Cardio 1: chest pain Flashcards Preview

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Flashcards in Cardio 1: chest pain Deck (52):
1

the three main features of angina are:

Constricting discomfort in the chest or neck, shoulders, jaw and arms
Precipitated by exercise
Relieved by rest or GTN within 5 mins

All 3 features = typical angina
2 features = atypical angina
1 feature = likely to be non-anginal pain

This is very much a clinical diagnosis, but exercise ECG may be used to precipitate angina and look for ECG changes

2

the main cause of angina

Atherosclerotic disease

3

Differentiate between:
decubitus angina
prinzmetal angina
coronary syndrome x

Decubitus angina – symptoms occur when lying down
Prinzmetal angina – symptoms caused by coronary vasospasm
Coronary syndrome X – symptoms of angina but with normal exercise tolerance and normal coronary angiograms

4

conservative management for angina

smoking cessation
lose weight
exercise

5

medical management for angina

Anti-anginals (BB/CCB)
Symptomatic (GTN spray)
Risk factor reduction (aspirin, statins, ACEi)
If medical treatment is ineffective, consider PCI or CABG

6

what is the difference between stable angina and acute coronary syndrome

Stable Angina: chest pain resulting from myocardial ischaemia that is precipitated by exertion and relieved by rest.

Acute Coronary Syndrome: a constellation of symptoms caused by sudden reduced blood flow to the heart muscle.

7

acute coronary syndrome is a triad of:

Unstable Angina Pectoris – chest pain at rest due to ischaemia without cardiac injury
Non-ST elevation MI
ST-elevation MI

8

acute coronary syndrome signs and symptoms

Acute-onset central, crushing chest pain
Radiates to arms/neck/jaw
Pallor
Sweating
NOTE: silent infarcts in elderly and diabetics

9

acute coronary syndrome investigations

ECG
STEMI: Hyperacute T waves, ST elevation, new-onset LBBB
UAP/NSTEMI: ST depression, T wave inversion
Old Infarct: pathological Q waves
Troponins
Elevated troponins suggests myocardial injury (i.e. STEMI or NSTEMI)

10

ST elevation is seen in which leads on ECG to show which type of STEMI

Inferior (right coronary artery): II, III, aVF

Anterior (left anterior descending): V1-V5

Lateral (left circumflex): I, aVL, V5/6

Posterior (posterior descending): tall R wave + ST depression in V1-3

11

acute coronary syndrome is managed acutely using:

Morphine
Oxygen
Nitrates
Antiplatelets (aspirin + clopidogrel)
Beta-blockers
ACE inhibitors
Statins
Heparin

12

what is the aim of STEMI treatment?

Coronary reperfusion either by PCI or fibrinolysis

13

How do timings affect STEMI treatment

Patient presenting < 12 hours from onset of symptoms
Send to cathlab for PCI if it can happen within 120 mins of the time that fibrinolysis could have been administered

Patient presenting > 12 hours from onset of symptoms
Coronary angiography followed by PCI if indicated

14

NSTEMI/UAP immediate management

Aspirin + other antiplatelet (e.g. clopidogrel, ticagrelor)
Fondaparinux – if low bleeding risk unless coronary angiography planned within 24 hrs of admission
LMWH – if coronary angiography is planned

15

How do you risk stratify for ACS?

Risk Stratify using GRACE score
HIGH risk
GlpIIb/IIIa inhibitor (e.g. tirofiban)
Coronary angiography (within 72 hours)
LOW risk
Conservative management (control risk factors)

16

Complications of ACS: DARTH VADER

Death, Arrhythmia, Rupture, Tamponade, Heart failure
Valve disease, Aneurysm, Dressler’s syndrome, Embolism, Reinfarction

17

A 76-year-old woman is brought into A&E with central crushing chest pain that radiates to her jaw and left arm. An ECG is performed, which shows ST elevation in leads ll, lll and aVF. Her SaO2 is 90%. Before she is sent to the cathlab for percutaneous coronary intervention, she is started on a combination of drugs. Which of the following should not be given?
A  Morphine
B  Oxygen
C  Aspirin
D  Clopidogrel
E  Warfarin

E. warfarin

IMPORTANT: warfarin causes an initial pro-thrombotic phase because it blocks protein C and protein S. Therefore, heparin must be co-administered with warfarin to begin with, until the INR stabilises (between 2-3).

18

A 54-year-old man has been brought into A&E with a suspected acute coronary syndrome. An ECG is performed, which reveals ST elevation in leads I, aVL, V5 and V6. Which coronary artery has been occluded?
A  Left main stem
B  Left anterior descending coronary artery
C  Left circumflex coronary artery
D  Right coronary artery
E  Posterior descending artery

C  Left circumflex coronary artery

19

causes of pericarditis

Idiopathic
Infective (e.g. Coxsackie B)
Connective tissue disease (e.g. sarcoidosis)
Dressler Syndrome (2-10 weeks after MI)
Malignancy

20

symptoms and signs of pericarditis

Sharp, central chest pain
Pleuritic
Relieved by sitting forward
Fever/flu-like symptoms (if viral)
Pericardial friction rub
Tamponade (if pericardial effusion)

21

investigations for pericarditis

ECG
Bloods (FBC, CRP)
CXR (pericardial effusion)

22

pericarditis management

Management: treat the underlying cause
Viral pericarditis is usually self-limiting
Pericardiocentesis may be needed if the pericardial effusion is causing tamponade

23

what is Beck's triad?

Features of Tamponade: Beck’s Triad
Muffled heart sounds
Raised JVP
Low blood pressure

24

what is the ECG finding for pericarditis?

widespread saddle-shaped ST-elevation

25

A 54-year-old man is complaining of sharp, central chest pain that has arisen over the last 24 hours. On inspection, the patient is sitting forward on the examination couch. On auscultation, a scratching sound is heard – loudest over the lower left sternal edge, when the patient is leaning forward. He has a past medical history of a ST-elevation MI which was diagnosed, and treated with PCI, 6 weeks ago. What is the most likely diagnosis?
A  Viral pericarditis
B  Constrictive pericarditis
C  Cardiac tamponade
D  Dressler syndrome
E  Tietze syndrome

D  Dressler syndrome

26

What is Tietze syndrome?

Tietze syndrome = a rare inflammatory disorder characterised by chest pain and swelling of the cartilage of one or more of the upper ribs (costochondral junction), specifically where the ribs attach to the sternum.

27

state some causes of AF

Causes – ABSOLUTELY LOADS
Examples
Pneumonia
PE
Hyperthyroidism
Ischaemic heart disease
Alcohol
Pericarditis

28

what are the signs and symptoms of AF?

Symptoms and Signs
Palpitations
Syncope
Symptoms of underlying causes
Irregularly irregular pulse

29

AF investigations

ECG
Tests for underlying cause

30

when do you perform DC cardioversion a patient with AF?

haemodynamically unstable

31

what are the three parts of AF management

rhythm control
rate control
stroke risk stratification

32

AF management
rhythm control

< 48 hrs since onset of AF
DC cardioversion
OR chemical cardioversion (flecainide or amiodarone)
NOTE: flecainide is contraindicated if there is a history of IHD
> 48 hrs since onset of AF  anticoagulate for 3-4 weeks before attempting cardioversion

33

AF management
rate control

Verapamil
Beta-blockers
Digoxin

34

AF management
Stroke Risk Stratification

CHA2DS2-Vasc score
LOW risk  aspirin or none
HIGH risk  warfarin

CHADS-Vasc Score of 1 or more suggests that anticoagulation should be considered

35

SVT definition

Definition: a regular, narrow-complex tachycardia with no p waves and a supraventricular origin.

AF technically counts as a type of SVT

However, SVT generally refers to:

Atrioventricular Nodal Re-entry Tachycardia (AVNRT)

Atrioventricular Re-entry Tachycardia (AVRT)

36

SVT symptoms

Palpitations
Syncope
Chest discomfort
Dyspnoea

37

what is the difference between AVNRT and AVRT?

Atrioventricular Nodal Re-entry Tachycardia (AVNRT)
A local circuit forms around the AV node

Atrioventricular Re-entry Tachycardia (AVRT)
A re-entry circuit forms between the atria and ventricles due to the presence of an accessory pathway (Bundle of Kent)

38

ECG findings for SVT, before and after termination

ECG during tachycardia
Regular
Narrow complex tachycardia
Absent p waves

ECG after termination of SVT
AVNRT = normal
AVRT = ’Delta wave’ (slurred upstroke on QRS complex)

39

ECG finding for WPW

Presence of an accessory pathway resulting in a delta wave on ECG:
Wolff-Parkinson-White Syndrome

40

tests for SVT causes

cardiac enzymes, electrolytes, TFTs, digoxin level

41

SVT managment

STEP 1: is the patient haemodynamically stable?
NO  Synchronised DC cardioversion
YES  STEP 2

STEP 2: Vagal Manoeuvres – did it work?
YES  Good Job
NO  STEP 3

STEP 3a: IV Adenosine 6 mg – did it work?
YES  Good Job
NO  Step 3b, if that fails, Step 3c, then, Step 4
STEP 3b: IV Adenosine 12 mg
STEP 3c: IV Adenosine 12 mg (again)

STEP 4: Choose from:
IV b-blocker (e.g. metoprolol)
IV amiodarone
IV digoxin
Synchronised DC cardioversion

42

A patient with asthma has SVT, which drug do you administer?

IF ADENOSINE IS CONTRAINDICATED (e.g. ASTHMA), USE:
VERAPAMIL

43

A 46-year-old man has been admitted to A&E after experiencing palpitations, which began about 4 hours ago. An ECG is performed, which reveals atrial fibrillation. He has no previous history of ischaemic heart disease. He refuses DC cardioversion. What is the next most appropriate treatment option?
A  Defibrillation
B  Low molecular weight heparin
C  Warfarin
D  Flecainide
E  Digoxin

D  Flecainide

44

A 27-year-old man presents with palpitations and light-headedness. An ECG shows features consistent with a supraventricular tachycardia. Adenosine is administered and the SVT is terminated. A repeat ECG shows a short PR interval and a QRS complex with a slurred upstroke. What is the diagnosis?
A  Brugada syndrome
B  LBBB
C  Romano-Ward syndrome
D  Wolff-Parkinson-White syndrome
E  Complete heart block

D  Wolff-Parkinson-White syndrome

45

A 52-year-old man was watching TV yesterday when he suddenly become very aware of his heart beating rapidly. This lasted for around 45 mins and then subsided spontaneously. It has happened several times over the past 2 months. An ECG reveals no abnormalities. However, due to the strong suspicion of atrial fibrillation, the patient is placed on a 24-hr tape, which confirms the diagnosis. Which scoring system would be used to determine the benefit of long-term anticoagulation in this patient?
A  QRISK2 score
B  ABCD2 Score
C GRACE score
D  CHA2DS2-VASc score
E  CURB-65 score

D  CHA2DS2-VASc score

46

differentiate between the different causes of syncope:
vasovagal
arrhythmia
outflow obstruction
postural hypotension

Vasovagal
↑ vagal discharge  drop in BP and HR
Can be precipitated by situations (e.g. standing for a long time, sight of blood)
May feel sweaty/pale before collapse

Arrhythmia
Can lead to a low-output state
May have palpitations before collapse

Outflow Obstruction
E.g. HOCM, aortic stenosis

Postural Hypotension
Caused by the failure to compensate for the drop in blood pressure caused by standing up
Medications (e.g. antihypertensives) and dehydration are common causes

47

HOCM clinical features

Jerky carotid pulse
Double apex beat
Ejection systolic murmur
Family history of sudden death at a relatively young age (< 65 yrs)

48

other causes of collapse

Niche Syncopal Causes
Vertebrobasillar insufficiency
Subclavian steal syndrome
Aortic dissection

Non-Syncopal Causes
Intoxication
Head trauma
Metabolic (e.g. hypoglycaemia)
Epileptic seizure

49

A 21-year-old woman has fainted 4 times in the past 3 months. She becomes sweaty and nauseous before she faints and is usually unconscious for a few seconds. Her friends have told her that she looks abnormally pale before she collapses. She doesn’t know if she jerks whilst unconscious, but has not lost control of her bladder or bitten her tongue. When she regains consciousness, she feels slightly dizzy but does not feel confused. What is the most likely cause of her fainting?
A  Hypoglycaemia
B  Epileptic seizure
C  Vasovagal syncope
D  Arrhythmia
E  Hypertrophic obstructive cardiomyopathy

C  Vasovagal syncope

50

A 52-year-old man has collapsed 3 times in the past couple of months. His father died of a heart condition when he was 56 years old, although he cannot recall the details of the condition. On examination, a jerky carotid pulse is palpated and a crescendo-decrescendo murmur is heard over the carotid artery. What is the most likely diagnosis?
A  Aortic stenosis
B  Hypertrophic obstructive cardiomyopathy
C  Left heart failure
D  Mitral regurgitation
E  Constrictive pericarditis

B  Hypertrophic obstructive cardiomyopathy

51

A 76-year-old man is found collapsed in the care home
and has a suspected hip fracture. He says that he
temporarily lost consciousness as he got up from his arm
chair and came about, a matter of seconds later, on the
floor. He has never experienced a fall before. He has a
past medical history of a total knee replacement and
heart failure which is treated with ramipril, furosemide and
bisoprolol. What is the most likely cause of his collapse?
A Vasovagal syncope
B Medication side-effect
C Arrhythmia
D Anaemia
E Dilated cardiomyopathy

B Medication side-effect

52

A 52-year-old patient is recovering on the cardiology ward after undergoing a valve replacement. A routine blood test reveals the following results:
Na+ : 135 mmol/L (135 – 145)K+ : 8.7 mmol/L (3.5 – 6.0)Ca2+ : 0.3 mmol/L (2.2 – 2.6)An ECG is performed which shows no obvious abnormalities. He has a past medical history of hypertension which is treated with ramipril.
Given the above information, what should be the next step in the management of this patient?

A Urgently draw another blood sample
B 10 mL 10% calcium gluconate
C 20 mL 20% calcium gluconate
D 50 mL 50% dextrose + 10 U insulin
E IV salbutamol

A Urgently draw another blood sample