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Year 4 General Medicine > Chest pain and management of arrhythmia > Flashcards

Chest pain and management of arrhythmia Flashcards

(61 cards)

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1
Q

what do you do for a man who has developed chest pain

A

Take a full history and examination

NEWS

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2
Q

what do you want to rule out for a patient with chest pain

A

MI - ACS

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3
Q

investigations for chest pain

A 
12 lead ECG - compare it with old ECGs 
IV access 
CXR 
bloods - FBC, U+E, 12hr troponins, d-dimers, amylase
ABG 
ECHO 
CT chest
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4
Q

list high risk ECG changes

A

transient or persistent ST elevation
>1mm ST depression
Deep T wave inversion

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5
Q

curveball in CXR

A

pneumothorax

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6
Q

big 3 differential diagnoses of chest pain

A
  1. ACS - STEMI, NSTEMI, unstable angina, coronary spasm
  2. Acute aortic syndrome - rupture, dissection, penetrating ulcer
  3. PE
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7
Q

what are the ‘smaller’ causes of chest pain

A 
pericarditis 
pneumonia 
pneumothorax 
oesophageal spasm/reflux/rupture 
GB/pancreas 
MSK/mechanical/costochondritis/rib #/fibromyalgia 
Neuro - shingles HZV, nerve root pain 
psychosocial - panic attack 
drugs - cocaine, triptans, 5FU
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8
Q

initial treatment of ACS

A 
MONA 
Morphine + antiemetic 
Oxygen if hypoxic 
Nitrate - SL/buccal/PO/topical/IV
Aspirin - 300mg chewed
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9
Q

further treatment for ACS

A 
heparin/LMWH/Clopidogrel/ticagrelor 
B blocker 
CCU 
angiography +- angioplasty 
IV GTN
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10
Q

stable angina

A

significant artery narrowing but predictable limiting symptoms

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11
Q

plaque rupture

A

unpredictable
rapid onset
sudden occlusion of arteries –> MI

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12
Q

stable angina approach

A 
outpatient no rush situation 
medical therapy 
RF modification 
aspirin 
statins 
B blockers 
GTN
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13
Q

NSTEMI

A

ruptured atherosclerotic plaque
unstable symptoms
pain at rest
artery still open but severe and critical narrowing
threatening situation and significant mortality

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14
Q

STEMI pathophysiology

A

ruptured plaque
completely blocked artery and dying muscle
severe pain at rest
autonomic upset
emergency: time = muscle
immediate opening of artery required either PCI or thrombolysis
immediate rush

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15
Q

management of suspected ACS

A 
hospital by ambulance 
300mg aspirin unless contraindicated 
12 lead ECG within 10 min arrival 
admitted to CCU/HDU or telemetry bed 
managed by specialist CVS services for drugs/PCI/CABG
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16
Q

why should patients be taken by ambulance with MI

ie why do people die from MI

A

VF

need access to defibrillator

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17
Q

ECG interpretation structure

A 
rate 
rhythm 
ST T wave 
QRS 
PR, QT other funny stuff
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18
Q

territories in ECG
lateral
inferior
anteroseptal

A

lateral V5-6
high lateral I and aVL
inferior II, III and aVF
anteroseptal V1-4

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19
Q

what are reciprocal changes

A

ST depression in leads that dont have ST elevation

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20
Q

LBBB

A

wide QRS and goes down in V1

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21
Q

LBBB can mask ischaemia, true or false

A

true

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22
Q

RBBB

A

more subtle than LBBB

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23
Q

you can interpret RBBB ECG changes, true or false

A

true

cannot interpret LBBB underlying ECG changes

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24
Q

tall big QRS with T wave inversion

A

LVH and strain

think HOCM

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25
broad QRS and up/down in V1
up - RBBB | down - LBBB
26
deep T wave inversion
stress induced MI
27
where should you look for P waves
V1 and lead II
28
sinus rhythm with atrial ectopics
seen in healthy people
29
long QT interval
need to measure it
30
broad and narrow complete heart block - which is worse
broad QRS complete heart block is more malignant | could drop dead at any moment
31
fusion beats
atria and ventricles collide at same time | seen in VT
32
pericarditis ECG changes
widespread ST elevation across territories with no reciprocal changes PR depression
33
how can a patient with AF have a regular rhythm
pacemaker causing | broad QRS and very sharp spikes
34
aVR is a reference strip
if the ECG has been done properly the aVR lead should go down
35
what is the most likely cause of a student collapsing halfway through a teaching session
vasovagal | manage by elevating feet
36
what is syncope
transient loss of consciousness due to cerebral hypoperfusion characterised by a rapid onset, short duration and spontaneous complete recovery 'not enough blood to the brain'
37
what is TLOC
transient loss of consciousness group of things which syncope is one of them LOC with loss of awareness, amnesia, abnormal motor control, loss of responsiveness and a short duration
38
classification of syncope
reflex syncope orthostatic hypotension cardiac syncope
39
causes of reflex syncope
``` triggered by an event can be: vasovagal situational carotid sinus syncope atypical it is so common ```
40
causes of orthostatic hypotension
``` problem with autonomics can be: PD, MSA DM, amyloid, uraemia drug induced volume depletion ```
41
causes of cardiac syncope
pathology in the heart causing you to black out can be: bradycardia tachycardia tachy brady disease structural disease - Ao stenosis, HOCM, MI, tamponade, rupture other - PE, dissection
42
what is vasovagal syncope
trigger results in reflex activation and decreased cerebral blood flow and pooling of blood in peripheral arterial circulation
43
what are the 3 Ps of vasovagal syncope
no features suggesting other disease AND Posture - prolonged standing or prevent by sitting Provoking factors - pain, procedure Prodromal features - sweats, feeling hot, blacking of vision
44
what is situational syncope
type of reflex syncope | clearly and consistently provoked by trigger e.g. straining, coughing, swallowing, post exertion syncope
45
define orthostatic hypotension
fall in SBP >20 or DBP >10 after standing 3 min
46
history taking for syncope
``` circumstances posture prior to event prodromal symptoms appearance - eyes open, pallor tongue biting (tip vs side - seizure) injuries duration of onset to return of consciousness post event confusion? ```
47
features suggestive of epilepsy
``` biting side of tongue head turning no memory of abnormal behaviour prior, during or after post ictal confusion unusual posturing prodromal deja/jamais vu ```
48
people who are syncopal may jerk?
yes | but doesnt look like a TC seizure
49
red flags for syncope
``` abnormal ECG heart failure TLOC on exertion FH of sudden cardiac death <40y new/unexplained breathlessness heart murmur ```
50
where can syncopal patients be referred to
TLoC clinic | after routine investigations
51
what investigation must everyone who has had syncope must have
ECG
52
what should you screen for in an ECG for syncope
conduction abnormalities - QT prolongation, pre-excitation, Brugada structural abnormalities - hypertrophy, T wave changes
53
what is an r test
ECG monitoring for long periods of time
54
Implantable loop recorders are commonly used
not commonly as they are expensive but are very useful when they are used machine inserted under skin
55
Indications for ECHO
structural disease concern previously known heart disease abnormal ECG presence of murmur
56
DVLA at a glance
updated DVLA and driving guidance for medical professionals
57
advanced treatments for arrhythmias
implantable defibrillators (ICD) cardiac resynchronisation pacemakers radiofrequency ablation
58
radiofrequency ablation
common procedure multiple venous access catheters in the heart diathermy or cryotherapy
59
indications for radiofrequency ablation
SVT atrial flutter AF
60
subcutaneous ICD
sits under the skin in the axilla and the tip is at the sternal notch more cosmetically appealing no need to enter venous circulation
61
list the investigations for working up a patient with syncope palpitations
Everyone - 12 lead ECG Recurrent symptoms - ECG when symptomatic Daily / short lived - 24 hour tape / r test Less frequent symptoms - 7 day r test Recurrent infrequent syncope - implantable loop recorder Exertional symptoms - exercise treadmill test Murmur, abnormal ECG, suspected HF... - ECHO Seizures - Neurology

Year 4 General Medicine (16 decks)

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