Cardiolovascular Flashcards

Question

What are the investigations of MR?

Answer 1

* ECG (P-mitrale, AF, LVH) * Bloods (FBC, U&E, NT-proBNP, lipids, glucose) * CXR (LA/LV hypertrophy, calcified mitral valve, pul. oedema) * Echo ± doppler (severity, cusp calcification, LV function); **severe MR**… * Jet width \>0.6cm * Systolic pul. flow reversal * Regurgitant volume \>60mL * Coronary angiography

Answer 2

Initial drug therapy * aspirin 300mg * oxygen should only be given if the patient has oxygen saturations \< 94% in keeping with British Thoracic Society oxygen therapy guidelines * morphine should only be given for patients with severe pain * previously IV morphine was given routinely * evidence, however, suggests that this may be associated with adverse outcomes * nitrates * can be given either sublingually or intravenously * useful if the patient has ongoing chest pain or hypertension * should be used in caution if patient hypotensive

Answer 3

* clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (\> 20 minutes) ECG features in ≥ 2 contiguous leads of: * 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years * 1.5 mm ST elevation in V2-3 in women * 1 mm ST elevation in other leads * new LBBB (LBBB should be considered new unless there is evidence otherwise)

Answer 4

There are two types of coronary reperfusion therapy: * percutaneous coronary intervention * should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI) * if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered * drug-eluting stents are now used. Previously 'bare-metal' stents were sometimes used but have higher rates of restenosis * radial access is preferred to femoral access * fibrinolysis e.g. altepase * should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given * a practical example may be a patient who presents with a STEMI to a small district general hospital (DGH) that does not have facilities for PCI. If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI

Answer 5

Further antiplatelet prior to PCI * this is termed 'dual antiplatelet therapy', i.e. aspirin + another drug * if the patient is not taking an oral anticoagulant: prasugrel * if taking an oral anticoagulant: clopidogrel Drug therapy during PCI * patients undergoing PCI with radial access: * unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI) - this is the action of using a GPI during the procedure when it was not intended from the outset, e.g. because of worsening or persistent thrombus * patients undergoing PCI with femoral access: * bivalirudin with bailout GPI

Answer 6

Other procedures during PCI * thrombus aspiration, but not mechanical thrombus extraction, should be considered * complete revascularisation should be considered for patients with multivessel coronary artery disease without cardiogenic shock

Answer 7

Patients undergoing fibrinolysis should also be given an antithrombin drug. An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered

Answer 8

Further drug therapy * antithrombin treatment * fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately * if immediate angiography is planned or a patients creatinine is \> 265 µmol/L then unfractionated heparin should be given

Answer 9

GRACE Score The Global Registry of Acute Coronary Events (GRACE) is the most widely used tool for risk assessment. It can be calculated using online tools and takes into account the following factors: * age * heart rate, blood pressure * cardiac (Killip class) and renal function (serum creatinine) * cardiac arrest on presentation * ECG findings * troponin levels

Answer 10

Based on this risk assessment key decisions are made regarding whether a patient has coronary angiography (with follow-on PCI if necessary) or has conservative management. * immediate: patient who are clinically unstable (e.g. hypotensive) * within 72 hours: patients with a GRACE score \> 3% i.e. those at intermediate, high or highest risk * coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission

Answer 11

Further drug therapy * unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not * further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) prior to PCI * if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor * if taking an oral anticoagulant: clopidogrel

Answer 12

There are two types of coronary reperfusion therapy: * percutaneous coronary intervention * should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI) * if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered * drug-eluting stents are now used. Previously 'bare-metal' stents were sometimes used but have higher rates of restenosis * radial access is preferred to femoral access * fibrinolysis e.g. altepase * should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given * a practical example may be a patient who presents with a STEMI to a small district general hospital (DGH) that does not have facilities for PCI. If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI

Answer 13

* *Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%.* * For patients \< 40 years consider specialist referral to exclude secondary causes.

Answer 14

* a low salt diet is recommended, aiming for less than 6g/day, ideally 3g/day. * caffeine intake should be reduced * the other general bits of advice remain: stop smoking, drink less alcohol, eat a balanced diet rich in fruit and vegetables, exercise more, lose weight

Answer 15

* angiotensin receptor blockers should be used where ACE inhibitors are not tolerated (e.g. due to a cough) * for patients of black African or African–Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor *

Cardiolovascular Flashcards

(42 cards)