ACS and hypertension Flashcards
(37 cards)
What are the signs and symptoms of ACS?
Signs: distress, anxiety, pallor, sweatiness, low grade fever, signs of heart failure (raised JVP, basal crepitations, 3rd heart sound)
Symptoms: acute central crushing chest pain lasting >20 minutes, nausea, sweating, dyspnoea, palpitations
What can cause false positive elevation of hs-TnI, meaning the patient is not having an MI?
Common: advanced renal failure, PE, CPR, ablation therapy
Less common: severe congestive heart failure, myocarditis, prolonged tachyarrhythmia
Rare: aortic dissection, aortic stenosis, hypertrophic cardiomyopathy, malignancy, stroke, severe sepsis
ALWAYS TAKE SERIAL MEASUREMENTS AND LOOK AT THE TREND NOT THE VALUE OF TEST
What are the sequential ECG changes following an MI?
Within hours: ST elevation and hyperacute T waves or LBBB
24 hrs: T wave inversion, ST normal
Few days: pathological Q waves that persist
What is T wave pseudonormalisation?
NSTEMIs often have T wave inversion that represents reperfusion of the area
On repeat ECG T waves may appear back to normal after firstly being inverted but this just means the artery is reoccluded
Apart from an ECG and cardiac enzymes, what other investigations should you carry out for a patient who presents with cardiac chest pain ?MI?
CXR: look for cardiomegaly, pleural effusion, widened mediastinum
Bloods: FBC, U+Es, random glucose, lipid profile, HbA1c, cardiac enzymes (2 tests 3 hours apart)
ECHO: regional wall abnormalities
What are some differential diagnoses for ACS?
Stable angina
Pericarditis
Myocarditis
Takotsubo cardiomyopathy
Pneumothorax
PE
Oesophageal spasm/reflux
MSK pain
What are some contraindications for treating a STEMI with thrombolysis?
Previous intracranial haemorraghe
Ischaemic stroke <6months ago
Recent major head trauma/surgery
Known bleeding disorders
Liver biopsy or LP in past 24 hours
Pregnancy
GI bleeding
Cerebral malignancy
What blood tests are essential for a patient with a STEMI?
Cardiac enzymes (TropI)
FBC
Lipid profile
Random blood glucose
HbA1c
What medications are patients started on after an MI and for how long?
- Aspirin 75mg for life
- Ticagrelor (or another antiplatelet e.g Clopidogrel/Prasugrel) for 12 months
- ACEi or ARB for hypertension (checking renal function)
- Beta-blocker to lower heart rate (e.g Bisoprolol)
- Statin (e.g atorvastatin 80mg or rosuvastatin 5mg). Use ezetimibe if all statins have side effects
ATABS (also consider PPI for gastric protection with antiplatlets)
What are some complications of a STEMI and how are they managed?
- Heart failure: diuretics e.g Epleronone
- Cardiogenic shock: need inotropes and balloon pumps]
- Valve damage e.g Mitral Regurg: may present with pulmonary oedema, needs valve replacement
- Ventricular Septal Defect: pansystolic murmur that is diagnosed on ECHO and needs surgery
- Pericarditis: give NSAIDs
What are some associated symptoms with angina if it is severe, and what symptoms make the diagnosis of angina less likely?
Associated symptoms: fear, sweating, nausea, dyspnea
Less likely to be angina: pain that is continuous, pleuritic or worse with swallowing, palpitations, dizziness, tingling
Apart from exercise, what are some other things that can precipitate angina?
Emotion
Cold weather
Heavy meals
Angina is usually due to atheromas in the coronary arteries (coronary artery disease). What are some other conditions that can cause symptoms of angina in the absence of coronary artery disease?
Aortic stenois
Hypertensive heart disease
Hypertrophic cardiomyopathy
Patients who have angina like pain are scored based on their estimated likelihood of CAD. What investigations should you offer for different likelihood scores?
- 61-90%: Invasive coronary angiography
- 30-60%: Functional imaging e.g stress MRI, echo or myoview
- 10-29%: CT calcium scoring. If zero likelihood is minimal. If 1-400 consider CTCA or stress perfusion imaging. If >400 CTCA
How do the following drugs act as anti-anginal medicine and when are they used?
Nicorandil
Ivabradine
Ranolazine
Used 1st line as monotherapy if CCB and BB contraindicated or used in conjunction with one of them as 2nd line
Nicorandil: K+ channel activator. Can’t use in pulomary oedema or hypotension
Ivabradine: Reduces HR without lowering BP by blocking sinus node. Do not give if HR<70 or not in sinus rhythm, and do not coprescribe with CCB
Ranolazine: Inhibits late Na current. Caution in heary failure, elderly, <60kg, eGFR<30
what is the managment for angina?
B-Blockers: Atenolol or bisoprolol
or
NDHP CCB if above Cx: Diltiazem or Verapamil
2nd Line
- BB + CCB
If one of the above is Cx give one with long acting nitrate isosorbibe mononitrate, nicorandil or ranolazine
surgical management: PCI or CABG
When should BB and CCB not be used in the acute setting?
BB: acute pulmonary oedema or heart failure
CCB: as negative inotrope in acute setting
What is malignant hypertension?
Rapid rise in blood pressure to over 200/130, leading to vascular and organ damage
Can causes bilateral retinal haemorrhages, headache, visual disturbances
Needs urgent treatment (BB or CCB)
What other tests apart from BP are performed when a patient is newly diagnosed with hypertension?
Urine dip
Bloods
Retinopathy
ECG
ECHO
What are target blood pressures to bear in mind when treating hypertension?
Low-moderate risk: <140/90
- Diabetic/Previous Stroke: <130/80 (keep below 85)
- Elderly >80: <150/90
Reduce slowly, can be fatal if lower too rapidly!
Why should you drop hypertension slowly?
Any sudden drops in BP increases stroke risk as cerebral autoregulation is poor
What is the definition of a hypertensive emergency?
Increase in BP which if sustained over the next few hours will cause irreversible end organ damage (encephalopathy, LV failure, aortic dissection, unstable angina, renal failure)
What is the difference between a hypertensive emergency and urgency?
Emergency - High BP with critical illness (AKI,MI, Encephalopathy). Will cause damage over hours
Urgency - High BP without critical illness at the moment, often accompanied by retinal damage. Will cause damage over days
How is hypertensive urgency managed?
Reduce diastolic gradually to <100 over 48-72 hours using PO drugs
Usually a combination of ACEi and CCB or Nifedipine AND Amlodipine for 3 days and then continue Amlodipine alone
Amlodopine
Diltiazem
Lisinopril
