects: Postural Hypotension, Dizziness)
- 5. Diuretics ( Fluid Overload):
o Loop Diuretics (Fr emide La i )
o [IF SEVERE] Aldosterone Antagonists (Spirinolactone) (Also K+ Sparing)

- (+/- Digoxin to Contractility ; or Rate Control in AF) (Symptomatic Improvement, but no Mortality)
- (+/- Oxygen if SpO2 <88%)
- (+/- Vasodilators Eg. Hydralazine / Nitrates)
- (+/- Internal Cardiac Defibrillator as 50% of mortality is due to sudden lethal arrhythmias)

Management of Acute, Decompensated CCF:

- As Above (ACEi + B-Blocker)
- + Diuretics (Frusemide)
- + Digoxin (For Inotropic Support)
- +/- Nitrates

Complications:
- Sudden Lethal Arrhythmias (VT/VF) Death
- Acute (Cardiogenic) Pulmonary Oedema (See CVS PATH Acute Cardiogenic Pulmonary Oedema)

Other Info:

-
- NYHA Functional Classification:
o Class I: No Limitation in ANY Activities; (Asymptomatic)
o Class II: Slight Limitation of Activity; (Asymptomatic with Mild Exertion).
o Class III: Marked Limitation of Activity; (Comfortable ONLY @ Rest).
o Class IV: Symptoms Occur at Rest or with ANY Physical Activity.

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 CVS Pathology:
Hypertension
HYPERTENSION:
- What is it?:
o Consistent Systolic of +140mmHg. AND/OR
o Consistent Diastolic of +90mmHg

- Aetiologies & Types:

o Primary “Essential” Idiopathic Hypertension:
Idiopathic Likely multifactorial (not curable)
Risk factors for HT:
GENETICS/FamHx
High Cholesterol/Salt Diet
Diabetes/Obesity
Smoking/Alcohol
Stress
Age
Subtypes:
Isolated Diastolic HTN (Typically Older Men)
Isolated Systolic HTN (Eg. >160/<90)
o In Young Adults (Due to Overactive Sympathetic NS CO)
o In Older Adults - (Due to Arterial Compliance (Calcification/Fibrosis))
o 5% = Secondary Hypertension:
Cardio - Coarctation, Hypervolaemia, Rigid Aorta
Renal - Acute Glomerulonephritis, CKD , Polycystic Kidneys, Renal Artery Stenosis
Endocrine Hyper-Adrenalism, Acromegaly, Hypo/hyperthyroidism, Phaeo C hing .
Neurologic - Psychogenic, Raised ICP, Sleep Apnea, Acute Stress
Pre-Eclampsia: (10% of pregnancies) - Placental Ischaemia Placental vasoactive
mediators Ma e nal BP in effo o Placen al Pe f ion
o Accelerated “Malignant” Hypertension :
= Rapid in BP (>200/120mmHg) Sufficient to cause Vascular Damage
Retinopathy (Papilloedema, Haemorrhages, Bulging Discs)
Brain (Mental Status Changes)
Renal (Creatinine Rise)
Rapid Organ Failure
NB: Malignan HTN i a e, but can arise in HT of any Aetiology.
Pathophysiology Not well Understood:
Common Causes:
o Cessation of Antihypertensives (Rebound HT)
o Sympathetic Hyperactivity
o Stimulants (Cocaine/Amphetamines)
o Glomerulonephritis (Nephritic Syndrome)
o Head Trauma ICP
o Tumours (Eg. Thyroid, Phaeo, Adrenal)
o Pre-Eclampsia
Symptoms Include:
Vision Disturbance (Papilloedema/Retinal Bleed)
Headache, Drowsiness, Confusion
Nausea, Vomiting
Management:
Smoothly Reduce BP over 24 to 36 hours to <150 / 90
(NB: Excessive reduction may Coronary/Cerebra/Renal Ischaemia)

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- Clinical Features:
o Symptoms:
Typically Asymptomatic (Unless Malignant Headache, Dizziness, N/V, Visual Changes)
o Signs:
Signs of 1o causes Eg. Thyroid, C hing Acromegaly, Polycythaemia, CKD, Pregnancy.
Abdomen: Renal or Adrenal Masses (for possible causes), or for AAA
Renal Bruit: (Renal Artery Stenosis)
o Diagnosis Essential Vs. Secondary?:
If Essential HT: Diastolic Pressure will RISE on standing.
If Secondary HT: Diastolic Pressure will FALL on standing.
o Classification (Adults):

- Diagnostic Evaluation:
o >3 Consecutive Readings of >140/>90 over 6mths = HTN
o BUT: Needs to be >Stage 2 (>160/>100) to Prescribe Antihypertensives.
o +FBC (Eliminate Polycythaemia)
o +Lipids Sc een Ri k F fo IHD
o +UEC (Screen Renal Failure, Electrolyte Disturbances)
o +Urinalysis (Screen Renal Failure & Urine Electrolytes)
o +BSL (Screen Diabetes)
o +ECG (Screen IHD)

Category Systolic (mmHg) Diastolic (mmHG) % Population

Normal 120-140 80-90 83
Stage 1 Hypertension (Mild) 140-160 90-100 13.5
Stage 2 Hypertension (Moderate) 160-180 100-110 2
Stage 3 Hypertension (Severe) 180-210 110-120
Stage 4 Hypertension (Severe) 1

- MANAGEMENT:
o (Identify & treat underlying causes)
o (NB: Reduction should be SLOW, otherwise can be fatal)
o 1. Lifestyle changes:
Reduce Risk Factors (Eg. Quit Smoking, -Fat Diet, Alcohol Salt, Exercise)
o 2. Treatment drugs (If >Stage 2 [>160/>100]):
Monotherapy First, Then Add ONE Other (In Order of Recommendation):
ACEi (Perindopril [ Coversyl ]) / ARB (Candesartan A acand
o NB Be a e K+)
o (Beware Dry Cough)
Ca-Ch-Blocker (Amlodipine No a c / Nifedipine Adalat
Thiazide Diuretic (Hydrochlorothiazide Ami ide
o NB Be a e K+)
{B-Blocker (Carvedilol Dila end Atenolol No en } Now Controversial!
o Only used if Pt also has IHD / CCF.
(Therapeutic Target <140/90mmHg or <130/80mmHg in diabetics)
o + (3. Home BP Monitoring):
If: Non-Complian Diabe ic Whi e-Coa HTN

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- Complications of Hypertension:
o Is a Major Precursor For:
CAD/IHD
Hypertensive Heart Disease (Heart Failure, Hypertrophic Cardiomyopathy)
Stroke
Aortic Dissection
PVD
Renal Failure
Microangiopathy/ Ar eriolosclerosis (Small Vessel Diseases)
o Relationship between Degree of hypertension & Degree of Complications.

o Heart:
Afterload LV-Hypertrophy Eventually Diastolic Failure
Workload O2 Demand Exacerbated Coronary Ischaemia
o Lungs:
Pulmonary Congestion Pulmonary Oedema & RV-Hypertrophy
o CerebroVascular:
Intracerebral Haemorrhage (Rupture of Artery/Arterioles in brain)
o Aortia/Peripheral Vascular:
Mechanical Arterial Damage (eg. Aneurysms/Dissecting Aneurysms/Atherosclerosis)
o Kidneys:
Nephrosclerosis (hardening of kidney blood vessels) Renal Failure

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 CVS Pathology:
Infective Endocarditis

INFECTIVE ENDOCARDITIS
- = Infection of the Endothelial Lining of the Heart (including the heart valves)
- Risk Factors:
o Valve Abnormality (Valve Murmurs, Calcification, Congenital, Artificial)
o Open-Heart Surgery
o Poor Dental Hygiene (Source of Bacteria)
o Bacteraemia
o IV Access (Haemodialysis, IVDU, Surgery)
o Immunosuppression
- Aeitologies:
o Subacute Bacterial Endocarditis (Most Common - 50-60% of Cases):
(Oral) Strep Viridans/(Surgical) Strep Epidermidis (Low Virulence)
Epi: Recent Oral Surgery, or Post-Prosthetic Valve Insertion.
o Acute Bacterial Endocarditis (Rare 10-20% of Cases):
Staph. Aureus (High Virulence - 50% Mortality)
Epi: IV Drug Users
- Pathogenesis:
o Bacterial Infection of Valves/Endocardium Vegetations on Valve Cusps
Typically Strep. Viridans (Subacute-BE) or Staph Aureus/MRSA (Acute-BE)
Affects Aortic & Mitral Valves.
(RH-Valves may be affected in IV Drug Users)

- Clinical Signs:
o Symptoms:
**Fever + New Murmur** = Endocarditis until proven otherwise
+Fatigue, Malaise, Weight Loss
o Physical Signs:
Septic Emboli Infarcts:
Splinter Haemorrhages (In the nail bed)
Osler s Nodes (painful erythematous nodules in pulp of digits)
Janeway Lesions (Red, nontender lesions on palms/soles)
Roth Spots (Retinal Haemorrhages - red ring lesions with a yellow centre)
Splenomegaly
Arrhythmia
o Complications Begin ks af er onse
Renal Failure (Renal Emboli/Immune Complex Deposit Glomerulonephritis, Haematuria)
TIA (Cerebral Septic Embolism Ischaemia TIA/Stroke)
Septicaemia
CCF
- Investigations:
o Clinical (Fever + New Systolic Murmur +/- Septic Emboli)
o 3x Blood Cultures (@ Different Times & From Different Sites Eliminate Contamination)
o ECG (Rule out Ischaemia/MI/Arrhythmias)
o Echo (Valvular Vegetations & Mitral Regurgitation)
- Management:
o 2-6wks of High Dose IV Vancomycin - (Initially Empirical; Then Culture-Directed Therapy).
o Refer to Cardiac Surgeon (For ?Valve Replacement Surgery?):
If IV-ABs are Unsuccessful.
Or If Valve is Destroyed (Ie. In Acute-BE) Heart Failure
- Prognosis:
o 30% Mortality with Rx.

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NON-INFECTIVE ENDOCARDITIS (NBTE - Non Bacterial Thrombotic Endocarditis):
- Aetiology:
o Hypercoaguable States Eg. DIC, Malignancy, Sepsis, SLE, Pregnancy.
- Pathogenesis:
o Deposition of small Sterile Th bi leafle f Ca diac Val e Ie The ffi i i i NOT c ec
o Preference for Valves: Mitral>Aortic>Tricuspid>Pulomonary
- Clinical Signs:
o Signs:
Of Hypercoaguable States:
DIC: Acutely Ill, Shocked, Widespread Haemorrhage (Mouth, Nose, Bruising, Renal)
Sepsis: Fever, Acutely Ill, Shocked, Infective Focus
SLE: Fever, Fatigue, Malaise, Butterfly/Malar Rash, Lymphadenopathy, Arthritis
Pregnancy: Baby Bump, DVT
Of NBTE:
Heart Murmurs
Stroke
MI
If 2o Infective-BE:
Fever + New Murmur
Septic Infarcts (Splinters, Oslers, Janeways, Roths, Abscesses, Haematuria)
o Symptoms are those of Systemic Arterial Embolism (Complications):
Thrombo-Embolic Infarcts (eg. Brain Stroke; Heart MI)
Secondary Bacterial Colonisation on Vegetations.
- Investigations:
o Clinical (Fever + New Systolic Murmur +/- Septic Emboli)
o 3x Blood Cultures (@ Different Times & From Different Sites Eliminate Contamination)
o + Coags Screen!!
o ECG (Rule out Ischaemia/MI/Arrhythmias)
o Echo (Valvular Vegetations)
- Management:
o Treatment of Underlying Aetiology
o Anticoagulant Therapy (Heparin Then Warfarin)

o +(If 2o Bacterial Endocarditis 2-6wks of High Dose IV Vancomycin)

o Refer to Cardiac Surgeon (For ?Valve Replacement Surgery?):
If IV-ABs are Unsuccessful.
Or If Valve is Destroyed (Ie. In Acute-BE) Heart Failure

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 VALVULAR HEART DISEASE
❏ see Cardiac Surgery Chapter

INFECTIVE ENDOCARDITIS (IE)

Etiology
❏ Strep viridans (commonest, spontaneous bacterial endocarditis (SBE) on abnormal valve – prosthetic, MVP, etc.)
❏ Enterococcus (Group D strep, SBE)
❏ Staph aureus (enter through break in skin: IV drug abusers, usually rightsided, catheter-associated sepsis)
❏ Staphylococcus epidermidis (prosthetic valve)
❏ Strep bovis (underlying GI malignancy)
❏ others: gram-negative bacteria, Candida, HACEK organisms (Haemophilus species, Actinobacillus
actinomycetemcomitans, Cardiobacterium hominis, Eikenella, and Kingella), Pseudomonas (IV drug)
❏ frequency of valve involvement: MV >> AV > TV > PV
❏ risk of IE in various cardiac lesions (JAMA 1997;227:1794)
• high risk: prosthetic heart valves, previous IE, complex cyanotic congenital heart disease,
surgically constructed systemic to pulmonary shunts or conduits
• moderate risk: most other congenital cardiac malformations, acquired valvular dysfunction,
HCM, MVP with MR and/or thickened leaflets
Pathogenesis and Symptomatology
❏ usually requires source of infection, underlying valve lesion, +/– systemic disease/immunocompromised state
❏ portal of entry: oropharynx, skin, GU, drug abuse, nosocomial infection ––> bacteremia ––>
diseased valve/high flow across valve ––> turbulence of blood across valve ––>
deposition of bacteria on endocardial surface of valve
(vegetation = clump of fibrin, platelets, WBCs and bacteria) ––> endocarditis ––> septic embolization
❏ symptoms
• fever, chills, rigors
• night sweats
• 'flu-like' illness, malaise, headaches, myalgia, arthralgia
• dyspnea, chest pain
Signs
❏ fever, regurgitant murmur (new onset or increased intensity), constitutional symptoms, anemia
❏ signs of CHF (secondary to acute MR, AR)
❏ peripheral manifestations: petechiae, Osler's nodes ("ouch!" raised, painful, 3-15 mm, soles/palms),
Janeway lesions ("pain away!" flat, painless, approx. 1-2 cm, on soles/plantar surfaces of toes/palms/fingers),
splinter hemorrhages (especially on proximal nail bed, distally more commonly due to local trauma)
❏ CNS: focal neurological signs (CNS emboli), retinal Roth spots
❏ clubbing (subacute)
❏ splenomegaly (subacute)
❏ microscopic hematuria (renal emboli or glomerulonephritis) ± active sediment
❏ weight loss
Investigations
❏ blood work: anemia, uncreased ESR, positive rheumatoid factor
❏ serial blood cultures (definitive diagnosis)
❏ echocardiography (transesophageal > sensitivity than transthoracic)
• vegetations, degree of regurgitation valve leaflet perforation, abscess
• serial ECHO may help in assessing cardiac function
Natural History
❏ adverse prognostic factors
• CHF, Gram (–) or fungal infection, prosthetic valve infection, abscess
in valve ring or myocardium, elderly, renal failure, culture negative IE
❏ mortality up to 30%
❏ relapses may occur - follow-up is mandatory
❏ permanent risk of re-infection after cure due to residual valve scarring
Complications
❏ CHF (usually due to valvular insufficiency)
❏ systemic emboli
❏ mycotic aneurysm formation
❏ intracardiac abscess formation leading to heart block
❏ renal failure: glomerulonephritis due to immune complex deposition; toxicity of antibiotics

C36 – Cardiology MCCQE 2002 Review Notes

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 VALVULAR HEART DISEASE . . . CONT.

Management
❏ medical
• antibiotic therapy tailored to cultures (penicillin, gentamicin, vancomycin, cloxacillin) minimum
of 4 weeks treatment
• serial ECGs - increased PR interval
• prophylaxis (JAMA 1997;227:1794)
• dental/oral/respiratory/esophageal procedures
• amoxicillin 2 g 1 hour prior
• GU/GI (excluding esophageal) procedures
• high risk: ampicillin + gentamicin
• moderate risk: amoxicillin, ampicillin, or vancomycin
❏ surgical
• indications: refractory CHF, valve ring abscess, valve perforation, unstable prosthesis, multiple major
emboli, antimicrobial failure, mycotic aneurysm
RHEUMATIC FEVER
Epidemiology
❏ school-aged children (5-15 yr), young adults (20-30 yr), outbreaks of Group A ß-hemolytic Streptococcus,
upper respiratory tract infection (URTI), social factors (low socioeconomic status (SES), crowding)
Etiology
❏ 3% of untreated Group A ß-hemolytic Streptococcus (especially mucoid, highly encapsulated stains,
serotypes 5, 6, 18) pharyngitis develop acute rheumatic fever
Diagnosis
❏ 1. Modified Jones criteria (1992): 2 major, or 1 major + 2 minor
• major criteria
• pancarditis
• polyarthritis
• Sydenham's chorea
• erythema marginatum
• subcutaneous nodules
• minor criteria
• previous history of rheumatic fever or rheumatic heart disease
• polyarthralgia
• increased ESR or C-reactive protein (CRP)
• increased PR interval (first degree heart block)
• fever
plus
❏ 2. Supported evidence confirming Group A Streptococcus infection: history of scarlet fever, group A
streptococcal pharyngitis culture, rapid Ag detection test (useful if positive), anti-streptolysin O Titers (ASOT)
Clinical Features
❏ Acute Rheumatic Fever: myocarditis (DCM/CHF), conduction system(sinus tachycardia, A fib), valvulitis
(acute MR), pericarditis (does not usually lead to constrictive pericarditis)
❏ Chronic: Rheumatic Valvular heart disease: fibrous thickening, adhesion, calcification of valve leaflets resulting
in stenosis/regurgitation, increased risk of IE +/– thromboembolic phenomenon. Onset of symptoms
usually after 10-20 year latency from acute carditis of rheumatic fever. Mitral valve most commonly affected.
Management
❏ acute treatment of Streptococcal infection (benzathine penicillin G 1.2 MU IM x 1 dose)
❏ prophylaxis to prevent colonization of URT (age < 40): benzathine penicillin G 1.2 MU IM q3-4 weeks,
within 10 yr of attack
❏ management of carditis in rheumatic fever: salicylates (2g qid x4-6 wk for arthritis), corticosteroids
(prednisone 30 mg qid x4-6wk for severe carditis with CHF)
AORTIC STENOSIS
Etiology
❏ congenital (bicuspid > > unicuspid) ––> calcified degeneration or congenital AS
❏ acquired
• degenerative calcified AS (most common) - "wear and tear"
• rheumatic disease
Definition
❏ AS = narrowed valve orifice (aortic valve area: normal = 3-4 cm2
severe AS = < 1.0 cm2
critical AS = < 0.75 cm2 )
❏ Note: low gradient AS with severely reduced valve area (< 1.0 cm2) and normal gradient in setting of
LV dysfunction
Pathophysiology
❏ pressure overloaded LV: increased LV end-diastolic pressure (EDP), concentric LVH, subendocardial ischemia
––> forward failure
❏ outflow obstruction: fixed cardiac output (CO)
❏ LV failure, pulmonary edema, CHF
MCCQE 2002 Review Notes Cardiology – C37

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 VALVULAR HEART DISEASE . . . CONT.

Symptomatology
❏ ASD (triad of Angina, Syncope, and Dyspnea; prognosis associated with onset)
❏ angina (exertional): due to concentric LVH and subendocardial ischemia (decreased subendocardial flow and
increased myocardial O2 demand), may have limitation of normal activity or resting angina in tight AS
(associated with < 5 year survival)
❏ syncope: due to fixed CO or arrhythmia (< 3 year survival)
❏ dyspnea (LV failure): systolic +/– diastolic dysfunction, pulmonary edema, may have orthopnea, if secondary
RHF may have ascites, peripheral edema, congestive hepatomegaly (< 2 years)
Signs of AS
❏ pulses
• apical-carotid delay
• pulsus parvus et tardus (decreased amplitude and delayed upstroke) narrow pulse pressure,
brachial-radial delay
• thrill over carotid
❏ precordial palpation
• PMI: sustained (LVH) +/– diffuse (displaced, late, with LV dilation)
• +/– palpable S4
• systolic thrill in 2nd right intercostal space (RICS) +/– along left lower sternal bender (LLSB)
❏ precordial auscultation
• most sensitive physical finding is SEM radiating to right articular head
• SEM – diamond shaped (crescendo-decrescendo), harsh, high-pitched, peaks progressively later
in systole with worsening AS, intensity not related to severity, radiates to neck, musical quality of
murmur at apex (Gallavardin phenomenon)
• +/– diastolic murmur of associated mild AR
• S2 – soft S2, absent A2 component, paradoxical splitting (severe AS)
• ejection click
• S4 – early in disease (increased LV compliance)
• S3 – only in late disease (if LV dilatation present)
Investigations
❏ 12 lead ECG
• LVH and strain +/– LBBB, LAE/A fib
❏ chest x-ray
• post-stenotic aortic root dilatation, calcified valve, LVH + LAE, CHF (develops later)
❏ ECHO
• test of choice for diagnosis and monitoring
• valvular area and pressure gradient (assess severity of AS)
• LVH and LV function
• shows leaflet abnormalities and "jet" flow across valve
❏ cardiac catheterization
• r/o CAD (i.e. especially before surgery in those with angina)
• valvular area and pressure gradient (for inconclusive ECHO)
• LVEDP and CO (normal unless associated LV dysfunction)
Natural History
❏ asymptomatic patients have excellent survival (near normal)
❏ once symptomatic, untreated patients have a high mean mortality
• 5 years after onset of angina, < 3 years after onset of syncope; and < 2 years after onset of CHF/dyspnea
❏ the most common fatal valvular lesion (early mortality/sudden death)
• ventricular dysrhythmias (likeliest cause of sudden death)
• sudden onset LV failure
❏ other complications: IE, complete heart block
Management
❏ asymptomatic patients - follow for development of symptoms
• serial echocardiograms
• supportive/medical
• avoid heavy exertion
• IE prophylaxis
• avoid nitrates/arterial vasodilators and ACEI in severe AS
❏ indications for surgery
• onset of symptoms: angina, syncope, or CHF
• progression of LV dysfunction
• moderate AS if other cardiac surgery (i.e. CABG) required
❏ surgical options (see Cardiac and Vascular Surgery Chapter)
• AV replacement
• excellent long-term results, procedure of choice
• open or balloon valvuloplasty
• children, repair possible if minimal disease
• adults (rarely done): pregnancy, palliative in patients with comorbidity, or to stabilize patient
awaiting AV replacement - 50% recurrence of AS in 6 months after valvuloplasty
• complications: low CO, bleeding, conduction block, stroke

C38 – Cardiology MCCQE 2002 Review Notes

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 CVS Pathology:
Ischaemic Heart Disease

Review of Coronary Anatomy:

LAD Apex, Anterior LV, Anterior 2/3 of IV-Septum

LCX Lateral LV
RCA Entire RV, Postero-Superior LV, Posterior 1/3 of IV-Septum

Degrees of Coronary Blockage:

– <70% Occlusion: Asymptomatic
– 70-75% Occlusion: Angina
– 90% Occlusion: Chronic IHD
– Unstable Plaque: Unstable angina +/- Rupture Acute MI
– > 90% Occlusion: MI

*Ischaemia Vs. Hypoxia Vs. Infarction:

Ischaemia: A FLOW Limitation, Typically due to Coronary Artery Stenosis (Narrowing)
Hypoxia: An O2 Limitation,Typically due to High-Altitude/Respiratory Insufficiency/etc.
Infarction: Irreversible Cell-DEATH, Typically due to sustained Ischaemia.

Regional Vs. Global Myocardial Ischaemia:

- Regional Ischaemia:
o Local Atherosclerosis/Thrombosis Ischaemia Confined to Specific Region of Heart.
- Global Ischaemia (Rare):
o Severe Hypotension/Aortic Aneurysm Ischaemia of Entire Heart

What Happens During Myocardial Ischaemia:

- Myocardial Damage: Initially Subendocardial -Ischaemia/Infarction (ST-Depression & T-Wave Inversion)
Progresses to Transmural -Ischaemia/Infarction (ST-Elevation & Pathological Q-Waves).

- Metabolic Changes (Aerobic Anaerobic): Lactate Anaerobic Metabolism pH

- Pain: Nociceptor (pain receptor) Activation Angina Pain
- Global Autonomic Symptoms: Tachycardia, Sweating, Nausea.
- Pulmonary Congestion: Eg. LV-Failure Pulmonary Congestion Shortness of Breath
- Ventricular Arrhythmias: Eg. SVT or VT or VF (due to Re-Entrant Focus & Altered Conduction Patterns)

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ANGINA PECTORIS:
- Aetiology:
o Myocardial Perfusion (relative to demand) due to Coronary Insufficiency.
o Causes: **Atherosclerosis / Vasospasm / Embolism / Ascending Aortic Dissection
o Exacerbated by (Vent-Hypertrophy, Tachycardia, Hypoxia, Coronary Arteritis (e.g. in SLE))
- Pathogenesis:
o (= A Late Sign of Coronary Atheroma Symptoms Imply >70% Occlusion!!)
o Insufficient Coronary Perfusion Relative to Myocardial Demand
o Stable Angina:
Due to: Stable Atherosclerotic Coronary Obstruction (No Plaque Disruption)
Presentation: Chest Pain on Physical Exertion, which fades quickly with Rest (minutes)
o Variant/Prinzmetal Angina:
Due to: Coronary Vasospasm (May not be Atheroma).
Presentation: Angina Unrelated to Activity (Ie. At Rest)
o Unstable Angina “Pre-Infarction Angina” :
Due to: Unstable Atherosclerotic Plaque (+/- Plaque Disruption & Thrombus).
Presentation: Prolonged Angina @ Rest (Either New-Onset/ Severity/ Frequency).
**NB: = Red Flag that MI may be Imminent
o Silent Ischaemia:
Due to: Ischaemia masked by neuropathy (eg. Diabetes/ B12/etc)
Presentation: Painless, but may have Nausea, Vomiting, Diaphoresis + Abnormal ECG
- Clinical Features of Angina:
o Common Presentation:
**<15mins of Crushing, Central, Retrosternal Chest Pain Radiating to Arms, Neck or jaw:
(Stable: On exertion)(Prinzmetal: Rest)(Unstable: Worsening/Prolonged/@Rest)
+Dyspnoea (Pulm.Congestion)
+ Fear of Impending Doom
o Signs:
Sympathetic Drive Diaphoresis
Hypotension Cold/Clammy/Peripheral Shut-Down/Thready Pulse
Pulmonary Congestion Dyspnoea, JVP
- Investigations:
o (1st Line) Resting ECG:
During Attack: ST-Depression, T-wave Inversion (Normal between Attacks)
(Path-Q-Waves if Previous MI).
nd
o (2 Line) Cardiac Stress Test + ECG: Suggests Severity of CAD (Any ST Depression is a +Ve Result)
o (3rd Line) Stress Echocardiography: Assess Ventricular Function
o (4th Line) Coronary Angiography (Cath-Lab): Pre-Angioplasty to Map the Coronary Anatomy
o (5th Line) Myocardial Perfusion Scans (Nuclear Medicine):
- Management/Treatment:
o (Prevention/Management of CV Risk Factors):
Smoking/Hypertension/Hyperlipidaemia/Diabetes/Obesity/Etc.
o Medical Therapy (Maintenance):
1. Anti-Anginal Therapy:
Nitrates (GTN) Coronary Vasodilation Cardiac Perfusion
B-Blockers (Metoprolol) To Workload of the Heart
Ca-Channel Blockers (Diltiazem/Verapamil) To Afterload
2. Antiplatelet Therapy:
Aspirin / Clopidogrel
3. Lipid-Lowering Therapy:
Atorvastatin/Simvastatin
o Revascularisation (Definitive) - OPTIONAL:
PCI (Per-Cutaneous Intervention)/Coronary Angioplasty:
Balloon Dilation/Stenting of Coronary Arteries via Femoral Artery
OR... CABG - (Coronary Artery Bypass Grafting):
Harvested Vein (Saphenous/Wrist) Bypasses the blockage

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Acute Coronary Syndromes - (Unstable Angina/STEMI/NSTEMI):
- Aetiology:
o Unstable Atheroma
- Pathogenesis:
o Unstable Atheroma Rupture Prolonged Ischaemia Necrosis/Death of Myocardium.
( Sudden Death, Acute Systolic Dysfunction & Heart Failure, Vent.Rupture)
o Progression of Ischaemic Necrosis “ST-ELEVATION?”:
1. Initially “Subendocardial Necrosis” NON-ST-ELEVATION MI:
ST-Depression + T-Wave Inversion (As with Angina)
2. Then “Transmural Necrosis” ST-ELEVATION MI:
ST-Elevation + T-Wave Inversion + Path.Q-Waves
NB: The Endocardium is spared due to O2/Nutrients of Ventricular Blood.

o Most Common Coronary Obstruction & Locations of Ischaemia:

50% - LAD Obstruction:
Anterior-LV + Apex + Ant.2/3 of IV-Septum
30% - RCA Obstruction:
Posterior-LV + Posterior Septum + Free wall of RV.
20% - LCX (Left Circumflex) Obstruction:
Lateral LV (except for the apex.)
(NB: Nearly ALL Infarcts involve a portion of the LV)

- Clinical Features of NSTEMI/STEMI:

o Common Presentation:
**>20mins Crushing, Central, Retrosternal Chest Pain Radiating to Arms, Neck or Jaw.
NB: Some are Silent Eg. Diabetes, Post Cardiac Surgery, Elderly)
+Dyspnoea (Pulm.Congestion)
+ Fear of Impending Doom
o Signs:
Sympathetic Drive Diaphoresis
Hypotension Cold/Clammy/Peripheral Shut-Down/Thready Pulse
Pulmonary Congestion Dyspnoea/Tachypnoea/ JVP
Signs of PVD

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- Investigations:
o (1st Line):
Serial Resting 12Lead ECGs (Every 15 Mins):
ST-Changes and Diagnosing MI:
o V1, V2, V3, V4 = Anterior MI
o II, III, AVF = Inferior Wall MI
o I, AVL, V5, V6 = Lateral
3-Lead Cardiac Telemetry (Screening for Arrhythmias)
Serial Troponin Levels (Cardiac Troponin-I/T, or CK-MB):
1st. On Presentation
2nd. @ 6hrs ( Troponin = MI)
3rd. Within 24hrs
+ Bloods (FBC, Serum Electrolytes, Glucose, Lipids)

o (2nd Line):
TTE/TOE Transthoracic/Transoesophageal Echo:
Assess LV-Function
(+ Excludes DDXs - Aortic Dissection / Pericarditis / Pulmonary Embolism)
Myocardial Perfusion Scans (Nuclear Medicine):
? Location of Infarct

- Management (As with Angina PLUS MORPHINE, O2 & ANTICOAGULATION + DEFINITIVE Mx):
o (Simplified: MONA = Morphine, Oxygen, Nitrates, Aspirin)
o 1. Medical Therapy (Maintenance):
1. Anti-Anginal Therapy:
Nitrates (GTN/Isosorbide Mononitrate) Coronary Vasodilation Cardiac Perfusion
B-Blockers (Propanolol/Metoprolol) To HR & Contractility Cardiac Workload
Ca-Channel Blockers (Nifedipine/Verapamil) To Afterload Cardiac Workload
2. Antiplatelet Therapy:
(Aspirin / Clopidogrel)
3. Lipid-Lowering Therapy:
(Atorvastatin/Simvastatin)
+4. Morphine: (Analgesia + Vasodilation)
+5. Oxygen: (To Maximize O2 @ Myocardium)
+6. Anticoagulation: (Heparin/LMWH or Warfarin) (Prevent Further Thrombogenesis).
o 2. STAT Revascularisation (Definitive) WITHIN 4 HRS:
**PCI (Per-Cutaneous Intervention)/Coronary Angioplasty:
Balloon Dilation/Stenting of Coronary Arteries via Femoral Artery
OR... Thrombolysis/Fibrinolysis (With TPA “Tissue Plasminogen Activator “Alteplase ):
Contraindicated in: Hx of CVA, Stroke <3mths, Aortic Dissection, Active Bleeding.
+/- CABG:
- Complications:
o Acute Complications:
LV-Failure: Acute Pulmonary Oedema, Shock (70% Mortality)
Lethal Arrhythmias: VT, VF
Weakening of Necrotic Myocardium Myocardial Rupture: Tamponade / Acute VSD
Stasis Mural Thrombosis Embolization Stroke
o Chronic Complications:
Ventricular Aneurysm, Papillary Muscle Rupture Mitral regurgitation, CCF.

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 ISCHEMIC HEART DISEASE (IHD)
BACKGROUND
Epidemiology
❏ commonest cause of cardiovascular morbidity and mortality
❏ male: female ratio
• = 2:1 with all age groups included (Framingham study)
• = 8:1 < age 40
• = 1:1 > age 70
• disparity due to protective effect of estrogen
❏ peak incidence of symptomatic IHD is from ages 50 to 60 in men and ages 60 to 70 in women
❏ spectrum of IHD/CAD ranges anywhere from asymptomatic to sudden death
Atherosclerosis and IHD
❏ atherosclerosis and thrombosis are by far the most important pathogenetic mechanisms in IHD
Major Risk Factors For Atherosclerotic Heart Disease
❏ smoking
• risk can be halved by cessation of smoking
❏ diabetes mellitus (DM)
• micro and macrovascular complications
❏ hypertension (HTN)
• depends on degree and duration
❏ family history (FHx)
• first degree male relative < 55 or first degree female relative < 60
❏ hyperlipidemia
Other Minor Risk Factors
❏ obesity
• > 30% above ideal weight
❏ sedentary lifestyle
❏ hyperhomocysteinemia
Preventative Measures
❏ smoking cessation
❏ tight glycemic control in diabetics
❏ BP control
• major reason for the recent decrease in IHD
❏ lipid-modifying therapy
❏ dietary measures e.g. mild alcohol consumption
❏ weight loss
❏ exercise improves weight, HTN, cholesterol and glycemic control
❏ family screening (high risk groups)

ANGINA PECTORIS
Definition
❏ symptom complex resulting from an imbalance between oxygen supply and demand in the myocardium
Pathophysiology of Myocardial Ischemia

O2 O2
Demand Supply
Heart Rate Length of Diastole
Contractility Coronary Diameter
Wall Tension Hemoglobin
SaO2
Figure 9. Physiological Principles

Etiology
❏ decreased myocardial oxygen supply
• atherosclerotic heart disease (vast majority)
• coronary vasospasm (variant angina= Prinzmetal’s Angina)
• severe aortic stenosis or insufficiency
• thromboembolism
• severe anemia
• arteritis (e.g. Takayasu’s syndrome, syphilis, etc.)
• aortic dissection
• congenital anomalies
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 ISCHEMIC HEART DISEASE (IHD) . . . CONT.

❏ increased myocardial oxygen demand

• myocardial hypertrophy
• severe tachycardia
• severe hyperthyroidism
• severe anemia
DDx
❏ musculoskeletal (MSK) disease
• rib fracture
• intercostal muscle tenderness
• costochondritis (Tietze’s syndrome)
• nerve root disease (cervical radiculitis)
❏ gastrointestinal (GI) disease
• peptic ulcer disease (PUD)
• reflux esophagitis
• esophageal spasm and motility disorder (may be improved by NTG)
❏ pulmonary disease
• pulmonary embolism (PE)
• pneumothorax
• pneumonia
❏ cardiovascular (CV) disease
• aortic dissection (asymmetrical BP and pulses, new AR murmur)
• pericarditis
❏ Other
• intercostal neuritis (shingles)
• anxiety
❏ note
• careful history and physical required
• consider risk factors for each entity
• beware cardiac and non-cardiac disease may coexist
Diagnosis of Angina Pectoris
❏ history
• classically precordial chest pain, tightness or discomfort radiating to left shoulder/arm/jaw
• dyspnea or fatigue may present as "chest pain equivalents," especially in females
• associated with diaphoresis or nausea
• predictably precipitated by the "3 E's" Exertion, Emotion and Eating
• brief duration, lasting < 10-15 minutes and typically relieved by rest
• note: always list the presence or absence of the cardiac risk factors in a separate subsection
in the history (e.g., + FHx, + HTN, +DM, + smoking, - hypercholesterolemia)
❏ stress testing (see Cardiac Diagnostic Tests section)
Variant Angina (Prinzmetal’s Angina)
❏ vasospasm of coronary arteries results in myocardial ischemia
• may occur in normal or atherosclerotic vessels
❏ typically occurs between midnight and 8 am
❏ unrelated to exercise; relieved by Nitrates
❏ typically ST elevation on ECG (may be confused with acute MI)
❏ diagnose by provocative testing with ergot vasoconstrictors (rarely done)
Syndrome X
❏ patient has typical symptoms of Angina yet has normal angiogram
❏ may show definite signs of ischemia during exercise testing
❏ pathogenesis thought to be due to inadequate vasodilator reserve of coronary resistance vessels
❏ has better prognosis than patient with overt atherosclerotic disease
Medical Treatment
❏ ß blockers (first line therapy)
• decrease overall mortality
• decrease heart rate, contractility, and to a lesser degree, blood pressure (afterload)
• increase coronary perfusion
• avoid agents with intrinsic sympathomimetic activity (ISA) (e.g. Acebutolol) (these increase demand)
❏ nitrates
• used for symptomatic control
• no clear impact on survival
• decrease myocardial work and, therefore, oxygen requirements
through venous dilatation (decrease preload) and arteriolar dilatation (decrease afterload)
• dilate coronary arteries
• maintain daily nitrate-free intervals to try to prevent nitrate tolerance
❏ calcium channel blockers (CCB)
• variably decrease afterload, decrease heart rate and decrease contractility, produce coronary dilatation
❏ ECASA
• all patients
• decrease platelet aggregation
❏ lipid lowering

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 ISCHEMIC HEART DISEASE (IHD) . . . CONT.

Coronary Artery Disease (CAD) Lipid Therapy

Trial Drug Dose CHD Event Reduction

primary WOSCOPS pravastatin 40 31%

prevention AFCAPS lovastatin 20-40 24%
secondary LIPID pravastatin 40 23%
prevention 4S simvastatin 20-40 34%
CARE pravastatin 40 24%

2000 Canadian Guidelines for Treatment of Dyslipidemia

Target Values
Level of Risk LDL TC:HDL Ratio Tryglycerides
(Definition)
Very High
(History of cardiovascular < 2.5 <4 <2
disease or 10 yr risk of CAD > 30%)
High
(10 yr risk of CAD 20-30%) <3 <5 <2
Moderate
(10 yr risk 10-20%) <4 <6 <2
Low
(10 yr risk < 10%) <5 <7 <3
Risk calculated based on Framingham data: dertermined by gender, age group, total cholesterol level, HDL level, SBP, history of smoking

❏ treatment strategy
• short acting nitrates on PRN basis to relieve acute attacks
and PRN prior to exertion
• be careful when combining ß blockers and verapamil/diltiazem
• both decrease conduction and contractility and may result in sinus bradycardia or AV block
• use nitrates and CCB for variant angina

low likelihood intermediate likelihood high likelihood

non-nuclear otherwise healthy poor surgical candidate

with multiple co-morbidities
+
– nuclear stress testing nuclear stress testing
–
– + +
medical follow-up cath medical follow-up

low risk high risk

medical management PTCA, CABG

Figure 10. Diagnostic Strategies in the Management of IHD

Indications for Angiography

❏ strongly positive exercise test
❏ significant, reversible defects on thallium scan
❏ refractory to medical therapy or patient unable to tolerate medical therapy
❏ unstable angina

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 ISCHEMIC HEART DISEASE (IHD) . . . CONT.

Percutaneous Transluminal Coronary Angioplasty (PTCA)

❏ uses a balloon inflated under high pressure to rupture atheromatous plaques
❏ may be used as primary therapy in angina, acute MI, post-MI angina or in patients presenting
with bypass graft stenosis
❏ optimally used for proximal lesions free of thrombus and distanced from the origins of large vessel branches –
not in Left Main
❏ primary success rate is > 80%
❏ use of intracoronary stent is associated with a lower restenosis rate (compared with PTCA alone)
❏ complications (overall 3-5%)
• mortality < 1%
• MI 3-5%
• intimal dissection + vessel occlusion requiring urgent CABG
Surgical Treatment- Coronary Artery Bypass Grafting (CABG)
❏ indications - for survival benefit, or symptomatic relief of angina
• stable angina (survival benefit for CABG shown)
• left main coronary disease
• three-vessel disease with depressed LV function
• multi-vessel disease with significant proximal LAD stenosis
• unstable angina (see below)
• above indications or
• continuing angina despite aggressive medical therapy
• complications/failed PTCA
❏ comparison of CABG with PTCA
• studies: RITA, GABI, BARI, EAST, ERACI, CABRI
• highly select patient population - no left main disease and minimal LV dysfunction
• overall no difference in survival, but PTCA group had more recurrent
ischemia and required more interventions
• BARI, subset analysis - CABG superior in patients with DM and multi-vessel IHD
❏ predictors of poor outcome
• poor LV function (EF < 40%), history of CHF, NYHA III or IV
• previous cardiac surgery
• urgent/emergent case, preoperative IABP
• gender (relative risk for F:M = 1.6:1)
• advanced age (> 70), DM, co-morbid disease
❏ CABG operative mortality
• elective case < 1%
• elective case, poor LV function 1-3%
• urgent case 1-5%
• overall (1980-1990) 2.2%
❏ efficacy: > 90% symptomatic improvement in angina
❏ conduits and patency
• internal mammary (thoracic) artery 90% patency at 10 years
• saphenous vein graft 50% patency at 10 years
• radial/gastroepiploic/inferior 85% patency at 5 years
epigastric arteries (improving with experience)

ACUTE CORONARY SYNDROMES (ACS)

Spectrum of ACS
A. Unstable Angina
B. Acute Myocardial Infarcion
C. Sudden Death
A. UNSTABLE ANGINA/NON ST ELEVATION MI (NSTEMI)
Definition
❏ accelerating pattern of pain
• increased frequency
• longer duration
• occurring with less exertion
• less responsive to treatment (eg. require higher doses or more frequent doses)
❏ angina at rest
❏ new onset angina
❏ angina post-MI
❏ post-angiography
❏ post-CABG
❏ note that unstable angina is a heterogeneous group and can be divided into a higher and lower risk groups

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 ISCHEMIC HEART DISEASE (IHD) . . . CONT.

Significance
❏ thought to represent plaque rupture and acute thrombosis with incomplete vessel occlusion
Diagnosis
❏ history
❏ ECG changes
• ST depression or elevation
• T wave inversion
❏ no elevation of cardiac enzymes
Management
❏ oxygen
❏ hospitalization/monitoring
❏ bed rest
❏ anti-anginal medications
• sublingual or IV nitroglycerine
• ß blockers are first line therapy
• aim for resting heart rate of 50-60
• CCB are second line therapy (use if ß blockers contraindicated, or if patient has refractory symptoms
despite aggressive treatment with ECASA, nitrates, and ß blockers)
• evidence suggests that they do not prevent MI or decrease mortality
• be cautious using verapamil/diltiazem with ß blockers
• use non-dihydropyridines if cannot use ß blockers otherwise may use amlodipine
or long-acting nifedipine if concomitant ß blockade
❏ ECASA
• 160-325 mg/day
❏ IV heparin or Plavix (GPIIB/IIIA inhibitor)
❏ angiography with view to potential PTCA or CABG – used to map areas of ischemia
❏ if aggressive medical management is unsuccessful
• may use intra-aortic balloon pump (IABP) to stabilize before proceeding
with revascularization – used to increase coronary perfusion during diasole
• proceed to emergency angiography and PTCA or CABG

B. ACUTE ST ELEVATION MYOCARDIAL INFARCTION (STEMI)

Definition
❏ syndrome of acute coronary insufficiency resulting in death of myocardium
Infarct Diagnosis Based on 2 of 3 - History, ECG, Cardiac Enzymes
❏ history
• sudden onset of characteristic chest pain for > 30 minutes duration
• may be accompanied by symptoms of heart failure (e.g. SOB, leg edema, etc.)
❏ ECG changes
• criteria: ST elevation of at least 1 mm in limb leads and 2 mm in precordial leads
• evolution of ECG changes in Q-wave MI
• 1st – abnormal T waves
• 2nd – ST-T elevations (hours post-infarct)
• 3rd – significant Q waves (hours to days post-infarct)
• 4th – inverted T waves, or may become flat or biphasic (days to weeks)
❏ cardiac enzymes
• follow CK-MB q8h x 3, Troponin q8h x 3
❏ cardiac Troponin I and/or T levels provide useful diagnostic, prognostic information and permit early
identification of an increased risk of mortality in patients with acute coronary syndromes
• Troponin I and T remain elevated for 5 to 7 days
❏ beware
• up to 30% are unrecognized or "silent" due to atypical symptoms
• DM
• elderly
• patients with HTN
• post heart-transplant (because of denervation)
❏ draw serum lipids within 24-48 hours because the serum values are unreliable after 48 hours,
but become reliable again 8 weeks post-MI

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 ISCHEMIC HEART DISEASE (IHD) . . . CONT.

Patient Evaluation “unstable angina”

history • physical exam • ECG • enzymes

ST elevation non ST elevation

presumed acute MI sample enzymes

assess for positive enzymes negative enzymes

thrombolysis acute MI

unstable angina non cardiac chest pain

Figure 11. Diagnostic algorithm in acute IHD
Etiology
❏ coronary atherosclerosis + superimposed thrombus on ruptured plaque (vast majority)
• vulnerable "soft" plaques more thrombogenic
❏ coronary thromboembolism
• infective endocarditis
• rheumatic heart disease
• intracavity thrombus
• cholesterol emboli
❏ severe coronary vasospasm
❏ arteritis
❏ coronary dissection
❏ consider possible exacerbating factors
• see Angina Pectoris section

Plasma
Enzyme CK-MB
Level x
Normal

ISCHEMIC
HEART DISEASE
. . . CONT.
DAYS POST-MI
Figure 12. Cardiac Enzyme Profile in Acute MI

Further Classification of MIs

❏ Q wave
• associated with transmural infarctions, involving full thickness of myocardium
❏ non-Q wave
• usually associated with non-transmural (subendocardial) infarctions,
involving 1/3 to 1/2 of myocardial thickness
• in-hospital mortality from non-Q wave infarction is low (< 5%)
but 1 year mortality approaches that of Q wave infarction
Management
❏ goal is to minimize the amount of infarcted myocardium and prevent complications
❏ emergency room measures
• ECASA 325 mg chewed stat
• oxygen
• sublingual nitroglycerine
• morphine for pain relief, sedation, and venodilation
• ß blockers to reduce heart rate if not contraindicated

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 ISCHEMIC HEART DISEASE (IHD) . . . CONT.

❏ thrombolytic therapy (see Table 7)

• benefits of thrombolysis shown to be irrespective of age, sex, BP, heart rate, or history of MI or DM
• indications for thrombolytic therapy
A. at least 0.5 hours of ischemic cardiac pain and
B. any of the following ECG changes thought to be of acute onset
• at least 1 mm of ST elevation in at least two limb leads
• at least 1 mm of ST elevation in at least two adjacent precordial leads or
• new onset complete BBB
C. presentation within 12 hours of symptom onset
• choice of thrombolytic agents include streptokinase and rt-PA
• patients having previously received streptokinase must
receive alternate agent due to development of immunity
❏ heparin
❏ PTCA, CABG
Long-Term Measures
❏ antiplatelet/anticoagulation therapy
❏ ECASA 325 mg daily
❏ nitrates
• alleviate ischemia but may not improve outcome
❏ ß blockers (first line therapy)
• start immediately and continue indefinitely if no contraindications
• decrease mortality
❏ CCB
• NOT recommended as first line treatment - Short Acting Nifedipine is contraindicated!
• Diltiazam and Verapamil are contraindicated in MI with associated LV dysfunction
❏ ACEI
• decrease mortality
• stabilize endothelium and prevent adverse ventricular remodeling
• strongly recommended for
• symptomatic CHF
• reduced LVEF (< 40%) starting day 3 to 16 post-MI (SAVE trial)
• anterior MI
❏ lipid lowering agent (HMG-C0A reductase inhibitors or niacin)
• if total cholesterol > 5.5 or LDL > 2.6
❏ coumadin (for 3 months)
• for large anterior MI, especially if LV thrombus seen on 2D-ECHO
❏ see Figure 13 for post critical care unit (CCU) strategy
Table 7. Contraindications to Thrombolytic Therapy in AMI
Absolute Relative

• active bleeding • GI, GU hemorrhage or stroke within past 6 months

• aortic dissection • major surgery or trauma within past 2-4 weeks
• acute pericarditis • severe uncontrolled hypertension
• cerebral hemorrhage • bleeding diathesis or intracranial neoplasm
(previous or current) • puncture of a noncompressible vessel
• significant chest trauma from CPR
❏ Indications for Post-thrombolysis Heparin
• tPA used for thrombolysis
• Anterior MI
• Ventricular aneurysm
• Post-thrombolysis angina
• A fib
• Previous deep vein thrombosis (DVT), PE, or ischemic stroke
Prognosis
❏ 20% of patients with acute MI die before reaching hospital
❏ 5-15% of hospitalized patients will die
• risk factors
• infarct size/severity
• age
• co-morbid conditions
• development of heart failure or hypotension
❏ post-discharge mortality rates
• 6-8% within first year, half of these within first 3 months
• 4% per year following first year
• risk factors
• LV dysfunction
• residual myocardial ischemia
• ventricular arrhythmias
• history of prior MI
• resting LVEF is most useful prognostic factor

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 ISCHEMIC HEART DISEASE (IHD) . . . CONT.

Table 8. Complications of Myocardial Infarction

Complication Etiology Presentation Therapy
Arrhythmia
(a) tachycardia sinus, AF, VT, VF early/late see Arrhythmia section
(b) bradycardia sinus, AV block early
Myocardial
Rupture
(a) LV free wall transmural infarction 1-7 days pericardiocentesis or surgery
(b) papillary muscle inferior infarction 1-7 days surgery
(MR) anterior infarction
(c) ventricular septum septal infarction 1-7 days surgery
(VSD)
Shock/CHF LV/RV infarction within 48 hours fluids, inotropes, IABP
aneurysm
Post Infarct Angina persistent coronary stenosis anytime aggressive medical therapy
multivessel disease PTCA or CABG
Recurrent MI reocclusion anytime see above
Thromboembolism mural thrombus in Q wave 7~10 days, heparin, warfarin
infarction up to 6 months
Pericarditis post-MI 1-7 days NSAIDs
(Dressler's) autoimmune (Dressler’s) 2-8 weeks NSAIDs, steroids

Acute MI Risk Stratification

Cardiogenic Shock ST Elevation or LBBB No ST Elevation

Acute Phase

(5% - 10%) and Presentation ≤ 12 hours and Presentation > 12 hours

(25% - 45%) (50% - 70%)

Thrombolysis
CCU Phase

? Rescue PTCA, CABS

No Reperfusion Reperfusion
(19% - 45%) (55% - 81%)

Non-Acute Risk Stratification

In-Hospital Phase

High-Risk (30% - 35%) Intermediate/Low-Risk

• prior MI (65% - 70%)
• CHF
• Recurrent Ischemia
• High-Risk Arrhythmia Non-invasive Stress Testing

Cardiac Catheterization

Ischemia or Normal Results

Poor Functional Status

Cardiac Catheterization No further testing at this time

••Please note that Echocardiography is done routinely post-MI.
It is controversial whether an EF < 40% is by itself an indication for coronary angiography.
Figure 13. Acute MI and Predischarge Risk Stratification

C26 – Cardiology MCCQE 2002 Review Notes

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 ISCHEMIC HEART DISEASE (IHD) . . . CONT.

C. SUDDEN DEATH
Definition
❏ unanticipated, non-traumatic death in a clinically stable patient, within 1 hour of symptom onset
❏ immediate cause of death is
• V fib (most common)
• ventricular asystole
Significance
❏ accounts for ~ 50% of CAD mortalities
❏ initial clinical presentation in up to 20% of patients with CAD
Etiology
❏ primary cardiac pathology
• ischemia/MI
• LV dysfunction
• severe ventricular hypertrophy
• hypertrophic cardiomyopathy (HCM)
• AS
• QT prolongation syndrome
• congenital heart disease
❏ high risk patients
• multi-vessel disease
• LV dysfunction
Management
Acute
❏ resuscitate with prompt CPR and defibrillation
Long Term Survivors
❏ identify and treat underlying predisposing factors
❏ IHD
• cardiac catheterization to evaluate cardiac anatomy, LV function and need for revascularization
❏ Holter monitoring
❏ electrophysiologic studies
Treatment
❏ antiarrhythmic drug therapy
• amiodarone, ß blockers
❏ surgery
• revascularization to treat ischemia
• map-guided subendocardial resection
• cryoablation, radiofrequency ablation
❏ implantable cardioverter-defibrillator
Prognosis
❏ 1 year mortality post-resuscitation 20-30%
❏ predictors of recurrent cardiac arrest in the "survivor" of sudden cardiac death
• remote MI
• CHF
• LV dysfunction
• extensive CAD
• complex ventricular ectopy
• abnormal signal-averaged ECG

HEART FAILURE
❏ overall, CHF is associated with a 50% mortality rate at five years
❏ see Colour Atlas R3 and R4
Definitions and Terminology
❏ inability of heart to maintain adequate cardiac output to meet the demands of whole-body metabolism
and/or to be able to do so only from an elevated filling pressure(forward heart failure)
❏ inability of heart to clear venous return resulting in vascular congestion (backward heart failure)
❏ either the left side of the heart (left heart failure) or the right side of the heart (right heart failure) or both
(biventricular failure) may be involved
❏ there may be components of ineffective ventricular filling (diastolic dysfunction) and/or emptying
(systolic dysfunction)
❏ most cases associated with poor cardiac function (low-output heart failure) but some are not due to intrinsic
cardiac disease (high-output heart failure; this is discussed separately below)
❏ CHF is not a disease itself - it is a syndrome involving variable degrees of both forward and backward
heart failure
MCCQE 2002 Review Notes Cardiology – C27

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 CVS Pathology:
Lymphangitis

LYMPHANGITIS:
- Aetiology:
o Commonly β-Haemolytic-Strep or Staphylococcus Aureus
- Pathogenesis:
o Bacterial Infection Spread to Lymphatics Acute Inflammation
If Severe Cellulitis/Abscesses
If Very Severe Bacteraemia/Sepsis
- Clinical Features:
o Fever/Chills/Malaise
o Painful Red Subcutaneous Streaks
o Painful Lymphadenitis (Swollen draining lymph nodes)
- Complications:
o Abscesses
o Cellulitis
o Sepsis
- Investigations:
o Blood Culture + Swab any open wounds.
o FBC +/- CRP
- Management:
o Immobilisation of Limb
o Antibiotics
o Analgesia

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 CVS Pathology:
Myocarditis - Viral & Toxic

MYOCARDITIS VIRAL & TOXIC:

- Inflamma ion of he Hear M scle
o + Characterized by Myocyte Necrosis – (Positive Troponin I results seen in 35% of Myocarditis)
- 2 Main Aetiologies:
o Viral Myocarditis. (Eg. Coxsackievirus, Rhinovirus, Influenza, Parvovirus B19, etc)
Either Direct Myocardial Injury OR 2o AutoImmune Response
Heart Thickens & Weakens Systolic Heart Failure
o Toxic Myocarditis (Eg. Chemo Drugs, Cocaine, Alcohol, Diuretics, Antibiotics, Venom, CO, etc)
Myocardial Damage & Inflammation due to Either:
Hypersensitivity to Drugs
Direct Toxic Damage
- Clinical Features:
o (May be Asymptomatic)
o Symptoms:
Flu-Like Syx - (Fever, Fatigue, Malaise)
LV-Failure – (Dyspnoea/Orthopnoea/PND/Cough)
Chest Pain – (Due to Myocarditis +/- Pericarditis)
Palpitations (Arrhythmias)
- Complications:
o Cardiomyopathy Heart Failure
o Arrhythmias Sudden Death
o Pericarditis Pericardial Effusion
- Investigations:
o ECG & Continuous Telemetry
o Serial Troponins I/T - (Immediately, then @6hrs, then @24hrs)
o FBC (↑WCC), CRP (↑), ESR (↑)
o CXR (Cardiomegaly)
o Echo (Dilated, Poor Vent-Function)
- Management:
o **Bed Rest
o **CCF Triple Therapy (ACEi/ARB + B-Blocker + Diuretics)
o **Warfarin (Prevent Thromboembolism)
o Supportive Rx. (Fluids, Analgesia)
o Treat Underlying Cause if Possible

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 CARDIOMYOPATHIES . . . CONT.

MYOCARDITIS
❏ inflammatory process involving the myocardium (an important cause of dilated cardiomyopathy)
Etiology
❏ idiopathic
❏ infectious
• viral: Coxsackie virus B, Echovirus, Poliovirus, HIV, mumps
• bacterial: S. aureus, C. perfringens, C. diphtheriae, Mycoplasma, Rickettsia
• fungi
• spirochetal (Lyme disease – Borrelia burgdorferi)
• Chagas disease (Trypanosoma cruzi), toxoplasmosis
❏ acute rheumatic fever (Group A ß-hemolytic Streptococcus)
❏ drug-induced: emetine, doxorubicin
❏ collagen vascular disease: systemic lupus erythematosus (SLE), polyarteritis nodosa (PAN),
rheumatoid arthritis (RA), dermatomyositis (DMY)
❏ sarcoidosis
❏ giant cell myocarditis
Clinical Manifestations
❏ constitutional illness
❏ acute CHF
❏ chest pain - associated pericarditis or cardiac ischemia
❏ arrhythmias (may have associated inflammation of conduction system)
❏ systemic or pulmonary emboli
❏ sudden death
Investigations
❏ 12 lead ECG
• non-specific ST-T changes +/– conduction defects
❏ blood work
• increased CK, Troponin, LDH, and AST with acute myocardial necrosis
+/– increased WBC, ESR, ANA, rheumatoid factor, complement levels
❏ perform blood culture, viral titers and cold agglutinins for Mycoplasma
❏ chest x-ray
• enlarged cardiac silhouette
❏ echocardiography
• dilated, hypokinetic chambers
• segmental wall motion abnormalities
Natural History
❏ usually self-limited and often unrecognized
❏ most recover
❏ may be fulminant with death in 24-48 hours
❏ sudden death in young adults
❏ may progress to dilated cardiomyopathy
❏ few may have recurrent or chronic myocarditis
Management
❏ supportive care
❏ restrict physical activity
❏ treat CHF
❏ treat arrhythmias
❏ anticoagulation
❏ treat underlying cause if possible

MCCQE 2002 Review Notes Cardiology – C35

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 CVS Pathology:
Pericarditis

PERICARDITIS:
- Aetiology:
o Usually Secondary to:
Infection (**Viruses**, Bacteria, Fungi, Parasites)
Immuno (Rheumatic Fever, SLE, Post-MI, Drug Hypersensitivity)
Other (MI, Post-Cardiac Surgery, Neoplasia, Trauma, Radiation)
- Classification:
o According to Composition of Pericardial Exudate:
Serous (Non-Infectious Inflammatory Diseases – SLE, Uraemia, Tumours)
Purulent (Infective - by Microbes)
Fibrinous/Serofibrinous (Due to Acute MI, Ch. Radiation, SLE, Trauma)
Caseous (Tuberculosis)
Haemorrhagic (Due to Metastasis, Cardiac Surgery).
- Pathogenesis:
o Various Aetiologies Inflammation of the Pericardium
Thickening of Pericardium Pericardial Exudate (Serous Fluid + Pus/Fibrin/Blood)
Rubbing of Parietal & Visceral Pericardium Further Inflammation & Exudate.
- Clinical Features & Complications:
o Symptoms:
Pleuritic Chest Pain (Better on Sitting Forward; Worse on Inspiration & Lying Down)
Fever, Fatigue
Dry Cough
Syx of CCF (Dyspnoea, Fatigue)
o Signs:
Fever, Tachycardia
Muffled Heart Sounds.
Friction Rub
↑JVP
Heart Failure Signs if Tamponade
o Complications:
Cardiac Tamponade/Pericardial Effusion
If >3mths Chronic Constrictive Pericarditis (Requires Surgery)
- Diagnosis:
o ECG – (Classical PR-Depression + ST-Elevation + Tachycardia)
o CXR – (Pulmonary Congestion)
o ECHO – (?Pericardial Effusion)
- Management:
o Rx Underlying Cause
o Anti-Inflammatories (NSAIDs / Steroids)
o Analgesia

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 CVS Pathology:
Peripheral Vascular Disease, Varicose Veins & Chronic Leg Ulcers

Revision of Lower Limb Vascular Anatomy:

- Arterial & Venous Circulation of the Legs:

o
- T eM ceP

o
- Superficial & Deep Leg Veins:

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ACUTE ARTERIAL OCCLUSION CRITICAL LIMB ISCHAEMIA :

- NB: Emboli Can also Deposit in Other Arteries Too:

o Eg. Mesenteric Ischaemia Ischaemic Gut (++ Painful + Bloody Diarrhoea)
o Eg. Renal Art.Thrombosis Abdo/Back/Flank Pain, ARF, Oliguria, Hypertension

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PERIPHERAL VASCULAR DISEASE (AKA: Peripheral ARTERIAL Disease):
- Definition:
o Obstruction of any of the PERIPHERAL ARTERIES (Not including Coronaries/Aortic Arch/Brain)
- Aetiologies:
o **Atherosclerosis (Most Common)
o (Major Risk Factors):
Smoking (10x) - the single greatest modifiable cause of PVD.
Diabetes
Dyslipidaemia
Hypertension
- Pathogenesis:
o Atherosclerosis Obstruction of Peripheral Arteries Chronic Ischaemia
Eg. Arterial Ulcers, Leg Claudication, Ra na d s Phenomenon
- Clinical Features:
o Symptoms:
(Acute Critical Limb Ischaemia See Prev. Page):
Pain, Pallor, Paraesthesia, Paralysis, Pulseless
Chronic:
Mild-Severe Claudication (Leg Pain/Cramping/Weakness on Exercise)
o 1. On Exertion (Typically in Calves)
o 2. Relived by Rest (2-3mins)
o Reprod cible Same Cla dication Distance
o (+ Rest Pain if SEVERE)
Distal Pulses Weak/Absent
Skin Changes (Hair-Loss, Atrophic Skin, Ulcerations, Gangrene)
Other Atherosclerotic Lesions (Impotence, CVD, CAD)
- Investigations:
o Non-Invasive:
ABI (Ankle-Brachial Index):
Ankle BP <90% of Brachial BP = Abnormal
ABI <0.3 Rest Pain & Night Pain *( Risk of Critical Limb Ischaemia)
Doppler Ultrasound
Contrast CT-Angiogram
o Invasive:
**Femoral Angiography (DSA Lab) = Gold Standard
o (NB: Check for Carotid-Artery Stenosis!!)
- Treatment:
o 1. Conservative Mx Can 70% Improvement:
Stop Smoking, ETOH, Control Diabetes/ Dietary Cholesterol/HTN.
Exercise
o 2. Medical Management:
Cholesterol-Lowering (Statins/Fibrates/Bile-Resins(Cholestyramine)/Ezetimibe)
Antihypertensives (B-Blockers, ACE-Is/ARBs, Ca-Ch-Blockers)
Diabetes Mx
Champix
o 3. Surgery:
Angioplasty (Balloon + Stent)
Bypass Grafting (Eg. Femoral-Popliteal Bypass)
Plaque Excision (Endarterectomy)
Amputation

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VARICOSE VEINS:
- Aetiology:
o Mechanical: Prolonged Leg Dependence
o (Risk Factors = Obesity, Pregnancy, Familial)
- Pathogenesis:
o Superficial Valve Incompetence (Due to Incompetent Valves & Venous Dilation)
Further Venous Stasis, Congestion, Oedema, Pain & Thrombosis.
o (NB: Can Also Occur in Oesophagus, Rectum, & Scrotum)
- Clinical Features:
o Symptoms:
Diffuse Aching, Tightness & Night-Cramping
Persistent Leg Oedema
Wound Healing
o Signs:
Distended, Tortuous Superficial Veins
Ischaemic Skin Changes (Eg. Stasis Dermatitis)
Venous Leg Ulcers
o NB: Embolism is RARE since only Superficial Veins are affected!!!!
o Complications:
Recurrent Superficial Thrombophlebitis (See Below)
Lipodermatosclerois
Haemorrhage
Ulceration
- Investigation:
o Trendelenberg Test (Pt Supine; Raise leg & occlude Saphenous Vein @ Thigh. Then convert to
standing and let go. If Veins Fill From The Top = Positive Test)
- Management:
o Conservative: Elevation + Compression Stockings
o Surgical: Stripping of Varicose Veins

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CHRONIC SKIN ULCERS (Lower Limbs Most Common):
- Locations:
o Venous Gaiter Region
o Arterial Foot Region, Anterior Shin & Pressure Points
o Neuropathic Pressure Points

- PRESSURE ULCERS:
o Aetiology:
Long-Term Pressure (Elderly, frail, bedridden, paraplegia, coma)
o Pathogenesis:
Long-term skin pressure Skin Ischaemia Necrosis Ulcer
o Clinical Features:
Location & Appearance:
Bony Prominences (sacrum, coccyx, heels, occiput, knee, elbow)
Initially Non-blanching Erythema Wet, oozing ulcer.
Pain:
Often Painful unless Neuropathic/Paraplegia/etc.
o Treatment:
Pressure Redistribution (Regular Turning, Air Mattress)
Debridement & Dressings
Antibiotics

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- ARTERIAL ULCERS:
o Aetiology:
Arterial Insufficiency (PVD) (Typically due to Atherosclerosis)
**Common in Diabetes
o Pathogenesis:
Arterial Insufficiency Tissue Hypoxia/Ischaemia Skin Necrosis + Wound Healing
(NB: Often occurs following Trivial Trauma or Localised Pressure)
o Clinical Features:
Locations:
Anterior Shin
Pressure Points of Ankle & Foot (Bony Prominences)
Appearance:
Superficial
Well Defined Edges
Pale, Non-Granulating Base (Often Necrotic)
Does not bleed to touch
*No surrounding dermatitis (As opposed to Venous Ulcers)
(Cold, Pale feet + Absent Pulses)
Symptoms:
**Severely Painful - Relieved by Depression
(+ Claudication)
o Management;
(DO NOT use Compression Bandage!!)
Control Risk Factors Smoking Diabetes H pertension Lipids
Clean Wound +/- Debride
Reperfusion (Surgery/Angioplasty)

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- VENOUS ULCERS:
o Aetiology:
Venous Valve Insufficiency of the legs Sustained Venous Hypertension
(May be Associated with Varicose Veins)
o Pathogenesis:
Venous Insufficiency of legs Venous Hypertension & Stasis Ulceration
o Clinical Features:
Location & Appearance:
Gaiter Region Above Malleoli
Wet, Oozing**
Moist, Granulating Base Bleeds on touch.
S rro nding Stasis Dermatitis Ec emato s
Oedematous
Presence of Varicose veins
Symptoms:
**Only Mild Pain - Relieved by Elevation
Dependent Oedema
Treatment:
Compression Bandage
Elevation @ Rest
Exercise
Clean Wound

- NEUROPATHIC ULCERS:
o Aetiology:
**Diabetic Neuropathy + **Arterial Insufficiency
o Pathogenesis:
Diabetic Neuropathy Damage/Injury goes Unnoticed Further Tissue Damage/Necrosis
(+ Arterial Insufficiency Tissue Hypoxia/Ischaemia Tissue Damage/Necrosis)
o Clinical Features:
Location & Appearance:
Occurs over Pressure Points
Deep P nched-O t lcers
***Often with surrounding Calluses (Hyperkeratosis)
Don t Bleed to To ch
Symptoms:
**Painless
Treatment:
(DO NOT apply Compression Bandage!!)
Debride (+/- Amputation)
Antibiotics
Fastidious Foot Care (Clean Wound, Podiatrist)
Control Other Risk Factors Esp Diabetes Smoking H pertension Lipids

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 CVS Pathology:
Rheumatic Fever & Rheumatic Heart Disease

RHEUMATIC FEVER & RHEUMATIC HEART DISEASE

- Background:
o Rheumatic Fever (RF) = Delayed Autoimmune Complication of a GA H S ep Tonsillo/Pharyngitis.
o Acute Rheumatic Fever / Carditis (Acute Phase of Rheumatic Fever)
o Chronic Rheumatic Heart Disease (RHD) (Typically Mitral Stenosis)
o (NB: Rheumatic Fever (RF) & Rheumatoid Arthritis (RA) are 2 different diseases)
RF - Licks joints but bites heart! (Temporary Arthritis, but Permanent Valvular Damage)
RA – Licks heart but bites joints! (Mild Myocarditis, but permanent Severe Arthritis)
- Aetiology 3 Factors:
o 1. Environmental factor Group-A-Beta-Haemolitic Strep (Pyogenes) Pharyngitis
o 2. Genetic Susceptibility (3% of Population) HLA DR-2 & DR-3 Positive
o 3. Autoimmunity Autoantibodies (Antigenic Mimickery)
GABH-Strep Production of Anti-M-Protein Ab Cross React with Cardiac Conn. Tissue.
- Pathogenesis Mitral Stenosis:
o 1. GABH Strep Pharyngitis (In HLA-DR2/3-Positive Person)
o 2. 2wks Later, Immune Response to GABH-Strep Rheumatic Fever Carditis
(NB: 2wk Delay due to Lymphocyte Activation)
o 3. Subsequent GABH-Strep Infections Secondary (STRONGER) Immune Responses:
Recurrent Rh-Fever Cumulative Valve Damage (Fibrosis) Rheumatic Heart Disease

- Clinical Features & Diagnosis:

o Acute Rheumatic Fever:
o Jones Criteria Rules - Must Have:
1) Evidence of Previous GABH-Strep (Strep. Pyogenes) Infection
2) (2x Major Criteria) OR (1 Major + 2 Minor)
o 1. (Evidence of Previous Strep Infection):
Anti-Streptolysin-O Titre
Anti-DNaseB Antibodies
Positive Throat Swab Culture
o 2a. (Major Criteria)
J Joints (Migratory Polyarthritis Not necessarily arthralgia)
Carditis (Incl. Pericarditis Friction Rub, Quiet Heart Sounds, Tachy)
N Nodules (Subcutaneous, painless, on extensor surfaces)
E Erythema Marginatum (Non-Pruritic, Tinea-like Rings on Trunk & Limbs)
S S denham Chorea (Rapid, Involuntary Movements)
2b. (Minor Criteria)
(Fever)
(Arthralgia)
(Elevated ESR)
(Prolonged PR-Segment)

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 o Chronic Rheumatic Heart Disease:
Cardiac Murmurs (Typically L-Heart):
Mitral Stenosis (+/- Regurg)
Aortic Stenosis (+/- Regurg)
Mitral Stenosis:
Mi ral Facie (Malar/Butterfly Rash over Cheeks & Nose)
Mid-Diastolic Rumbling Murmur (Loudest @ Apex on Expiration & Axilla).
Pulm.Congestion & CCF (RV-Hypertrophy, Exertional Dyspnoea)
Atrial Fibrillation (From Atrial Stretch due to Mitral Stenosis)
Risk of Infective Endocarditis

- Management:
o (Primary Prevention Rx of Strep Pharyngitis):
10days PO Penicillin-V (Or Amoxicillin or Cephalexin)
o Secondary Prevention:
Admit on Suspicion:
Based on Jones Criteria
Treating Acute Rheumatic Fever:
GABH Strep Eradication (Single dose IM Benz-Pen-G)
Joint pain (Arthralgia) (NSAIDs or Codeine).
Chorea (Carbamazepine or Valproate if Necessary)
Carditis/Heart Failure (ACEi + B-Blocker + Diuretics)
Treating to Prevent Recurrent Attacks:
Continuous AB-Prophylaxis for Minimum 10 years after last ARF Episode.
o ***First-line: Monthly IM Ben-Pen-G
o **Second-line: BD Oral Pen-V
o *(If Penicillin Allergy: BD Oral Erythromycin).
o (Tertiary Prevention):
Cardiac Surgery - Mitral Valve Replacement

- GLS Question - What is the difference between Rheumatic Fever (RF) & Rheumatic Heart Disease (RHD)?
o (NB: Neither RF or RHD is an Infection, and Both can affect the Heart.)
(The Distinction is whether it is Reversible (RF) or Irreversible (RHD).)
o Rheumatic Fever:
An acute, Post-GAS-Infection Inflammatory Disease.
Occurs a few weeks After a GAS Infection.
If not treated aggressively Acute Rheumatic Carditis Valvular Deformities.
o Rheumatic Heart Disease:
The Chronic Stage which causes Irreversible Myocardial Damage & Heart Valve Damage.

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 VALVULAR HEART DISEASE . . . CONT.

Management
❏ medical
• antibiotic therapy tailored to cultures (penicillin, gentamicin, vancomycin, cloxacillin) minimum
of 4 weeks treatment
• serial ECGs - increased PR interval
• prophylaxis (JAMA 1997;227:1794)
• dental/oral/respiratory/esophageal procedures
• amoxicillin 2 g 1 hour prior
• GU/GI (excluding esophageal) procedures
• high risk: ampicillin + gentamicin
• moderate risk: amoxicillin, ampicillin, or vancomycin
❏ surgical
• indications: refractory CHF, valve ring abscess, valve perforation, unstable prosthesis, multiple major
emboli, antimicrobial failure, mycotic aneurysm
RHEUMATIC FEVER
Epidemiology
❏ school-aged children (5-15 yr), young adults (20-30 yr), outbreaks of Group A ß-hemolytic Streptococcus,
upper respiratory tract infection (URTI), social factors (low socioeconomic status (SES), crowding)
Etiology
❏ 3% of untreated Group A ß-hemolytic Streptococcus (especially mucoid, highly encapsulated stains,
serotypes 5, 6, 18) pharyngitis develop acute rheumatic fever
Diagnosis
❏ 1. Modified Jones criteria (1992): 2 major, or 1 major + 2 minor
• major criteria
• pancarditis
• polyarthritis
• Sydenham's chorea
• erythema marginatum
• subcutaneous nodules
• minor criteria
• previous history of rheumatic fever or rheumatic heart disease
• polyarthralgia
• increased ESR or C-reactive protein (CRP)
• increased PR interval (first degree heart block)
• fever
plus
❏ 2. Supported evidence confirming Group A Streptococcus infection: history of scarlet fever, group A
streptococcal pharyngitis culture, rapid Ag detection test (useful if positive), anti-streptolysin O Titers (ASOT)
Clinical Features
❏ Acute Rheumatic Fever: myocarditis (DCM/CHF), conduction system(sinus tachycardia, A fib), valvulitis
(acute MR), pericarditis (does not usually lead to constrictive pericarditis)
❏ Chronic: Rheumatic Valvular heart disease: fibrous thickening, adhesion, calcification of valve leaflets resulting
in stenosis/regurgitation, increased risk of IE +/– thromboembolic phenomenon. Onset of symptoms
usually after 10-20 year latency from acute carditis of rheumatic fever. Mitral valve most commonly affected.
Management
❏ acute treatment of Streptococcal infection (benzathine penicillin G 1.2 MU IM x 1 dose)
❏ prophylaxis to prevent colonization of URT (age < 40): benzathine penicillin G 1.2 MU IM q3-4 weeks,
within 10 yr of attack
❏ management of carditis in rheumatic fever: salicylates (2g qid x4-6 wk for arthritis), corticosteroids
(prednisone 30 mg qid x4-6wk for severe carditis with CHF)
AORTIC STENOSIS
Etiology
❏ congenital (bicuspid > > unicuspid) ––> calcified degeneration or congenital AS
❏ acquired
• degenerative calcified AS (most common) - "wear and tear"
• rheumatic disease
Definition
❏ AS = narrowed valve orifice (aortic valve area: normal = 3-4 cm2
severe AS = < 1.0 cm2
critical AS = < 0.75 cm2 )
❏ Note: low gradient AS with severely reduced valve area (< 1.0 cm2) and normal gradient in setting of
LV dysfunction
Pathophysiology
❏ pressure overloaded LV: increased LV end-diastolic pressure (EDP), concentric LVH, subendocardial ischemia
––> forward failure
❏ outflow obstruction: fixed cardiac output (CO)
❏ LV failure, pulmonary edema, CHF
MCCQE 2002 Review Notes Cardiology – C37

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 VALVULAR HEART DISEASE . . . CONT.

Symptomatology
❏ ASD (triad of Angina, Syncope, and Dyspnea; prognosis associated with onset)
❏ angina (exertional): due to concentric LVH and subendocardial ischemia (decreased subendocardial flow and
increased myocardial O2 demand), may have limitation of normal activity or resting angina in tight AS
(associated with < 5 year survival)
❏ syncope: due to fixed CO or arrhythmia (< 3 year survival)
❏ dyspnea (LV failure): systolic +/– diastolic dysfunction, pulmonary edema, may have orthopnea, if secondary
RHF may have ascites, peripheral edema, congestive hepatomegaly (< 2 years)
Signs of AS
❏ pulses
• apical-carotid delay
• pulsus parvus et tardus (decreased amplitude and delayed upstroke) narrow pulse pressure,
brachial-radial delay
• thrill over carotid
❏ precordial palpation
• PMI: sustained (LVH) +/– diffuse (displaced, late, with LV dilation)
• +/– palpable S4
• systolic thrill in 2nd right intercostal space (RICS) +/– along left lower sternal bender (LLSB)
❏ precordial auscultation
• most sensitive physical finding is SEM radiating to right articular head
• SEM – diamond shaped (crescendo-decrescendo), harsh, high-pitched, peaks progressively later
in systole with worsening AS, intensity not related to severity, radiates to neck, musical quality of
murmur at apex (Gallavardin phenomenon)
• +/– diastolic murmur of associated mild AR
• S2 – soft S2, absent A2 component, paradoxical splitting (severe AS)
• ejection click
• S4 – early in disease (increased LV compliance)
• S3 – only in late disease (if LV dilatation present)
Investigations
❏ 12 lead ECG
• LVH and strain +/– LBBB, LAE/A fib
❏ chest x-ray
• post-stenotic aortic root dilatation, calcified valve, LVH + LAE, CHF (develops later)
❏ ECHO
• test of choice for diagnosis and monitoring
• valvular area and pressure gradient (assess severity of AS)
• LVH and LV function
• shows leaflet abnormalities and "jet" flow across valve
❏ cardiac catheterization
• r/o CAD (i.e. especially before surgery in those with angina)
• valvular area and pressure gradient (for inconclusive ECHO)
• LVEDP and CO (normal unless associated LV dysfunction)
Natural History
❏ asymptomatic patients have excellent survival (near normal)
❏ once symptomatic, untreated patients have a high mean mortality
• 5 years after onset of angina, < 3 years after onset of syncope; and < 2 years after onset of CHF/dyspnea
❏ the most common fatal valvular lesion (early mortality/sudden death)
• ventricular dysrhythmias (likeliest cause of sudden death)
• sudden onset LV failure
❏ other complications: IE, complete heart block
Management
❏ asymptomatic patients - follow for development of symptoms
• serial echocardiograms
• supportive/medical
• avoid heavy exertion
• IE prophylaxis
• avoid nitrates/arterial vasodilators and ACEI in severe AS
❏ indications for surgery
• onset of symptoms: angina, syncope, or CHF
• progression of LV dysfunction
• moderate AS if other cardiac surgery (i.e. CABG) required
❏ surgical options (see Cardiac and Vascular Surgery Chapter)
• AV replacement
• excellent long-term results, procedure of choice
• open or balloon valvuloplasty
• children, repair possible if minimal disease
• adults (rarely done): pregnancy, palliative in patients with comorbidity, or to stabilize patient
awaiting AV replacement - 50% recurrence of AS in 6 months after valvuloplasty
• complications: low CO, bleeding, conduction block, stroke

C38 – Cardiology MCCQE 2002 Review Notes

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 CVS Pathology:
Shock

SHOCK:
- EXAM Definition = Indequate Perfusion of Vital Organs (Heart/Brain/Kidneys)
- Aetiologies:
o Hypovolemic Shock:
Severe Dehydration - (Eg. Sweating, Vom/Dia, DKA & Diuresis, Seeping Burns)
Severe Blood Loss/Haemorrhage
o Cardiogenic Shock:
Heart Failure - (Eg. Acute MI, Valvular, Cardimyopathy, Myocarditis)
o Distributive Shock:
Septic Shock (Extracellular Fluid Shift Hypotension Shock)
Anaphylactic Shock (Extracellular Fluid Shift Systemic Oedema & Hypotension).
Neurogenic Shock (Sudden loss of Vasomotor Tone Massive VenoDilation)
o Obstructive Shock:
Massive PE
Cardiac Tamponade (Massive Pericardial Effusion Ventricular Filling SV CO)
Tension Pneumothorax
- Compensatory Mechanisms:
o CARDIAC RESERVE = Maximal % that CO can Increase Above Normal. (Typically 300-400%)
o (IMMEDIATE) Sympathetic Tone:
Baroreceptors SNS HR & Contractility CO
o (DELAYED) Renal:
Angiotensin-II General Vasoconstriction BP
Vasopressin (ADH) Urine Output Blood Volume BP
EPO Haematopoiesis Blood Volume BP
- 3 Stages of Shock:
o 1. Non-Progressive Stage (<15% (<750mL)Blood Loss):
Stable & Reversible.
Signs of Compensated Hypovolaemia:
Tachycardia
Oliguria (Low Urine Production)
o 2. Progressive Stage (15-40% (750-2000mL)Blood Loss):
Unstable, Decompensating, Reversbile.
Signs of Decompensation:
Hypotension
Delayed CRT ( Peripheral Perfusion)
Tachycardia
Organ Failure (Anuria, Confusion/ALOC, Heart Failure, Tachypnoea, Acidosis)
But Still Reversible with Treatment:
Reverse Causative Agents + Volume Replacement (Bolus 2L IV) +/- Inotropes
(Otherwise Fatal if Untreated)
o 3. Irreversible Stage (>40% (>2000mL) Blood Loss):
Unstable, Irrecoverable Organ Failure.
Pt WILL Die Treatment will delay death, but NO treatment will save Pt s life.
Symptoms:
Multi-Organ Failure (Renal/Cardiac/Pulmonary/CNS)
Acidosis
Anuria.
Coma.

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 - Recognising And Assessing Shock ?
o Obvious Causes? (Eg. Bleeding, seeping burns)
o Compensation? (Eg. Tachycardia)
o Hypotension? (Despite Compensation)
o Poor Tissue Perfusion?
Peripheral Shutdown? (Eg. Cold, sweaty)
Renal Failure? ( Urine Output)
Brain Hypoxia? (Confusion, ALOC, Coma)
Myocardial Ischaemia (Chest Pain, Heart Failure)

BASIC SHOCK MANAGEMENT:

- Hypovolaemic Shock: Recognise Severity, Replace Loss (Normal Saline), Stop Ongoing Losses
- Septic Shock: Blood Culture, IV ABs, IV Fluids, Inotropes, Vasopressors, Remove Infective Focus
- Anaphylactic Shock: ABC 1o Assessment, IM/IV/SC Adrenaline, +/- Steroids
- Cardiogenic Shock: Inotropes, Nitrates/Angioplasty/Reperfusion, Valvuloplasty, Transplant
- Mechanical:
o Tamponade: Pericardiocentesis, Correct Cause (Trauma/Infection)
o Pneumothorax: Thoracocentesis (Pleural Tap), Correct Cause (Trauma/Infection/Fluid Overload)
o PE: Thrombolysis (TPA/Alteplase), Thrombectomy

FLUID RESUSCITATION PRINCIPLES See Fluid Management Surgical Context for more Info :
- How Much???
o 1. Bolus (Vol. Of Estimated Acute Losses)
o 2. Maintenance ***(4,2,1 Rule)***:
4ml/kg/hr for 1st 10kg
2ml/kg/hr for 2nd 10kg (Ie. 60ml/hr for 1st 20kg)
1ml/kg/hr for every kg thereafter. (Ie. 100ml/hr for 1st 60kg Plus 1ml/kg/hr onwards)
- What happens to the Different IV Fluids?:
o Crystalloids (IV Saline Hartmann’s) Na Redistributed into ECF & Blood due to Na/K-ATPase.
(25% remains in Blood)
:. Somewhat useful in Pressure Fluid Resuscitation.
o Colloid (Albumin, Gelatine) Colloid Is Not Redistributed (Stays in blood).
(ALL fluid given remains in Circulation) - (500mL of Colloid = 2L of Crystalloid)
:. Most effective fluid in Pressure Fluid Resuscitation.
o IV Dextrose Actively taken into cells :. None Remains in Blood.
:. NOT Suitable for Pressure Fluid Resuscitation. (Good for Hypoglycaemia & Post-Surgery)
- Blood:
o = The best fluid to replace blood loss
o But Saline/Hartmanns or Colloid are still ok.
o BUT Blood has risks (immunogenic/infections/etc)

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 GLS SHOCK CASES:

Case 1 - Bart:
- He is pale and sweaty, has a distended abdomen and obvious bilateral femoral fractures. His pulse is 140 and
his blood pressure is 75/40.
What signs of shock are evident?
o Pale and Sweaty
o Tachycardic
o Hypotensive
What Type of Shock is This?
o Hypovolaemic (Haemorrhagic) Shock:
Seems to be bleeding into abdomen Hypovolaemia CO Hypotension +
Compensatory Tachycardia
Could Bart be shocked without a change in BP?
o Yes. Young, healthy people are able to compensate for up to 1500mL of blood loss by Tachycardia &
Vasopression, but then deteriorate rapidly afterwards.
Is this consistent with our definition of shock ?
o No - Our definition stipulates a loss of blood pressure.
o (Clinically important - Need to remember that relying on blood pressure changes alone to diagnose
shock means that we will not recognise shock until a patient has lost 30 - 40 % of their blood volume
(class 3))
Initial Treatment:
o Fluid Replacement (For Hypovolaemia)

Case 2 Homer:
- Suddenly collapsed and clutched his chest. He is pale and sweaty. His pulse is 40 and his blood pressure is
85/60. He is feeling short of breath. You note that his JVP is raised. Moe thinks that Homer has had a heart
attack.
What signs of shock are evident?
o Pale & Sweaty
o Hypotensive
o Bradycardic Suggests Cardiogenic Shock
What Type of Shock is This?
o Cardiogenic Shock:
Myocardial Infarction Heart Failure ( CO Bradycardia BP.
H e ECG a a a e ca d a fa c . Why might this have caused him to be shocked
?
o Myocardial Infarction Disrupted heart Contraction & Conduction HR (in this case), and CO
If Homer has a heart that is not pumping properly (decreased contractility) which direction will his Starling
curve move?
o His starling curve will shift Downwards (Ie. Stroke Volume & CO will be Less @ any given End-
Diastolic Volume)

Initial Treatment:
o Inotropes (For the Bradycardia)

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Case 3 - Marge:
- Marge has bought a special new brand of extra strong hairspray. Begins to feel very itchy and notices small
bumps coming up on her head. She collapses. She is conscious but confused. Skin is bright red & covered in
raised lumps. Her pulse is 120 and her blood pressure is 90/60.
What signs of shock are evident?
o Tachycardic
o Hypotensive
What Type of Shock is This?
o Distributive (Anaphylactic) Shock:
Itchy, red, bumps on skin + History of new Hairspray Allergy (Systemic release of
Histamine & Other Vasoactive Mediators Loss of Vasomotor Tone BP &
Compensatory Tachycardia.
What has happened to her:
o Venous Tone? Decreased
o Venous Capacitance? Increased
o Venous Return? Decreased
o Preload? Decreased
o Stroke Volume? Decreased
o Cardiac Output? Decreased
Why has she collapsed?
o Due to Postural Hypotension Hypo-Perfusion of Brain Momentary loss of consciousness.
(Regained once supine)
Initial Treatment:
o Adrenaline (For the Anaphylaxis)

Case 4 Lisa:
- Lisa has been playing her saxophone. She collapsed gasping for breath. Her pulse is 120 and her Blood
Pressure is 65/45. Neck veins are distended. No breath sounds on the left side. Tension pneumothorax.
What signs of shock are evident?
o Tachycardic
o Hypotensive
What Type of Shock is This?
o Obstructive Shock:
Spontaneous Tension Pneumothorax from Playing Saxophone Intra-Thoracic Pressure
Inhibits Cardiac Filling (Seen as raised JVP) CO Hypotension & Compensatory
Tachycardia
How might Lisa’s tension pneumothorax cause her to be shocked?
o If pressure in the tension pneumothorax is high enough it may:
Compress (Decrease) Venous Return to the chest & heart CO Shock
Shift the Mediastinum such that one more of the Great vessels gets kinked CO
Shock
Initial Treatment:
o Chest Drain For the Pneumothorax.

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Case 5 - Maggie:
- Her dummy fell in dog poo. Now very sleepy. Her skin is a mottled grey colour. Pulse of 180 and blood
pressure is 60/40. Angry inflamed area on her face which has pus in the middle of it.
What signs of shock are evident?
o Tachycardic
o Hypotensive
o Grey, colourless skin
What Type of Shock is This?
o Distributive (Septic) Shock:
Bacterial infection from dog faeces Endo/Exo Toxin Systemic Cytokine Release Loss
of Vasomotor Tone BP Compensatory Tachycardia
How have the following been affected ?
o Venous tone? Decreased
o Vessel Permeability? Increased
o Myocardial function? Inotropic
Initial Treatment:
o Antibiotics
o (Also check Lactic Acid Level):
High levels can indicate severe infection
& Can indicate lack of Tissue Perfusion & Production of Lactica Acid by Anaerobic Metabolic
Pathways.

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 CVS Pathology:
Tumours of Vessels

Tumours of Vessels (Blood & Lymphatics): p520

- HAEMANGIOMA:
o = Closely Packed Aggregates of Sub-Cutaneous Capillaries filled with Blood.
o Congenital & Benign

- PYOGENIC GRANULOMA:
o = A Granulating Haemangioma
o Rapidly Growing Cutaneous/Mucosal Red Nodule (Bleeds Easily & Often Ulcerated.)
o Consist of Capillaries, Granulation Tissue & Bacteria
o Often follow Trauma (Inflammatory tissue due to injury)

- TELANGIECTASIA:
o = A Tiny AV-Malformation
o Blanching, Spider-Like, Red Lesions.
o Composed of Capillaries, Venules & Arterioles.
o (Usually in Skin/Mucous Membranes)

- LYMPHANGIOMA:
o = Benign Lymphatic Version of a Haemangioma – (= Aggregations of Lymphatic Vessels)
o May be Simple Capilla L mphangioma; or Ca e no L mphangioma C ic H g oma .

- KAPOSI SARCOMA “ANGIOSARCOMA” :

o = Highly Malignant Endothelial Tumour Caused by HHV-8 Infection.
o Typically in Terminal AIDs Pts (Or other Immunodeficiency)
o Early Stages = Asymptomatic Surgical Excision effective.
o Late Stages = Metastatic Chemotherapy Required.

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 CVS Pathology:
Valvular Heart Disease & Murmurs

VALVULAR HEART DISEASE:

- 4 Most Common Murmurs & Their Causes:
Valve Lesion Aetiology/Pathological Cause
Mitral Stenosis **Rheumatic Fever (Post Inflamm. Scarring)
Mitral Regurgitation Mitral Prolapse M omato s Degeneration
Rheumatic Fever (Post Inflamm. Scarring)
Infective Endocarditis
MI (Papillary Muscle Fibrosis/Dysfunction)
Rupture of Papillary Muscles/Chordae Tendineae
Dilated Cardiomyopathy (Dilation of Valve Annulus)
Congenital (Degeneration of Cusps)
Aortic Stenosis Age-Related Calcification
Rheumatic Fever (Post Inflamm. Scarring)
Aortic Regurgitation Age-Related Dilation of the Ascending Aorta
HT-Related Dilation of the Ascending Aorta
Rheumatic Fever (Post Inflamm. Scarring)
Infective Endocarditis
Marfan s S ndrome
Syphilitic Aortitis
Rheumatoid Arthritis
Ankylosing Spondylitis
- (Red = Most Common)

- Other Less Common Murmurs:

Cause Diastolic/Systolic?
Pulmonary Stenosis Congenital Heart Defect Systolic
Rheumatic Heart Disease
Pulmonary Regurgitation Pulmonary Hypertension Diastolic
Tricuspid Stenosis Rheumatic Fever Diastolic
Tricuspid Regurgitation R-Ventricular Dilation (Eg. R-V Systolic
Infarction)

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MITRAL STENOSIS:
- Aeitiology:
o 99% Rheumatic Heart Disease
- Pathogenesis:
o Recurrent Acute Rheumatic Fever Autoimmune Mitral Valve Fibrosis Stenosis
- Clinical Features
o Symptoms:
CCF (Exertional Dyspnoea/Orthopnoea/PND/Wet cough (Pulmonary Oedema))
o Signs:
Low-Volume Pulse
Mid-Diastolic Rumbling Murmur (Loudest @ Apex on Expiration & Axilla).
Mi al Facie (Malar/Butterfly Rash over Cheeks & Nose)
Pulm.Congestion & CCF (RV-Hypertrophy, Exertional Dyspnoea)
If Cor-Pulmonale (RV-Failure) JVP, Pulsatile Liver, Ascites, Peripheral Oedema)
- Investigations:
o ECHO (Diagnostic)
o ECG (May have A.Fib, LA-Hypertrophy, RVH)
o CXR (LA-Hypertrophy, Pulmonary Congestion)
- Management:
o Medical Treat A.Fib, Warfarin, CCF Triples (ACEi + B-Blocker + Diuretics)
o Surgical Mitral Valvuloplasty (Repair) or Replacement

MITRAL INCOMPETENCE/REGURGITATION:
- Aeitiology:
o Myxomatous Degeneration, Rheumatic Fever, Infective Endocarditis or Ischaemia
- Pathogenesis:
o Myxomatous Degeneration (Pathological weakening of valve connective tissue)
o Rheumatic Fever Autoimmune Mitral Valve Fibrosis Stenosis & Regurg
o Infective Endocarditis Vegetations on Valve Edges Improper Closure Regurg
o Ischaemia (Post MI Papillary Rupture Ballooning of Mitral Valve during Systole)
- Clinical Features & Complications:
o Symptoms:
Exertional Dyspnoea
Wet Cough (Pulmonary Oedema)
o Signs:
High-Pitched Pansystolic Murmur (Loudest @ Apex on Expiration Axilla)
L-Parasternal Heave (L-Atrial Hypertrophy)
- Investigations:
o ECHO (Diagnostic)
o ECG (LAH, LVH)
o CXR (LAH, LVH, Pulmonary Congestion)
- Management:
o Medical CCF Triples (ACEi + B-Blocker + Diuretic)
o Surgical Mitral Valvuloplasty (Repair) or Replacement

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AORTIC STENOSIS:
- Aeitiology:
o Age-Related Calcification (Wear & Tear)
o (Also Rheumatic Heart Disease in 10% of cases)
- Pathogenesis:
o Wear & Tear Degeneration + Calcification.
- Clinical Features:
o Symptoms:
Ao ic S eno i T iad
1. Angina - (Due to LV-Hypertrophy & Demand)
2. Exertional Dyspnoea - (Due to Congestive Heart Failure)
3. Syncope/Dizziness - (Due to Cerebral Perfusion)
o Signs:
LV-Hypertrophy Displaced Apex Beat.
Loud Ejection Systolic Murmur +/- Thrill (Loudest @ 2ndICS R-Sternal Border)
Worse on Expiration
Radiates to Carotids
Congestive Heart Failure Dyspnoea + Pulmonary Oedema
- Investigations:
o ECHO (Diagnostic)
o ECG (LV-Strain & LVH)
o CXR (Calcified Valve, LVH, CCF/Pulmonary Oedema)
- Management:
o If Symptomatic Requires Cardiac Surgery:
Aortic Valve Replacement.
Or Balloon Valvuloplasty

AORTIC INCOMPETENCE/REGURGITATION:
- Aeitiology:
o Age/H e en ion S hili ic Ao i i Aortic Root Dilation
- Pathogenesis:
o Dilation of Aortic Root Valve Leaflets Misalignment Aortic Regurg
- Clinical Features & Complications:
o Symptoms:
Aortic Triad:
1. Angina - (Due to LV-Hypertrophy & Demand)
2. Exertional Dyspnoea - (Due to Congestive Heart Failure)
3. Syncope/Dizziness - (Due to Cerebral Perfusion)
o Signs:
Waterhammer Pulse (Bounding and Rapidly Collapsing)
Displaced Apex Beat (Due to LV-Hypertrophy)
Diastolic Decrescendo Murmur (Loudest @ R.2ndICS on Expiration)
Tachycardia (Compensation for CO)
- Investigations:
o ECHO (Diagnostic)
o ECG (LAH + LVH)
o CXR (LAH + LVH, CCF/Pulmonary Oedema)
- Management:
o Medicine: Vasodilators + CCF Triple Therapy (ACEi + B-Blocker + Diuretic)
o Surgery: Aortic Valve Replacement

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 CVS Pathology:
Vasculitides

NB Raynaud s Phenomenon A common feature of Blood Vessel Disorders):

- Aetiology: Exaggerated Vasoconstriction of Digital Arteries (Cold/Emotional Trigger)
- Clinical Features: Paroxysmal Pallor/Cyanosis of Digits (hands/feet)
o Usually benign

Vasculitis (General Vessel Inflammation):

- NB The e a e diffe en fo m of Va c li i Only focus on those Highlighted)
- 2 Aetiologes:
o Immune...OR...Infective
o (NB: MUST distinguish between aetiologies since treatments Contradict each other)
- Signs/Symptoms:
o Generals Fever, Malaise, Myalgias & Arthralgias.
o Specifics - Depend on Vessels Affected.

VASCULITIS IN LARGE ARTERIES:

** GIANT CELL (TEMPORAL) ARTERITIS:

- Aetiology:
o Chronic, Autoimmune Disease of TEMPORAL and OPHTHALMIC Arteries
- Pathogenesis:
o Autoimmune Inflammation of Temporal & Ophthalmic Arteries
- Clinical Features:
o (Typically in o
o Temporal Arteritis Triad:
1. Headaches
2. Jaw Claudication
3. Tender Temples
o + Fever, Fatigue, Weight Loss
o +/- Sudden Painless Blindness (Transient or Permanent)
o Sometimes Polymyalgia Rheumatica (Neck, Shoulder & Hip Pain/Stiffness)
- Complications:
o **RED FLAG If Untreated, can BLINDNESS
o Aortic Arch Syndrome Aortic Aneurysm +/- Rupture.
- Investigation:
o ESR + CRP **Temporal Artery Biopsy
(NB: Biopsy = Definitive Diagnosis)
o +/- Cranial Angiography
- Treatment:
o High-Dose Prednisone
o (+/- Azathioprine or Methotrexate if severe)

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 VASCULITIS IN MEDIUM ARTERIES (MUSCULAR ART):

POLYARTERITIS NODOSA:
- Aetiology:
o SYSTEMIC Autoimmune Inflammation of Medium Arteries.
- Pathogenesis:
o Immune Complex Deposition in Arteries (Particularly Renal Arteries)
Necrosis of Vessels Rupture/Thrombosis/Aneurysms Infarct/Ischaemia.
- Clinical Features:
o General Symptoms:
**Fever
Rash
Malaise
Weight Loss
o Organs-Specific Symptoms:
Skin Palpable Purpura, Ulcers
End-Arteries Gangrene, Digital Infarcts
Muscles Myalgia
Joints - Arthralgia
Kidneys - Hypertension
Heart Angina, MI, CCF
GIT Abdo Pain, Haematemesis, Malena, Ischaemic Gut
Liver Jaundice
Neuro Peripheral Neuropathy, Paraesthesia, Weakness
- Complications:
o Rupture/Thrombosis/Aneurysms Localised Infarct/Ischaemia
- Investigation:
o ESR + CRP
o Vascular Biopsy
o Or Angiogram
- Treatment:
o Prednisone
o + Cyclophosphamide (Chemotherapy)

KAWASAKIS DISEASE Mucocutaneous Lymph Node Syndrome :

- See Paediatrics

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 VASCULITIS IN SMALL ARTERIES (CAPS & ARTERIOLES):

WEGENER S GRANULOMATOSIS:
- Aetiology:
o Autoimmune (Probably Hypersensitivity to Inhaled Agents)
- Pathogenesis:
o Autoimmune Hypersensitivity Reaction to Inhaled Agent Necrotizing Lung Granulomas (~TB)
(Also Renal Glomerulonephritis).
- Morphology:
o Granulomatous Inflammation in Lungs & URT
URT Mucosal Granulomatous Lesions
Granulomas (which may cavitate) in the Lungs
o Necrotizing Vasculitis around Small Vessels (Particularly Renal/Glomerular).
Focal (early) or Diffuse (late) Glomerular Necrosis Glomerulonephritis
- Clinical Features:
o Systemic:
Fever, Malaise, Weakness, Myalgia, Rash.
o Respiratory:
Initially (Flu-like Illness):
Fever
Cough
Rhinorrhoea
Otitis Media
Later (Similar Features to TB):
Haemoptysis
Chronic Pneumonitis
Bilateral Cavitary Granulomas in Lungs
Chronic Sinusitis
o Renal:
Glomerulonephritis (Nephrotic +/- Nephritic Syndrome)
- Investigations:
o American College of Rheumatology Criteria (>2 of):
URTI Inflammation (Nasal/Oral)
CXR (Nodules/Cavitations)
Urinalysis (Protein/Casts)
Biopsy (Granulomatous Inflammation)
o + ANCA
o ESR & CRP
- Treatment:
o Prednisone (+/- Cyclophosphamide)
o + High-Dose Methotrexate
o (NB: 80% 1yr Mortality if Not Treated)

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CHURG-STRAUSS SYNDROME:
- Aetiology:
o Unknown
- Pathogenesis:
o Granulomatous Inflammation of Small/Medium-Sized Vessels.
- Clinical Features:
o Churg-Strauss Triad:
Systemic Vasculitis
Asthma
Allergic Rhinitis
o Others (Angina, Myocarditis, Neuropathy)
- Investigation:
o +ANCA
o ESR
o FBC (Eosinophilia)
- Management:
o Prednisone +/- Cyclophosphamide
o Then Methotrexate

BUERGER S DISEASE THROMBOANGIITIS OBLITERANS

- Aetiology:
o **Cigarette Smoking Direct Endothelial Toxicity
- Pathogenesis:
o **Cigarette Smoking Direct Endothelial Toxicity Vasculitis Ischaemia Gangrene
- Clinical Features:
o ***Occurs in Chronic HEAVY Smokers
o Digital Infarcts - Gangrene
o Distal Limb Ischaemia (Claudication, Arterial Ulcers, Gangrene)
- Treatment:
o Smoking Cessation (In early stages) Dramatic Relief.

(Lumen is occluded by thrombus containing abscesses (arrow), and the vessel wall is infiltrated with leukocytes.)

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