CVS Long Case (UKM) Flashcards
List the possible differentials (life-threatening) for ACS
- Aortic dissection
- Pulmonary embolism
- Pneumothorax
What is the immediate management of STEMI?
Immediate investigations:
- ECG within 10 minutes of arrival
- Set up 2 IV access
- Other urgent investigations: cardiac troponin, FBC, RP, glucose, lipid profile
- Put on continuous cardiac monitoring
- Assess hemodynamic status
- Medications: Aspirin 300mg STAT, Clopidogrel 300mg STAT, Sublingual GTN if SBP >90mmHg
- Supportive treatments:
1. Pain relief: IV MORPHINE 2-5mg by slow bolus injection every 5-15 minutes + IV antiemetic
2. Oxygen if SpO2 <90%
What is the definitive treatment of STEMI?
Choice of method depends on:
1. Time from symptom onset to first medical contact
2. Any CI to fibrinolytic therapy
3. Any high-risk features
Time from symptom onset to FMC:
1. Early (<3 hours): Both primary PCI and FT are equally effective (But, PCI is preferred if can be done)
2. Late (3-12 hours): PCI is preferred
3. Very late (>12 hours): not required PCI or FT if asymptomatic, PCI if symptomatic
What are the CI for fibrinolytic therapy?
- Risk of intracranial hemorrhage
- Risk of bleeding
List some high-risk feature in STEMI that requires a PCI to be done
- Large infarct
- Anterior infarct
- Hypotension, cardiogenic shock
- Significant arrhythmia
- Elderly
- Post-CABG or Post-PCI
- Post-infarct angina
Answer the following questions:
Fibrinolytic therapy
1. Golden hour to administer
2. ideal door-to-needle time
3. Regime
- within hours of symptom onset
- 30 minutes
- IV tenecteplase single bolus injection
Answer the following questions about PCI
1. Ideal door to balloon time
2. If delay due to transfer is expected, total duration should be less than?
3. What are the pre-procedure preparation, procedure, and post-procedure steps?
- 90 minutes
- <120 minutes
- PCI
Pre-procedure:
- Dual antiplatelet has been given: ASPIRIN 300mg + - Clopidogrel 300-600 mg loading or
- Prasugrel 60mg loading
- Ticagrelor 180mg loading
- Anticoagulation with UFH
Procedure:
- Vascular access: radial artery
- Stenting is performed during PCI using drug-eluting stent
Post-procedure:
- Stop anticoagulation
- Continue dual-antiplatelet for 12 months
Describe about the subsequent management of patient in the CCU
Admit all patients with STEMI to CCU
Supportive treatment:
- Pain relief: IV opioids
- Stool softener -> to avoid straining
- O2 to keep SpO2 above 95% via nasal prong
Monitoring
- Continuous vital signs and cardiac monitoring
- Vigilant about early complications of MI
Medical treatment:
- Dual antiplatelet: ASPIRIN 75-100mg daily +
1. Clopidogrel 75mg daily
2. Prasugrel 10mg daily
3. Ticagrelor 90mg BD
- Anticoagulation for patient who received fibrinolytic (LMWH or UFH if patient age>75, renal impairment)
- Beta-blocker (Start ASAP and continue after discharge)
- ACE-inhibitor (Should be started within 24 hour and continue indefinitely)
- High-intensity statin
- Mineralocorticoid receptor antagonist: SPIRONOLACTONE (In patients with LVEF <40% or with heart failure)
- Nitrates: not routinely prescribed
What are the CI in prescribing Beta blocker?
- HR <60bpm
- SBP <100mmHg
- Pulmonary congestion
- Signs of peripheral hypoperfusion
- 2nd or 3rd degree heart block
What are the risk stratification of patient before discharge?
- Evaluate patient’s short-term risk using STEMI TIMI score
- For long-term risk assessment: involves a series of investigations
1. Blood test
2. Echo to assess LVEF
3. Stress test -> identify any residual ischemia
4. Patient who did not undergo PCI should have coronary angiogram if TIMI score is high
Describe the immediate management of non-ST elevation ACS
- 12-lead ECG within 10 minutes of arrival to the ED
- Examination to look for signs of heart failure
- Set up IV access and take urgent investigations
1. Cardiac biomarkers: CK-MB, troponin I
2. Others: FBC, RBS, lipid profile, BUSE - Urgent medications
1. Aspirin 300mg crushed and swallowed
2. Clopidogrel 300mg
3. Sublingual GTN every 5 minutes for maximum 3 times in patient with continuous chest pain - Supportive treatment
1. Oxygen only when SpO2<90% or evidence of respiratory distress
2. Pain relief: IV Morphine 1-5mg, repeated 5-30 minutes is useful
Once diagnosis of non-STEMI is established, risk stratify the patient early
What is the purpose of risk stratification?
- To categorize patient into high, intermediate or low-risk group
- To guide subsequent treatment strategy
State the parameters in TIMI risk score
Mnemonic: AMERICA
A -> Age >65
M -> Markers (cardiac biomarker) elevated
E -> ECG shows ST segment deviation
R -> Risk factors for CAD (>3): DM, hypertension, hyperlipidemia
I -> Ischemic chest pain >2 episodes in previous 24 hours
C -> Coronary stenosis >50%
A -> Aspirin use within 7 days
Each parameter = 1 point
0-1 = low risk
3-4 = intermediate risk
>5 = high risk
How would you manage the patient after assessing his/her TIMI score?
Low to intermediate-risk patient -> ischemic guide strategy, together with further evaluation using a non-invasive test
High-risk patient -> manage with INVASIVE strategy which involves a coronary angiography followed by subsequent revascularization therapy (like PCI, CABG)
Medications:
- Dual antiplatelets: ASPIRIN + CLOPIDOGREL
- Anticoagulation
- Beta-blocker to all patient within first 24 hours
- ACE inhibitor when indicated: hypertension, DM, LVEF <40%
- High-intensity statins to all patient without CI
State the complications of MI
1. Immediate
2. Early
3. Late
Immediate
- Cardiac arrest
- Acute heart failure
- Cardiogenic shock
Early
- Papillary muscle rupture
- Pericarditis
- Interventricular septal rupture
- Left ventricular free wall rupture
Late
- Ventricular aneurysm (persistent ST elevation)
- Dressler syndrome
- Arrhythmia
- CCF
- Reinfarction
How would you diagnose and manage cardiogenic shock?
Diagnosis:
- SBP<90mmHg or MAP<65mmHg for 30 mins or requires vasopressor to achieve SBP>90mmHg
- Pulmonary congestion or elevated left ventricular filling pressure
- Evidence of impaired organ perfusion
Management:
- Inotropes: Noradrenaline to maintain MAP at least 65mmHg
- Pulmonary artery catheter insertion
- ECMO and LV assist device are last resort
What are the possible triggers to be asked in the current episode for a patient with stable angina?
- Physical exertion
- Anemia
- Emotional stress
- Extreme temperature
- Tolerance to nitrate
Topic of discussion: Stable angina
If this is a recurrent episode of CAD, what are the possible complications?
Also, what are the high risk features and common conditions associated with CAD
Bio -> Ischemic cardiomyopathy
Psycho -> Anxiety
Social -> Limited physical tolerance
High-risk features:
- Angina refractory to medical treatment
- Low level of effort tolerance
Common associated conditions
- Peripheral vascular disease
- Cerebrovascular disease
- Impotence/sexual dysfunction
How do you confirm the diagnosis of angina and assess its risk?
- Before any investigation, clinical probability of CAD must be first assessed thoroughly
- Patients with very low or very high clinical probability often DO NOT require any further non-invasive testing
- Patients with INTERMEDIATE clinical probability are recommended to undergo further NON-INVASIVE TESTING
What are the factors to consider whether revascularization therapy is necessary?
- Angina symptoms that affect quality of life
- Moderate to severe ischemia based on non-invasive testing
- Number of coronary vessels involved
- Anatomical complexity of the lesion
State (2) methods of revascularization in a case of stable angina
- Percutaneous coronary intervention (PCI)
- Coronary artery bypass grafting (CABG)
What is the common symptom of infective endocarditis?
Include also other symptoms based on the following headings:
1. Constitutional symptoms
2. Cardiac symptoms
3. Non-specific symptoms
Fever
Other symptoms:
Constitutional symptoms: Malaise, Weight loss, night sweats, loss of appetite
Cardiac symptoms: Chest pain, palpitation
Non-specific symptoms: Arthralgia, myalgia, back pain
State the risk factors of infective endocarditis
Due to thrombus
- Previous insult to the heart
- Pre-existing cardiac disease
- Cardiac prosthesis
Due to the introduction of bacteria
- IVDU
- Conditions that require long-term catheter in situ
- Immunocompromised
- Recent dental procedures**
Differentiate between acute IE from subacute IE
