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MRCS A > CARDIOLOGY - ACS and Angina > Flashcards

CARDIOLOGY - ACS and Angina Flashcards

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1
Q

Broad catergories - chest pain (5)

A

Cardiac
Pulmonary
GORD
MSK
Other

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2
Q

Myocardial ischaemia - SOCRATES

A

S - Retrosternal, central chest pain
O - builds over mins
C - crushing, gripping
R - Neck, shoulder, jaw (C5)
A - paraesthesia arms, sweating, nausea, breathlessness, collapse
T - mins –> hrs
E - Exertion, cold, stress, heavy meal.
S - severe

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3
Q

RF Myocardial ischaemia (10)

A

Hyperlipidaemia
DM
Smoking
FHx
HTN
Obesity
Race
Male
Age
Renal disease

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4
Q

Ix Myocardial ischaemia (5)

A

ECG
Trops
CK
CXR
Ddimers

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5
Q

Type A Aortic Dissection

A

Involves aortic arch and valve proximal to LSCA

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6
Q

Sx from type A Aortic dissection

A

Limb ischaemia
Cerebral ischaemia
Aortic regurg
Cardiac tamponade

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7
Q

Type B Aortic dissection

A

Involves descending thoracic aorta distal to LSCA

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8
Q

Sx from type B Aortic dissection

A

Paraplegia
Ischaemic bowel
Renal aa failure
Lower limb ischaemia

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9
Q

Who gets aortic dissection classically

A

Middle aged HTN males

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10
Q

Other RF Aortic dissection (5)

A

Bicuspid aortic valve disease
Atherosclerosis
Marfan’s
Ehlers Danlos
During pregnancy

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11
Q

Which gene defect is related to aortic dissection?

A

Fibulin-5 –> fibrillin

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12
Q

SOCRATES Aortic dissection

A

S - Central CHx/back/betw shoulder blades
O - V sudden
C - tearing, ripping, searing pain
R - back, shoulders, neck, abdo
A - collapse, sweating, HoTN , ischaemic pain, neuro. Peripheral pulses +/-
T - constant
E - none
S - severe

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13
Q

Ix Aortic dissection

A

CXR/AXR
CT - definitive diagnosis

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14
Q

What is pericarditis

A

Inflammation of the pericardium

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15
Q

Causes pericarditis

A

Idiopathic
Viruses - fl,EBV,mumps, HIV
Bacteria - pneumonia, FR, fever, TB, staph, strep,
Fungi
MI, Dresslers
Dx
RA/SLE, surgery, malig, radioT, sarcoidosis

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16
Q

SOCRATES - Pericarditis

A

S - retrosternal
O - gradual
C - sharp/sore
R - tip L shoulder, back, neck
A - fever, viral Sx, breathless
T - constant + can last days
E/R - worse on insp/lying flat, Relieved by sitting forward + analgesia
S - varies

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17
Q

ECG changes pericarditis

A

Saddle shaped ST elevation

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18
Q

What is pain in shoulder tip suggestive of?

A

Diaphragmatic pleural irritation

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19
Q

SOCRATES PE

A

S - localised to chest wall
O - sudden
C - sharp, pleuritic
R - shoulders/back
A - Dyspnoea, haemoptysis, dizzy, syncope, cough, fever
T - constant
E/R - worse on insp, coughing, moving. R - shallow breaths analgesia
S -varies

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20
Q

GORD and GTN spray

A

Relieves after 20 mins

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21
Q

Definition of ACS

A

Acute central chest pain, lasting > 20 minutes, not relieved by 3x GTN sprays at 5 min intervals

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22
Q

Who gets ACS without chest pain aka silent infarction

A

Elderly
Diabetics

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23
Q

Sympathetic activation Sx ACS

A

Tachycardia
HTN
Pallor
sweatiness

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24
Q

Vagal stimulation Sx ACS

A

Bradycardia
Vomiting

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25
STEMI vs NSTEMI
STEMI - ST elevation on ECG + LBBB = Complete occlusion of coronary aa + full thickness MI NSTEM = elevated troponin but no ST elevation or LBBB - subtotal occlusion occurs
26
Def unstable angina
Occuring at rest or sudden incr f/severity of existing angina
27
Blood results UA
Plasma Trops and CK = norm
28
ECG UA
Normal Or ST depression +/- T wave inversion
29
MI time course - 0-12hrs
Infarct not visible Loss of oxidative enzymes
30
MI time course - 12-24hrs
Infarct pale/blotchy, w/ intracellular oedema
31
MI time course - 24-72hrs
Infarcted area excites acute inflamm response, w/ dead area soft + yellow w/ neutrophilic involvement
32
MI time course - 3-10days
Organisation of infarcted area by vascular granulation tissue
33
MI time course - 10days to several m
Collagen deposition Infarct replaced by scar
34
Normal troponin levels
<10
35
How long can troponin stay elevated for?
Up to 2 w
36
What areas of the heart does the R coronary aa supply?
RA RV Posterior septum SAN (60%) AVN (80%)
37
What type of MI does a RCA give?
Post/inferior MI
38
Which leads does a posterior/inf MI show up in
II, III aVF
39
What 2 aa does the L coronary aa split into?
LAD Circumflex
40
What areas of the heart does the circumflex artery supply?
LA LV
41
What type of MI does circumflex aa give?
Lateral MI
42
What ECG leads does a lateral MI show up in
I aVL V5-6
43
What areas of the heart dose the LAD aa supply?
LV Anterior septum
44
What type of MI does LAD aa give?
Antero-sepatal MI
45
What ECG leads does an antero-septal MI show up in?
V1-4
46
MI ECG changes at: 5 mins
Tall, pointed T-waves
47
MI ECG changes at: 30 mins
ST elevation
48
MI ECG changes at: 2+hrs
T wave inversion + Q waves develop
49
MI ECG changes at: days after
ST segment returns to normal
50
MI ECG changes at: weeks after
Q wave remains
51
Which investigation is contraindicated in unstable angina?
Stress tests
52
When does troponin levels peak after an MI?
24hrs
53
What marker is useful for rapid diagnosis of MI?
Myoglobin
54
Why take FBC + U+E for MI Ix
Glucose is lowered Lipids are raised
55
CXR features MI (2)
Cardiomegaly Pulmonary oedema Widened mediastinum
56
Which test definitively defines presence, extent and severity of CAD?
Coronary angiography
57
What is the earliest sign of acute MI on ECG?
Hyperacute T waves
58
What leads are hyperacute T waves most evident in?
Anterior chest leads
59
What ECG change is often the earliest recognised sign of an acute MI
ST elevation
60
What ECG change is DIAGNOSTIC of a STEMI
1mm of ST elevation in 2 contingous leads
61
What ECG change is the only firm evidence of myocardial necrosis?
Q waves
62
How long may T wave inversion take to resolve?
2 weeks
63
Which type of MIs does T wave inversion tend to persist in?
Anterior MI
64
Mx STEMI (MOANA)
morphine IV 10mg O2 Antiplaetlets - aspirin (300mg) or clopidogrel (600mg) Nitrates/GTN Anti-emetics (10mg metocloperamide)
65
When do you not use GTN spray in STEMI Mx
if pt = hypotensive
66
What meds to give post PCI
Clopidogrel + abciximab (reduce complication rates)
67
C/I Thrombolysis (6)
Haemorrhagic stroke at any time Ischaemic stroke in last 6 months CNS damage/neoplasm Recent trauma (3 weeks) GI bleed within last month Bleeding disorder/aortic dissection
68
What is the GRACE score
Determines mortality risk in ACS
69
Highest GRACE score risk features in NSTEMI/UA
>6m raised trops Persistent pain ST depression Diabetes
70
Factors taken into account GRACE score
Age HR < BP class of CHF Renal fct ST segment changes Troponin Whether there was an arrest at admission
71
Lterm Mx ACS
48hr bed rest w/ ECG U+E's + cardiac enzymes 3 days Thromboprophylaxis Aspirin 75mg OD for life Clopidogrel 75mg OD 1 yr Bisoprolol (life) Start ACEi + statin after 24-48hr Address RF
72
Immediate complications MI
Arrhythmias
73
S term complications MI (6)
Pulmonary oedema Cardiogenic shock Thromboembolism Venticulo-septal defect Ruptured chordae tendinae Rupture of ventricular wall
74
When does rupture of ventricular wall happen after MI?
2-10 days after
75
Why does rupture of ventricular wall post MI happen?
B/C reorganisation + softening of wall --> haemopericardium, cardiac tamponade + rapid death
76
L term complications MI (3)
Heart failure Dressler's syndrome Ventricular aneurysm formation
77
What is Dressler's syndrome
Immune mediated pericarditis post MI
78
Sx Dressler's syndrome
Sharp chest pain Exaccerbated by movement + lying down Relieved by sitting forward
79
Tx Dresslers' syndome
High dose aspirin / NSAIDs
80
Define angina
Chest pain precipitated by exercise and relieved by rest. Usually fades within mins Caused by heart not getting enough O2
81
Causes angina (11)
Coronary aa disease Aortic stenosis LVH Anaemia/carboxyhaemoglobinaemia Atheroma Embolus Thrombosis Spasm Inflammation coronary aa Generalised HoTN Tachyarrhythmia Hyperthyroidism
82
What is atherosclerosis
Non-specific thickening of walls of aa --> loss of contractility + elasticity decreased blood flow
83
What is an atheroma
Specific degenerative disease affecting large/med size aa
84
Pathology of Angina
LDLs into intima LDLs taken up by macrophages --> fatty streak Macrophages stimulate cytokines --> collagen deposition --> plaque becomes fibrotic --> pressure atrophy Endothelium is fragile, ulcerates
85
RF Angina (9)
Age Male FH Smoking Diet Obesity HTN Hyperlipidaemia DM
86
What is decubitus angina
Angina precipitated by lying down as there is increased venous return to heart
87
Prinzmetal's angina
Occurs without provocation at rest as result of coronary aa spasm
88
Ix that show Prinzmetal's angina
ST elevation But no trops rise
89
PS Angina (socrates)
S- retrosternal O - builds over mins C- dull ache constriction, heavy R - l arm, shoulders, neck, jaw A - usually none T - mins E - exertion, stress, cold, food (R - rest, nitrates) S - mild
90
Ix Angina
Clinical assessment FBC,gluc, lipids, TFTs Resting 12 lead ECG lead Stress-12 lead ECG (if resting is normal) Nuclear medical testing CT angiography Coronary angiography scintigraphy Stress echo Stress perfusion MRI FFR FFI
91
NICE tool - likelihoodness of CAD
 >90%: treat as stable angina  61-90%: coronary angiography = indicated  31-60%: functional imaging = indicated – SPECT myocardial perfusion scan, exercise echo, stress MRI  10-30%: CT Ca scoring = used  <10%: investigate for another cause
92
FFR value that is significant in Angina
<0.75
93
FFI value that is significant in Angina
<0.89
94
Mx angina
Mx risk factors 1st line = GTN + B blocker or CCB
95
Mx - angina (refractory disease)
Combination therapy Or Nicorandil
96
2' prevention angina
Statin Low dose aspirin
97
SE aspirin
GI ulcer Bleeding
98
effect nitrates
Decrease pre-load and afterload - decr O2 req of myocardium --> VD --> Incr O2 delivery
99
SE nitrates (2)
Headache HoTN
100
effect B blockers
Negative inotroic and chronotropic effects Slow HR Reduces contractility Reduce aa pressure
101
SE b blockers (5)
GI problems Fatigue Poor perfusion Bronchoconstriction Hypoglycaemia
102
Effect CCB
Inhibit excitability of cardiac mm Prevents SM contraction, reduce afterload and --> coronary VD
103
What do rate limiting blockers (CCBs) do
Inhibit conduction through AVN and cause bradycardia
104
What does dihydropyrmidine blockers do
Reduce contractility but may --> reflex tachy C
105
Which Dx is 1st line in prinzmetal angina
CCB
106
SE CCB
Dizziness Flushing Headache Peripheral oedema
107
effect nicorandil
Combined NO donor + activator ATP sensitive K channels on vascular SM --> hypoerpolarisation + marked VD
108
What is PCTA
Dilate coronary atheromatous obstructions Inflate catheter-mounted balloon w/ obstruction using fluoroscopy
109
Risks PCTA (2)
Local dissection Acute coronary occlusion
110
When is CABG indicated
For sx control in patients unsuitable for PCI
111
How long after ACS should you avoid air travel
2 months
112
How long after ACS should you avoid intercourse
1 month

MRCS A (36 decks)

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