Cardiac Flashcards
(49 cards)
Primary Prevention
QRISK 3 Score - percentage risk of stroke or MI in 10years.
>10% = start a statin - atorvastatin 20mg night
Also CKD and diabetes T1 patient = atorvastatin 20mg
Aim for > 40% reduction in non-HDL cholesterol. Check at months.
SE statin- can cause rise in ALT, AST in first few weeks so LFTs check in 3months. (<3x rise from normal)
Myopathy - check creatine kinase if muscle pain
Secondary prevention
4 A’s
Aspirin + second antiplatelet - clopidogrel.
Atorvastatin 80mg
Atenolol (betablocker) or bisoprolol to max tolerated dose
ACE inhibitor - Ramipril to max titrated dose
PCI
Percutaneous Coronary Intervention
Angioplasty- dilating the blood vessel with ballon or stent.
Proximal or extensive disease on CTa
CABG
Coronary artery bypass graft
Severe stenosis
Open surgery - along sternum (midline sternotomy) graft vein from leg - graft saphenous vein. Bypass stenosis. Higher complication rate to PCI, longer recovery.
ISCES- check for fem/brach / chest scars.
Angina
Stable - Sx relived by rest or GTN
Unstable- type of ACS
Pain can radiate to jaw or arms. Constricting
Investigations: CT Coronary angiogram = gold standard Phy exam- BMI, Hr Sounds, signs Hr failure ECG FBC (anaemia ) LFT’s (prior to statin) U&Es (prior to ACEI) Lipid profile Thyroid tests HbA1C and fasting glucose.
Management: RAMP Refer to cardiology Advise Medical Tx Procedural or surgical interventions
GTN - immediate relief, 5min x2
Beta blocker- bisoprolol 5mg OD
Calcium channel blocker - amlodipine 5mg OD
Long acting nitrates - isosorbide mononitrate
Prevention: AAAA Aspirin 75mg OD Atorvastatin 80mg OD Ace I Already on BB
Acute coronary Syndrome
Thrombus from AS Plaque - made up mostly of platelets (fast flowing artery) 3 types: Unstable Angina ST elevation MI - STEMI NSTEMI
Diagnosis:
ECG - if elevation/ new LBBB = STEMI
Troponin ^ or other ECG changes (depression, t wave inversion, Path Q waves )= NSTEMI
Non= unstable angina or MSK chest pain.
ACS Sx
Central constricting Chet pain associated with: Nausea and vomiting Sweating and clamminess Feeling of impending doom SoB Palpitations Pain radiating to jaw or arms
Sx should continue at rest for >20mins. Diabetics - silent MI
Troponin levels
Elevate within 3-4 hours after damage, remain high for 14days.
Other causes ^ trop = myocarditis, PE, drug abuse, vasculitis, sepsis, renal failure, aortic dissection .
Acute STEMI Tx
Within 2hr = PCI
If PCI not available within 2hr = thrombolysis - fibrinolytic - streptokinase, alteplase, tenecteplase.
Acute NSTEMI Tx
BATMAN Beta blocker Aspirin 300mg stat Ticagrelor 180mg stat (or clopidogrel 300mg) Morphine Anticoagulant LMWH - Enoxaparin 1mg/kg BD 2-8days Nitrates - GTN to relieve spasm O2 only if stats below 95%
GRACE score - PCI in NSTEMI
6month risk of death or repeat MI <5%, 5-10%, >10%
Med, high risk considered for early PCI within 4 days.
Cor Pulmonale
Right Sided heart failure - resp disease
Back pressure into vent, atrium, VC and systemic venous system.
Causes: COPD, PE, Interstitial lung disease, CF, 1 Pulmonary HT
Pres: Often asymptomatic, SoB, Peripheral oedema, syncope, chest pain.
Signs: hypoxia, cyanosis, raised JVP, Edema, third heart sound, murmur ( pan-systolic in tricuspid regurgitate ), hepatomegaly.
Man: LT O2 therapy often, Tx cause.
Causes AF
SHIMMERS Soaring BP, hypertension Heart failure Ischemic heart disease Myocardial infarction Mitral value disease Ethanol / endocrine Eg thyrotoxicosis Resp causes; pneumonia, PE , bronchial carcinoma, rheumatic heart disease Sick sinus syndrome/ Sepsis
Medical cardioversion
If heamodynamically stable
IV flecanide or amiodarone if evidence of structural heart disease
Within 48hrs and stable
Plus rate control - bisoprolol
IV adenosine
Atrial flutter
PVST: paroxysmal supraventrical tachy
Wolff Parkinson white syndrome
Natural rate of heart parts
SA node: 60-100
AV node: 40-55
Bundle of his: 25-40
Bundle branches: 25-40
2 weeks post MI
Fever
Pleuritic chest pain
Pericardial rub on auscultation
Dressler’s syndrome
Local immune response causing pericarditis / pericardial effusion
Rarely a tamponade
Diagnosis: ECG- global ST elevation and T wave inversion
Echo
Raised CRP, ESR
Management: NSAIDs , severe cases steroids (prednisolone)
May need pericardiocentesis to remove fluid
Secondary prevention of MI medical management 6 As
Aspirin 75mg daily
Another anti platelet : clopidogrel for up to 12months
Atorvastatin 80mg
Ace inhibitor Ramipril
Atenolol
Aldosterone antagonist - those in clinical HF , eplerenone
SVT
Narrow QRS complex because rapid excitation of ventricles
VT
From ectopic focus
Wide QRS, 120-200 bpm
1. Monomorphic- classically myocardial scarring due to MI
2. Polymorphic - ischemia, not associated with scarring, different areas of V, brugada syndrome (autosomal dominate, Asian, st elevation, pseudo RBBB)
Tornadoes de pointes (k channels effected, prolonged QT interval)- Tx MgSO4
QT prolongation drugs
Anti arrhythmics B antibiotics macrolides C antipsychotics - olanzepine, haloperidol D antidepressants - TCA E antiemetics - ondansetron
Shockable rhythms
Ventricular tachycardia
Ventricular fibrillation
SVT- shock to cardioversion if other Tx fail
Non shockable rhythms
Pulseless activity
Asystole
External cause of 3rd degree heart block
Lyme disease
Meds: b blockers, amiodarone, digoxin, calcium channel blockers, adenosine
Neonatal lupus- congenital heart block
Av block may be normal in athletes
Rbbb
Wide QRS V123 RSR configuration - right side MaRRoW Causes: R ventricular hypertrophy, R HF, pulmonary embolism Can be normal
