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Medicine > Case 1 - Chest Pain - Progress Test Revision > Flashcards

Case 1 - Chest Pain - Progress Test Revision Flashcards

1
Q

What areas of the heart are supplied by the RCA?

A

Right atrium
Right ventircle
Inferior left ventricle
Posterior septum

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2
Q

What areas of the heart are supplied by the circumflex artery?

A

Left atrium

Posterior left ventricle

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3
Q

What areas of the heart are supplied by the LAD?

A

Anterior left ventricle

Anterior septum

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4
Q

What is a stunned myocardium?

A

Acute myocardial ischaemia results in a prolonged heart wall motion abnormality which eventually resolves

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5
Q

What is somatic pain?

A

Pain in the skin, muscles, bones or joints

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6
Q

What is visceral pain?

A

Pain in the organs in the thoracic or abdominal cavities

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7
Q

Risk factors for ischaemic heart disease

A

Unmodifiable:

  • Age
  • Male gender
  • Family history

Modifiable:

  • Smoking
  • Hypertension
  • Hypercholesterolaemia
  • Obesity
  • DM
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8
Q

Pathophysiology of ischaemic heart disease

A
  • Endothelial dysfunction triggered by smoking, hypertension and hyperglycaemia.
  • Causes pro-inflammatory, pro-oxidant, proliferative and reduced nitric oxide bioavailability.
  • Fatty infiltration of the subendothelial space by LDL particles.
  • Monocytes migrate from the blood and differentiate into macrophages.
  • Macrophages phagocytose oxidised LDL, forming large foam cells.
  • Macrophages die and propagate the inflammatory process.
  • Smooth muscle proliferation and migration from the tunica media into the intima forms a fibrous capsule covering the fatty plaque.
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9
Q

Who may not experience pain in an MI?

A

Elderly, diabetics

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10
Q

Where are ECG changes seen for MIs in different parts of the heart?

A 
Anterior = V1-V4 (LAD) 
Inferior = II,III, aVF (RCA) 
Lateral = I, V5-V6 (circumflex)
Posteroir = Tall R waves in V1-V2 (usually left circumflex)
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11
Q

Acute management of an MI:

A

Morphine
Oxygen (if O2 sats < 94%)
Nitrates (use in caution if hypotensive)
Aspirin 300mg

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12
Q

How is risk in an NSTEMI classified determining requirements for PCI?

A

GRACE score

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13
Q

Secondary prevention medications for ACS

A 
Aspirin 
A second antiplatelet (eg. clopidogrel / ticagrelor)
A beta blocker 
An ACE-i 
A statin
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14
Q

What score is used to stratify risk post myocardial infarction?

A 
Killip class I-IV 
(classifies 30 day mortality based on signs of HF)
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15
Q

When should PCI be considered?

A

Presentation within 12 hours of start of symptoms + PCI can be delivered within 120 minutes of the time when fibrinolysis could be given

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16
Q

What medication should you give before PCI

A

Aspirin + another antiplatelet.

If patient is not on an oral anticoagulant = prasugrel.

If patient is on an oral anticoagulant = clopidogrel

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17
Q

What medication should you give during PCI via radial access?

A

Unfractionated heparin + bailout glycoprotein IIb/IIIa inhibitor (GPI)

18
Q

What medication should you give during PCI via femoral access?

A

Bivalirudin + bailout GPI

19
Q

Medications to give with fibrinolysis

A

Give an antithrombin at the same time.
Give ticargrelor after procedurue.
If ongoing MI consider PCI.

20
Q

How long after fibrinolysis should an ECG be repeated?

A

60-90 minutes

21
Q

How is NSTEMI managed medically?

A

If no immediate PCI planned = give fondaparinux.

If managing without PIC = give ticagrelor

22
Q

If patient is at a high bleeding risk should you use ticagrelor / clopidogrel?

A

Clopidogrel

23
Q

Which calcium channel blocker should be used in AF?

A

Diltiazem

24
Q

What score is used to quantify stroke risk in AF?

A

CHA2DS2 VAS2

25
Q

What score is used to determine the risk / benefit of starting warfarin?

A

HASBLED

26
Q

What anticoagulation is used in AF?

A

Warfarin / NOAC

27
Q

What does a soft S1 indicate?

A

Mitral regurgitation

Long PR

28
Q

What does a loud S1 indicate

A

Mitral stenosis

29
Q

What does a soft S2 indicate?

A

Aortic stenosis

30
Q

What does S3 indicate?

A

Normal in < 30.

Left venticular failure (eg. dilated cardiomyopathy), constricive pericarditis (pericardial knock), mitral regurgitation

31
Q

What does S4 indicate?

A

Aortic stenosis, HOCM, hypertension

32
Q

What type of murmur is aoritc stenosis?

A

Ejection systolic murmur heard in the aortic area, with radiations to the carotids

33
Q

What signs are assoicated with aortic stenosis?

A 
Slow rising pulse 
Narrow pulse pressure 
Soft / absent S2 
S4
Thrill

Can have left ventricular hypertrophy or failure

34
Q

What are the most common causes of aortic stenosis?

A

Over 65s:
Degenerative calcification

Under 65s:
Bicuspid aortic valve

35
Q

How is aortic stenosis managed?

A

Asymptomatic:
- observe

Symptomatic / valvular gradient > 40:
- valve replacement

36
Q

What type of murmur is tricuspid regurgitation?

A

Pansystolic murmur which becomes louder on inspiration

37
Q

What type of murmur is aortic regurgitation?

A

Early diastolic

38
Q

What type of murmur is mitral stenosis?

A

Mid-diastolci

39
Q

What type of murmur is pulmonary stenosis?

A

Ejection systolic heard loudest on inspiration

40
Q

What type of murmur is mitral regurgitation?

A

Pansystolic murmur

41
Q

What are the signs associated with mitral regurgitation?

A

Quiet S1
Widely splity S2 (in severe cases)

May be broad p waves on an ECG
May have cardiomegaly on a CXR
echo is used to diagnose

42
Q

How is mitral reguritation managed?

A

Acute MR:

  • nitrates
  • diuretics
  • positive ionotropes
  • intra-aortic balloon pump to increase CO

In HF:

  • ACE-i
  • beta blockers
  • spironolactone

In acute severe cases:
- surgery (repair of valve preferable)

Medicine (15 decks)

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