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Year 3: Cardiology > Cardiology: Ischaemic Heart Disease II > Flashcards

Cardiology: Ischaemic Heart Disease II Flashcards

1
Q

A patient presented with an MI following a 1st-degree heart block. Where is the MI most likely to have taken place? [1]

A

MI has most likely affected the inferior leads (right coronary arteries also provide blood supply to the AV node).

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2
Q

What investigations should you conduct for ACS? [2]

A

ECG:
- STEMI
- NSTEMI
- T wave inversion
- R/LBBB

Troponin levels

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3
Q

Label A & B

A
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4
Q

What are the criteria or ECG changes to be classified as a STEMI [4]

A

Cinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:

  • 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years
    or
  • ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
  • 1.5 mm ST elevation in V2-3 in women
  • 1 mm ST elevation in other leads
  • new LBBB (LBBB should be considered new unless there is evidence otherwise)

USE THE J POINT TO WORK OUT IF ACS IF OCCURRING

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5
Q

Asides from ST elevation / ST depression (STEMI & NSTEMI), what other ECG changes may indicate ACS? [1]

How can this change help ID where ischaemia is? [1]

A

T wave inversion may be a feature of myocardial ischaemia, T wave inversion

T wave inversion even in the absence of ST changes.

Generally relates to the territory of the coronary artery affected by ischaemia.

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6
Q

What does fixed vs dynamic T wave inversion indicate in ACS? [1]

A

T wave inversion may be fixed, which is usually associated with a previous ischaemic event and associates with Q waves.

Alternatively, T wave inversion may be dynamic, which is associated with& acute myocardial ischaemia.

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7
Q

Name 5 differentials for causes of troponin rises [5]

A

Myo/pericariditis
CKD
PE
Cardiomyopathy
Afib / tachyarythmais

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8
Q

What indicates a patient is suffering unstable angina c.f STEMI or NSTEMI?

A

Unstable angina is diagnosed when there are symptoms suggest ACS, the troponin is normal, and either:

A normal ECG
Other ECG changes (ST depression or T wave inversion)

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9
Q

Describe how ST changes occur in a STEMI [3]

A

Firstly get tall tented / hyperacute T wave

This then moves to J point meeting the increased T wave

Then a Q wave will develop

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10
Q

Describe how ST changes occur in a NSTEMI [2]

A
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11
Q

In patients presenting with symptoms of acute coronary syndrome, the initial management can be remembered with the “[]” mnemonic

What is the immediate pain relief and management for ACS? [5]

A

“CPAIN” mnemonic:

C – Call an ambulance
P – Perform an ECG
A – Aspirin 300mg
I – Intravenous morphine for pain if required (with an antiemetic, e.g., metoclopramide)
N – Nitrate (GTN)

Oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines

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12
Q

Describe the management for a STEMI

A

Immediately assess eligibility for coronary reperfusion therapy. There are two types:

Primary coronary intervention:
- Offered if the presentation is within 12 hours of onset of symptoms AND PCI can be delivered within 120 minutes of the time when thrombolysis could have been given
- Prior to PCI: ‘dual antiplatelet therapy’, i.e. aspirin + another drug.
if the patient is not taking an oral anticoagulant: aspirin & prasugrel;
if taking an oral anticoagulant: aspirin & clopidogrel
- During PCI: patients with radial access:
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
- During PCI: patients with femoral access:: bivalirudin with bailout GPI

Thrombolysis:
- should be offered within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when thrombolysis could have been given
- streptokinase, alteplase and tenecteplase.

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13
Q

How do you determine which drugs to give if prior to PCI based on their current medication? [2]

A

Prior to PCI: ‘dual antiplatelet therapy’, i.e. aspirin + another drug.:

If the patient is not taking an oral anticoagulant:
- prasugrel

If taking an oral anticoagulant:
- clopidogrel

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14
Q

How do you determine which drugs to give if during to PCI based on their access? [2]

A

patients with radial access:
- unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)

Patients with femoral access:
- bivalirudin with bailout GPI

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15
Q

What is the treatment regimen for NSTEMI? [6]

A

B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)

Also condiser anti-emetic such as ondansetron

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16
Q

Ticagrelor works by which MoA? [1]

Name two more drugs that work this way [2]

A

P2Y12 inhibitor: inhibit the platelet activation and aggregation by antagonizing the platelet P2Y12 receptor.

clopidogrel
prasugrel

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17
Q

What do you need to consider with regards to blood glucose levels with STEMI & NSTEMI? [1]

A

Manage hyperglycaemia by keeping blood glucose levels < 11 mmol/L

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18
Q

What is the medication used following NSTEMI as seconary prevention? [6]

A

6 As AAAAAA

  • Aspirin 75mg once daily indefinitely
  • Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
  • Atorvastatin 80mg once daily
  • ACE inhibitors (e.g. ramipril) titrated as high as tolerated
  • Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
  • Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
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19
Q

Why do you need to monitor renal function with secondary prevention of NSTEMIs? [2]

A

Taking ACE inhibitors and aldosterone antagonists

Both can cause hyperkalaemia (raised potassium).

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20
Q

What is the name of the score used to calculate risk assessment / 6 month predicted 6‑month mortality for patients with ACS? [1]

A

Global Registry of Acute Coronary Events (GRACE)

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21
Q

State the different risk stratifications based of GRACE scores [5]

A
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22
Q

How do you determine if an NSTEMI patient needs coronary angiography (with follow-on PCI if necessary):

Immediately [1]
Within 72 hours [1]

A

immediate:
- patient who are clinically unstable (e.g. hypotensive)

within 72 hours:
- patients with a GRACE score > 3% i.e. those at immediate, high or highest risk

coronary angiography should also be considered for patients is ischaemia is subsequently experienced after admission

23
Q

What drug therapy should be given to patients with NSTEMI undergoing PCI? [2]

A

unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not

further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug) prior to PCI:

If the patient is not taking an oral anticoagulant:
- prasugrel or ticagrelor

if taking an oral anticoagulant:
- clopidogrel

24
Q

How do you decide which PY12 inhibitor should give for conservative managament of unstable angina / NSTEMI based off their risk of bleeding? [2]

A

if the patient is low-risk of bleeding:
- ticagrelor

if the patient is at a high-risk of bleeding
- clopidogrel

25
Q

Complications of MI:

Patients commonly enter cardiac arrest due to developing which arythmia? [1]

A

ventricular fibrillation

26
Q

Why may bradycardia occur post MI? [1]

A

If AVN is damaged, get atrioventricular block.

Post inferior MI

27
Q

What condition is common 48hrs post a transmural MI? [1]

How can you detect this upon examination? [1]

A

Pericarditis

Perfom a pericardial rub: generally heard over the left sternal border, it is often louder at inspiration but sometimes can be better heard on forced expiration while the patient bends forward

28
Q

Describe what is meant by Dressler’s syndrome

A

Post-myocardial infarction syndrome:

It usually occurs around 2 – 3 weeks after an acute myocardial infarction

It is caused by a localised immune response that results in inflammation of the pericardium

29
Q

How does Dressler’s syndrome present? [6]

A

2-6 weeks post-MI

combination of:
- fever
- pleuritic pain
- dysopnoea
- pericardial effusion that can lead to cardiac tamponade
- a raised ESR
- concurrent pleural effusion may be present in up to 50% of patients with Dressler’s syndrome

30
Q

What ECG changes would be exhibited in Dressler’s syndrome? [2]

A

global ST elevation and T wave inversion

31
Q

How do you treat Dressler’s Syndrome? [2]

A

NSAIDs (e.g., aspirin or ibuprofen)

severe cases: steroids (e.g., prednisolone

32
Q

What is the difference between myocardial infarction and myocardial injury? [2]

A

Myocardial injury = trop > 99% percentile ULN

Acute MI = Injury +
- Symptoms
- ECG changes
- Imaging showing loss of viable myocardium
- Evidence of coronary aetiology
Implies ischaemia

33
Q

Describe the 4 types of MI [4]

A

Type 1: Traditional MI due to an acute coronary event

Type 2: Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension)

Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event

Type 4: MI associated with procedures such as PCI, coronary stenting and CABG

NB: Type 1 MI have better prognosis than Type 2 MIs

34
Q

Describe what causes T ype 2 MI [1]

Give two examples of Type 2 MI [2]

A

Troponin leak due to ischaemia due to oxygen supply and demand imbalance.

E.g. Severe HTN & sustained tachy arythmias

35
Q

Describe what causes Type 3 MI [2]

Give 2 examples [2]

A

Troponin rise without acute ischaemia due to acute myocardial inury

E.g. Acute heart failure or myocarditis

36
Q
A
37
Q

STEMI identified, aspirin given, having fibrinolysis. What do you give next? [1]

A

An antithrombin - fondaparinoux

38
Q

Which complications might occur that would cause loud pan-systolic murmur? [2]

What secondary symptom might this cause? [1]

A

VSD
Papillary muscle rupture causing MR

Both can cause pulmonary oedema

39
Q

MI complications:

What would cause persistent ST elevation without chest pain? [1]

A

Ventricular aneurysm

40
Q

Describe what is meant by Takotsubo’s disease [1]

Which population is it most common in? [1]

A

AKA broken heart syndrome

Unobstructed coronaries and transient LV impairment which causes myocardial stunning

Might occur due to microvascular spasm from catecholamines [?]

Catecholamine mediated stress in post-menopausal women

41
Q
A

Give aspirin 300mg

42
Q
A

give ticagrelor

43
Q
A

recent stroke or myocardial infarction (NICE recommend waiting 6 months)

44
Q

Which diabetic drug is contraindicated in recent MI patients? [1]

A

metformin may cause lactic acidosis if taken during a period where there is tissue hypoxia.

45
Q
A

PCI within 72 hrs

46
Q
A

Left ventricular free wall rupture

This is seen in around 3% of MIs and occurs around 1-2 weeks afterwards. Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). Urgent pericardiocentesis and thoracotomy are required.

47
Q

A patient is noted to have a new early-to-mid systolic murmur 10 days after being admitted for a myocardial infarction is a stereotypical history of:

Atrial myxoma
Ischaemia of the papillary muscle
Dresselers syndrome
Left ventricular aneurysm

A

A patient is noted to have a new early-to-mid systolic murmur 10 days after being admitted for a myocardial infarction is a stereotypical history of:

Atrial myxoma
Ischaemia of the papillary muscle
Dresselers syndrome - occurs 4 weeks after; fever; pleuritic chest pain also
Left ventricular aneurysm

48
Q
A

Give prasugrel or ticagrelor

49
Q
A

Aspirin, nitrates, morphine, clopidogrel, calculate GRACE score

50
Q

What is important to note when treatng ACS when looking at BP levels? [1]

A

ACS management: nitrates should be used with caution if the patient is hypotensive

51
Q

A patient has acute HF.

Under what circumstances would you prescribe norepinephrine? [1]

A

If hypotensive / in cardiogenic shock and have an insufficient response to inotropes and there is evidence of end-organ hypoperfusion

52
Q

How do you differentiate between a posterior and anterior MI on an ECG?

A

Anterior MI
- ST-segment elevation in the precordial leads V1-V4

Posterior MI
- tall R waves V1-3 PosteRioR contains 2 tall Rs
- Horizontal ST depression in V1-3

Posterior MI
53
Q

Posterior MI is usually by an occlussion to which which arteries? [2]

A

Left circumflex;
RCA

54
Q

How do you confirm a posterior MI? [1]

A

Posterior infarction is confirmed by ST elevation and Q waves in posterior leads (V7-9)

Year 3: Cardiology (26 decks)

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