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Cardio Flashcards

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1
Q

What is the cardinal symptom of Stable Angina?

What is typical and atypical Angina?

A

RESTRICTIVE chest pain upon EXERTION that gets better with REST/GTN.
Typical is all three present. Atypical is 2 or less.

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2
Q

What investigations for Stable Angina and what would they show?

A

ECG - ST depression
Bloods - check haem, lipids, glucose and TFTs for risk of angina.
Check LFTs for statin therapy benchmark, and U+Es for ACEi benchmark.

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3
Q

What is Gold standard Ix for Stable Angina?

A

CT Coronary Angiography

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4
Q

What is “Variant Angina” and what is the test for it?

A

Variant Angina is caused by artery spasm - Test is Angiography with Provocation.

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5
Q

What is the general management for Stable Angina?

A

1) Refer to cardiologist
2) Lifestyle Education - lower risk factors
3) Drugs
4) Surgery - particularly in left sided/ 3 vessel/ 2 vessel and diabetes disease

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6
Q

What drugs are used to treat Stable Angina?

A

Immediately: GTN spray - repeat once after 5 minutes, then wait 5 mins. If pain continues, call Ambulance.

Long term: Beta blocker (e.g. Bisoprolol 10mg) +- Calcium Channel blocker (e.g. Amlodipine 5mg)
- Increase dose of monotherapy before adding the other.

Secondary prevention: Beta blocker + Aspirin + Atorvastatin (or ezetimibe) + Acei

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7
Q

What makes up “Acute Coronary Syndrome”?

A

STEMI
NSTEMI
Unstable Angina

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8
Q

What are the general symptoms of ACS?

A

“Crushing chest pain” +- SOB, Nausea, Sweating
In women, atypical pain in neck and shoulders
In elderly, delirium

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9
Q

What investigations for ACS?

A 
ECG:
        - STEMI = ST elevation
        - NSTEMI = ST dep or T changes 
Troponin:
        - STEMI = increased
        - NSTEMI = increased

If no ST elevation, and low troponin but N-STEMI still suspected - take another trop at 1h then another at 3h - if Trop low at 3h, NSTEMI can be ruled out.

CXR
Bloods: FBC, U&Es and creatinine (for GRACE score)

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10
Q

What other things can cause raised Troponin?

A

Myocarditis, Aortic Dissection, Acute PE, Sepsis

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11
Q

What is the level Glucose should be at in an ACS event?

A

< 11 mmol

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12
Q

What is the immediate management for ACS in general?

A

1) ASPIRIN! 300mg stat
2) Start DAPT with:
- Prasugrel 60mg
or - Ticagrelol 180mg
or - Clopidogrel 300mg
3) Oxygen if O2 < 90%
4) GTN sublingual - not if systolic <90 or used P5 inhibitor for erectile dysfunction in last 48h
5) IV morphine
6) IV anti-emetic - Ondansetron 4mg/ Met 10mg x3/ Cyclizine 50mg x3

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13
Q

What is the specific management of a STEMI?

A

Remember DAPT (Aspirin + Prasugrel/Ticagrelol/Clopidogrel) for all ACS!

If symptom onset <12h + PCI available within 2h–> PCI

If symptom onset <12h + PCI not available within 2h –> Fibrinolysis + Anti-coagulation –> Repeat ECG within 90 mins: If there is still 50% ST elevation, transfer for Rescue PCI

NOTE: If fibrinolysing, start DAPT and anti-coagulation AFTER fibrinolysis

If symptom onset >12h + Ischaemia –> consider PCI
If symptom onset >12h + No ischaemia –> Just meds

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14
Q

What drugs can be used for fibrinolysis and anti-coagulation?

A
  • Tenecteplase - one time bolus of 50mg - most ideal outside of the hospital
  • Alteplase - 15mg bolus then IV infusion
  • Streptokinase - 1.5m units per hour
    ~Note: Do not give STK if given before, will have antibodies~

Anti-coagulation options:

  • Enoxaparin
  • Unfractionated Heparin
  • Fondaparinux - only if STK given
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15
Q

What are some contra-indications to Fibrinolysis?

A 
Neoplasm of the CNS
Pessure puncture in the last 24 hours - LP, biopsy 
Ischaemic stroke < 6m
Haemmorhagic stroke (not trauma) ever
Trauma/surgery <1m
GI bleed <1m
Blood disorders
Aortic dissection
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16
Q

What is the long-term management of a STEMI?

How does this differ from long-term management of NSTEMI?

A

Continue DAPT for 12 months
Beta Blocker or Calcium Channel Blocker
Ace-inhibitor
Atorvastatin

NSTEMI: Same, but no Ca-channel blocker

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17
Q

What is the immediate management of a N-STEMI?

A

Same drugs as STEMI:

  • DAPT with Aspirin + Prasugrel/Ticagrelol/Clopi
  • GTN
  • Oxygen if <90%
  • IV Morphine
  • IV anti-emetics

+ Fondaparinux 2.5mg for 8 days
+ Risk evaluate with GRACE score

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18
Q

Complications of ACS?

A 
DREAD
Death
Rupture of muscles
Edema
Arryhthmia/aneurysm
Dressler's Syndrome
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19
Q

What are the different types of muscle ruptures after a MI?

A

Ventricular Septal Rupture - associated w Anterior MI

Ventricular Free Wall Rupture - causes tamponade!

Papillary Muscle rupture - associated w Inferior MI

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20
Q

What is Dressler’s Syndrome and what is the management?

A

Dressler’s = complication 2-6 weeks post MI –> Pericarditis! Pain worse when lying down, better on sitting forward.

Mx: Aspirin and Colchicine

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21
Q

What kind of bradycardias can be caused by MI?

A

Bradycardia caused by Anterior MI = Pacing

Bradycardia caused my Infrior MI = self-limiting

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22
Q

What are the causes of Left sided heart failure?

A

Cardiomyopathies
Ischaemia
HTN

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23
Q

How does left sided HF cause pulmonary oedema?

A

Increased pressure in Pulmonary Vein = leaky vein = fluid in lungs = pulm. oedema

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24
Q

What are some signs of Left sided HF?

A

Displaced apex beat, S3, pulmonary oedema

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25
What causes Right sided HF?
Main cause is left sided heart failure where the right side pumps blood to every resistant lungs --> initially hypertrophy then dilation of right ventricle. Cor Pulmonale = Right sided HF caused by Lung disease such as COPD/PE.
26
What are some signs of Right sided HF?
Raised JVP, hepatomegaly, ascites, peripheral oedema
27
What is the difference between Systolic and Diastolic HF?
Systolic HF - Problem during systole where ventricles don't contract properly - means not all of the blood is ejected out = reduced EF HF (<40%) Diastolic HF - Problem during diastole where the ventricles are stiff and don't fill properly - but the limited blood that comes in is adequately ejected out = preserved EF HF (>50%)
28
What are come causes of Acute HF?
Iatrogenic! - too many fluids Sepsis MI
29
What are the investigations for Heart Failure?
``` Bloods B-type BNP CXR TTEcho ECG ```
30
What are the hallmarks on a CXR with heart failure?
``` Alveolar oedema B lines (Kerley) Cardiomegaly Diversion of upper lobe Effusion ```
31
How does management differ with BNP hormone result in HF?
If BNP > 100, refer in 6 weeks | If BNP > 400, refer + Echo in 2 weeks
32
What management for HF?
1) Lifestyle changes - restrict fluid and salt
33
What are the stages of Hypertension?
Stage 1) Clinic >140/90 ABPM >135/80 Stage 2) Clinic 160/100 ABPM >150/95 Severe) Systolic >180 Diastolic >120
34
Investigations for suspected hypertension?
Clinic BP: - If near 140/90, recheck within 5Y - If between 140/90 and 179/119, do home/ ABMP - If >180 or >120, check end organ damage immediately + maybe start anti-hypertensive + recheck in clinic in 7 days ABPM: 2 readings each hour Home monitoring: 2 readings each day - each reading must be an average of two taken one minute apart
35
When should you start treatment for HTN?
Start treatment for all Stage 2 HTN (i.e. BP > 160/100) Start treatment for Stage 1 if there is end organ damage, or CVD or Renal or Diabetes or >10% CVD risk
36
What is the management algorithm for HTN?
1) If <55 / T2DM: ACEi/ARB If >=55 / black: CCB 2) If <55 / T2DM: ACEi/ARB + CCB or Thiazide If >=55 / black: CCB + ACEi/ARB or Thiazide 3) ACEi/ARB + CCB + Thiazide 4) If K <4.5, add Spironolactone If K >4.5, add Alpha/Beta blocker
37
What are some examples of each class of HTN drugs?
ACE inhibitors: Ramipril, Lisonopril, Enalapril - prils ARBs: Candesartan, Losartan - tans Calcium Channel blockers: Amlodipine, Nifedipine, + Verapamil, Diltiazem Thiazide- like dieuretics: Indapamide, Chlorothiazide, Chlorthalidone Potassium-sparing dieuretic: Spironolactone Alpha-blockers: Doxazosin, Alfusozin, Labetolol
38
What are the common causes of Pericarditis?
Post MI Auto-immune: SLE Viruses: Coxsackie, EBV, Echovirus Drugs: Hydralazine, Isoniazid, Procainamide, Penicillin
39
What is the cardinal symptom of Pericarditis?
Left sided chest pain that gets better when sitting up
40
Investigations for Pericarditis?
ECG - ST Elevation/PR depression Bloods: WBC, CRP, Troponin up CXR/Echo
41
Management for Pericarditis?
- Aspirin / other NSAIDs - specifically Aspirin if post MI - Colchicine for 3 months - prevents recurrence - Restrict exercise until no symptoms + CRP normal (+ ECG and Echo normal in athletes) - Consider Prednisolone if definitely NON-infective If bacterial pericarditis, consider antibiotics and pericardiocentesis
42
What is Constrictive Pericarditis, what are the causes, and the cardinal signs?
Constrictive Pericarditis is thickening of the Pericardium, caused by surgery or MI, and it causes a KNOCK and KUSSMAUL sign Kussmaul sign = JVP rises on inhalation
43
What is Rheumatic Fever?
Autoimmune reaction to Group A strep infection
44
What is the diagnostic criteria for Rheumatic Fever called?
Duckett-Jones criteria
45
What is the Duckett-Jones criteria?
``` 5 Majors: Carey's Red Nodules ruined Arthur's Career Carditis Rash (Erythema Marginatum) Skin nodules Artheritis Chorea ``` ``` 7 Minors: Fever >38.5 Raised ESR >60 Raised CRP >3.0 Raised WCC PR prolonged ECG Joint pain Previous RF ```
46
Investigations for Rheumatic Fever?
Anti-ASO/DNAase antibodies Strep A throat culture Bloods: WCC, ESR, CRP, Cultures to rule out IE ECG + Echo
47
Management of Rheumatic Fever?
1) Reduce movement 2) Antibiotics for Group A strep --> Benzathine Benzylpenicillin 900mg IM - If Arthritis, Aspirin 1000mg 4x day - If Carditis leading to Heart failure, Furosemide - If Chorea, usually self-limiting but if it's really bad, Sodium Valproate or Carbemazepin
48
What is the drug for secondary prophylaxis of Rheumatic Fever?
Benzathine Benzylpenicillin given every 4 weeks
49
How long should secondary prophylaxis of Rheumatic Fever last?
Benzathine Benzylpenicillin given every 4 weeks No carditis and no valve disease = 5 y / until 18Y Yes carditis and no valve disease = 10 y / until 21Y Yes carditis and yes valve disease = 10 y / unitl 40Y If valve surgery, forever
50
What are the two main causative organisms for infective endocarditis?
Staph Aureus - if IVDU Strep Viridians - if teeth (on previously damaged valves)
51
What kind of endocarditis does SLE cause?
SLE causes LSE - Liebman Sach's Encdocarditis
52
What are some signs of IE?
Fever Changing heart murmur Emboli, causing: Janeway lesions / Osler nodes = painful! Roth spots Splinter haemmorhages
53
What criteria is used to diagnose Infective Endocarditis?
Duke's criteria for Infective Endocarditis
54
What is the Duke's criteria?
Criteria for Infective Endocarditis. 2 Majors: Positive blood cultures Echo 5 minors: - Vascular involvement - Immunological involvement - Microbiological involvement - Fever >38.5 - Pre-disposing factor to IE
55
How many majors and minors do you need in Duke's for a definitive IE diagnosis?
All 2 Majors - Blood cultures and Echo 1 Major + 3 minors All 5 minors
56
What are the investigations for IE?
Blood cultures - xthree 12 hours apart each Echo - TTE Bloods + urinanalysis - proteinuria and haematuria
57
What is the management for IE?
If Native valves, vancomycin and gentamycin 4-6 weeks If Prosthetic valves, vanco + gent + rifampicin 6 weeks If Fungal, IV Flucytosine + oral flucanozole Straight surgery if acute AR/MR w heart failure
58
What is a wacky bacteria that can cause IE and what extra investigation should you do if it is that?
Strep gallolyticus can cause IE --> also do colonoscopy, as it's associated with colorectal tumours
59
What is the management for sinus bradycardia (<60bpm)?
Atropine 0.5mg IV - repeat every 5 mins until 3mg reached or Isoprenaline or Adrenaline
60
What can bradycardia caused by Beta blockers be reversed by?
Glucagon
61
What can bradycardia caused by Calcium channel blockers be reversed by?
Calcium or Adrenaline
62
What is the management for Narrow Complex Tachycardia?
1) Vasovagal manouvers 2) IV Adenosine 6mg --> 12mg --> 18mg - remember saline flush with it or Digoxin 500 mcg/30 mins or Amiodarone 300 mg/1 hour or Verapamil 10mg
63
What can you not give to patients w a tachycardia who have asthma, and what is an alternative?
No Adenosine, give Verapamil instead
64
What is the management for Broad Complex Tachycardia?
IV Amiodarone 300 mg/1hr (which is also an option in Narrow complex, but after Adenosine) or lidocaine
65
What is characteristic on an ECG of Wolff-Parkinson-White syndrome?
Delta waves
66
What are some causes of AF?
AGE Cardiac conditions: HTN, atherosclerosis, congenital heart disease, cardiomyopathy, pericarditis Others: Hyperthyroidism, Pneumonia, asthma, COPD, lung cancer, T2DM, PE, CO poisoning

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