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GP block (Y3) > Week 10: IHD, AF, HF > Flashcards

Week 10: IHD, AF, HF Flashcards

1
Q

chest pain approach

A

history

cardiac examination

investigations

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2
Q

chest pain history

A
  • General
    • Nature
    • Onset
    • Duration
    • Site
    • Radiation
      • Cardiac
        • Acute onset
        • Central crushing pain
        • Radiates to persons jaws, arm or back
      • Non cardiac e.g. pulmonary or MSK
        • Persistent
        • Localised
        • Worse on inspiration
  • Exacerbating/ relieving
    • Angina- exertional
    • MSK or pulmonary- worse on inspiration
  • Associated symptoms
    • Breathlessness (cardiac and pulmonary)
    • Palpitations
    • Dizziness
    • NPD
  • Ask about previous pain and examination e.g. ECG or X-ray
  • Cardiovascular risk factors
    • Male
    • Older
    • Smoking
    • HTN
    • DM
    • Hypercholesteremia
    • Fx
  • Psychogenic factors e.g. anxiety and depression
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3
Q

cardiac examination summary

A
  • Hands: CRT, nail signs e.g. splinter haemorrhage
  • Pulse/ BP
  • Face: JVP, signs of cyanosis, corneal arcus, xanthomata, tooth decay, sweating
  • Inspect: chest wall for deformity and scars
  • Palpate: Apex beat/Thrills (valves)/ heaves (RVH)
  • Auscultate: heart sounds, manoeuvres, lung fields
  • Ankles- oedema
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4
Q

investigations for chest pain

A
  • ECG
  • troponin
  • FBC, U and E, TSH, liver function, CRP, BM, BNP
  • Chest X-ray
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5
Q

Cardiac causes of chest pain

A
  • Acute coronary syndrome
    • Unstable angina
    • MI
  • Stable angina
  • Dissecting thoracic aneurysm e.g. AAA
    • Tearing pain radiating to back
    • High BP
  • Pericarditis
    • Sharp, constant pain relieved by sitting forwards
    • Pericardial rub
  • Acute congestive cardiac failure
    • Ankle sweeling, tiredness, severe breathlessness, elevated JVP
  • Arrhythmias
    • Chest pain associated with palpitations, breathlessness, and syncope
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6
Q

Pulmonary causes of chest pain

A
  • Pulmonary embolisms
    • Acute onset breathlessness, pleuritic chest pain (worse on inspiration, pain can be localised), cough, haemoptysis’s, syncope, signs of DVT
  • Pneumothorax
    • Sudden onset pleuritic pain, breathlessness, reduced chest wall movement and breath sounds, increased resonance of percussion , tracheal deviation, tachycardia, hypotension
  • Community acquired pneumonia
    • Cough, sputum, wheeze, dyspnoea, pleuritic chest pain
  • Lobar collapse
    • Localised chest pain, breathlessness, cough. Reduced chest wall movement, dull percussion note, reduced breath sounds
  • Lung cancer
    • Chest/shoulder pain, haemoptysis, dyspnoea, weight loss, appetite loss, hoarseness, cough, finger clubbing
  • Pleural effusion
    • Localised chest pain, progressive breathlessness, reduced chest wall movement, stony dull percussion, absent breath sounds
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7
Q

ACS summary

A

(Stable angina is not an ACS but comes under the bracket of IHD)

A terms used to describe conditions which cause sudden, reduced blood flow to the heart

  • Unstable angina
  • NSTEMI
  • STEMI

Causes

  • reduction of blood flow to part of myocardium, caused by a blood clot that forms on a patch of atheroma within a coronary artery.
  • Problems range from unstable angina (reduced blood flow)→ MI (total arterial blockage).
  • Reduced blood supply →ischaemia → pain
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8
Q

RF for IHD

A
  • Increased age
  • Male
  • HTN, hypercholesteremia
  • Smoking
  • Obesity/ lack of activity
  • DM
  • Fx
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9
Q

Suspect ACS if

A
  • Pain last >15 mins
  • Pain is dull, central/crushing
  • Nausea, vomiting, sweating, syncope
  • Breathlessness
  • Haemodynamic instability
  • New onset
  • No response to GTN
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10
Q

investigations for ACS

A
  • 12-lead ECG
    • STEMI/NSTEMI
    • Troponin I/T
    • FBC, BM
    • CXR, echocardiography
    • Coronary angiography
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11
Q

if cardiac sounding chest pain >72 horus ago

A

(consider diagnosing in primary care)

  • ECG signs will show pathological Q wave, LBBB, ST-segment abnormalities
  • High sensitivity serum troponin
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12
Q

management of ACS

A

will be dependent on the levels of the ACS.

Medical emergency à immediate hospital admission

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13
Q

unstable angina presentation

A
  • Angina occurs at any time
  • Normal ECG and troponins
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14
Q

NSTEMI presentation

A
  • Normal/ ST depression or T wave inversion
  • Elevated troponins
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15
Q

management of UA and NSTEMI is

A

the same

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16
Q

Management of UA/ NSTEMI

A
  1. Morphine
  2. Aspirin 300mg loading dose
  3. LMWH
  4. Clopidogrel
  5. Angiography
  6. Consider nitrates
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17
Q

STEMI presentation

A
  • Hyperacute T waves or ST elevation
  • Elevated troponins
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18
Q

management of STEMI (long but think MONA)

A
  1. Cardiopulmonary resus and defib if cardiac arrest
  2. Aspirin 300 mg orally
  3. Clopidogrel
  4. Morphine
  5. Oxygen is sats <94%
  6. GTN sublingual
  7. If <120 minutes of ECG diagnosisà percutaneous coronary intervention
  8. If >120 mins thrombolysis
    1. thrombolytic therapy e.g. streptokinase or alteplase
    2. unfractionated heparin or LMWH
  9. antiplatelet therapy
    1. low dose aspirin long term
    2. clopidogrel
  10. Beta blockers e.g. bisoprolol
  11. ACEi àremodelling of the heart
  12. Statins / metformin
  13. Coronary bypass surgery
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19
Q

if <120 of ECG diagnosis of STEMI

A

percutaneous coronary intervention (PCI)→ get to cath lab

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20
Q

if >120 of ECG diagnosis of STEMI

A
  1. thrombolytic therapy e.g. streptokinase or alteplase
  2. unfractionated heparin or LMWH
21
Q

stable angina

A
  • Angina is chest pain caused when the myocardium’s blood supply is restricted due to narrowing of one or more coronary arteries by plaques
  • Pain in stable angina occurs during exercise or emotional stress
22
Q

RF for stable angina

A
  • Same as ACS
  • Cardiac abnormalities e.g. aortic stenosis or hypertrophic obstructive cardiomyopathy
23
Q

presentation of stable angina

A
  • Typical angina pain
    • Constricting discomfort in the front of the chest, neck, shoulders, jaw or arms.
    • Precipitated by physical exertion.
    • Relieved by rest or GTN in about five minutes.
    • Atypical angina pain
      • Two of the features of typical angina
24
Q

diagnosis of stable angina

A
  • History
    • Of pain
    • Risk factors
    • Cardiac examination
    • Investigations
      • 12-lead ECG
      • FBC (anaemia) , U and E, TSH, troponin I/T, cholesterol, LFTs
      • Echocardiography
25
Q

management of stable angina

A
  • Modification of cardiovascular risk factors
    • Lose weight
    • Stop smoking
    • Exercise
    • Diet modification
    • Blood pressure management
    • GTN when angina occurs
      • Stop what they are doing and rest
      • Use GTN spray (spray under tongue)
      • Take second dose after 5 mins if pain has no eased (take another spray after 5 mins if still not raised)
      • If pain does not ease after 3 doses call 999
    • Further pharmacological treatment
      • First line- Beta blocker or CCB
      • Add on- long acting nitrate
    • Coronary revascularisation if patient at high risk of STEMI
    • ACEi
    • Statins
26
Q

What is Dressler syndrome? When does it occur?

A

Dressler’s syndrome is an autoimmune mediated pericarditis occurring 2-6 weeks after a myocardial infarction. The patient presents with:

  • pleuritic chest pain in nature
  • fever
  • friction rub sound
27
Q

AF

A
  • Tachycardiac arrythmia
28
Q

AF increases risk of

A
  • Cardioembolic stroke- due to statis of blood in the atria
  • Cardiac instability
  • Reduced CO= HF
  • And higher risk of death
29
Q

RF of AF

A
  • High BP
  • Atherosclerosis
  • hyperthyroidism (thyrotoxicosis)
  • Heart valve disease
  • Congenital heart disease
  • COPD
  • PE
30
Q

triggers of AF

A
  • Binge drinking
  • Obesity
  • Cocaine and amphetamines
31
Q

presentation of AF

A
  • Pulse- tachy and irregularly irregular
  • Symptoms
    • Breathlessness
    • Palpitations
    • Syncope/dizziness
    • Chest discomfort
    • Stroke or TIA
32
Q

investigations for AF

A

ECG

  • Tachycardic
  • Absent P waves
  • Wavy baseline
  • Irregularly irregular

Echocardiogram

  • if structural heart disease suspected e.g. if murmur on exam
  • where cardioversion is being considered
  • baseline echocardiogram required to inform long term management

if paroxysmal → 24h cardiac monitor

33
Q

management of AF

A

anticoagulation

rate control

rhythm control

34
Q

anticoagulation for AF

A

DOAC- apixaban, dabigatran, edoxaban, rivaroxaban

  • Assessment of stroke risk- CHA2DS2-VASc stroke risk score
35
Q

rate controller in AF

A

B blockers

36
Q

rhythm control in AF if haemodynamically unstable

A
  • electrical cardioversion
37
Q

rhythm control in AF if haemodynamically stable

A
  • Long term rhythm control- B blockers, consider amiodarone for people with left ventricular impairment or HF
38
Q

HF risk /causes

A
  • Ischaemic heart Disease (most common)
  • Hypertension
  • Valvular heart disease (Rheumatic fever in elderly)
  • Atrial fibrillation
  • Chronic lung disease (right sided- cor pulmonale)
  • Cardiomyopathy (Hypertrophic, dilated and right ventricular, post viral, post-partum)
39
Q

presentation of HF

A
  • Dyspnoea on exertion and fatigue (may limit exercise tolerance).
  • Orthopnoea (breathlessness on lying flat).
  • Paroxysmal nocturnal dyspnoea (PND).
  • Fluid retention (may cause pulmonary or peripheral oedema. If the latter, the patient may complain of weight gain, ankle swelling, or a bloating sensation).
  • Nocturnal cough (± pink frothy sputum) or wheeze.
  • Light-headedness or syncope.
  • Anorexia.
40
Q

investigations for HF

A
  • Bloods
    • FBC, LFTs, TFTs, U&E
    • Ferritin and transferrin (haemochromatosis)
  • BNP- NT-proBNP
  • CXR
  • Echocardiography
  • Cardiac MRI – assessment of LV function
41
Q

management of heart failure

A

BAD

  • Beta blockers
  • ACEi/ARB
  • Diuretics
    • Loop diuretics most effective
      • Furosemide
        • IV (if very fluid overloaded)
        • Bumetanide
          • Better absorbed orally
      • If hypokalaemia starts- spironolactone
    • Nitrates
42
Q

CXR in heart failure

A
  1. Cardiomegaly
  2. Could be pleural effusions
  3. Perihilar shadowing/consolidations
  4. Alveolar oedema
  5. Air bronchograms phenomenon of air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli
  6. Increased width of vascular pedicle
43
Q

classification of HF by

A

EF or ventricle involved

44
Q

Ejection fraction

A
45
Q

stroke volume

A

end diastolic volume - end systolic volume

46
Q

HFrEF (most common)

A
  • Reduce EF <40%
  • Contractility problem
47
Q

HFpEF

A
  • Preserved ejection fraction
  • Filling problem
    • Stiff/smaller ventricles
48
Q

left sided heart failure

A
  • Causes: IHD, MI, HTN, valvular
  • Presentation: pulmonary oedema, fatigue, tiredness, SoB

GP block (Y3) (39 decks)

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