finals 1 cardio/gynae/surigcal/gastro Flashcards
When a thrombus forms in a fast-flowing artery what is it mainly made out of and hence what is the mainstay of treatment?
It is formed mainly of platelets.
This is why antiplatelet medications such as aspirin, clopidogrel and ticagrelor are the mainstay of treatment.
What are the 2 ECG changes found in a STEMI and and NSTEMI?
STEMI:
ST elevation
new LBBB
NSTEMI:
ST depression
T wave inversion
what does a pathological Q wave? (when the q wave dips greater than usual)
Pathological Q waves suggest a deep infarction involving the full thickness of the heart muscle (transmural) and typically appear 6 or more hours after the onset of symptoms.
Pathologic Q waves are a sign of previous myocardial infarction. They are the result of absence of electrical activity. (they are a marker of electrical silence).
which heart artery represent supplies each part of the heart and which ecg lead correlate
Right coronary artery
Inferior
II, III, aVF
Left anterior descending
Anterior
V1-4
lca/circumflex
the rest lateral
1, aVL, V3-6
Are troponin LEVELS required to diagnose a STEMI?
NO only nstemi
normally repeated on baseline then 3 hours, then should see a raise
nstemi vs unstable angina
NSTEMI is diagnosed when there is a raised troponin, with either:
A normal ECG
Other ECG changes (ST depression or T wave inversion)
Unstable angina is diagnosed when there are symptoms suggest ACS, the troponin is normal, and either:
A normal ECG
Other ECG changes (ST depression or T wave inversion)
NSTEMI is diagnosed when there is a raised troponin, with either:
A normal ECG
Other ECG changes (ST depression or T wave inversion)
Unstable angina is diagnosed when there are symptoms suggest ACS, the troponin is normal, and either:
A normal ECG
Other ECG changes (ST depression or T wave inversion)
managment of STEMI
M- Morphine
O- Oxygen
N- Nitrate (GTN) - vasodilatior
A- Aspirin 300mg
C- cloplidogrel
Patients with STEMI presenting within 12 hours of onset should be discussed urgently with the local cardiac centre for either:
-Percutaneous coronary intervention (PCI) (if available within 2 hours of presenting)
-Thrombolysis (if PCI is not available within 2 hours)
if you give Thomobolysis and it doesnt work try arange for PCI
What is PCI and thromobolysis?
Percutaneous coronary intervention (PCI) involves putting a catheter into the patient’s radial or femoral artery (radial is preferred), feeding it up to the coronary arteries under x-ray guidance and injecting contrast to identify the area of blockage (angiography). Blockages can be treated using balloons to widen the lumen (angioplasty) or devices to remove or aspirate the blockage. Usually, a stent is inserted to keep the artery open.
Thrombolysis involves injecting a fibrinolytic agent. Fibrinolytic agents work by breaking down fibrin in blood clots. There is a significant risk of bleeding, which can make thrombolysis dangerous. Some examples of thrombolytic agents are streptokinase, alteplase and tenecteplase.
what is post MI treatment
can remember as 4 A’s
Aspirin 75mg (forever) + SECOND antiplatelet either clopigogrel or trcagrelor - THIS IS CALLED DUAL ANTIPLATELET THERAPY - at least 12 months
Atorvastatin - A Statin (FOREVER)
Atenalol - A beta blocker normally is is bisoprolol (At least 12 months
ACE- inhibitor- normally ramipril (FOREVER)
or 6 A’s
Aspirin 75mg once daily indefinitely
Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril) titrated as high as tolerated
Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
Dual antiplatelet therapy will vary following PCI procedures, depending on the type of stent that was inserted.
MANAGMENT ON NSTEMI
he medical management of an NSTEMI can be remembered with the “BATMAN” mnemonic:
B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)
Unstable patients are considered for immediate angiography, similar to with a STEMI.
The GRACE score gives a 6-month probability of death after having an NSTEMI.
3% or less is considered low risk
Above 3% is considered medium to high risk
Patients at medium or high risk are considered for early angiography with PCI (within 72 hours).
2 main side affects of statins
muscle weakness/pain
Rhabdomyolysis (muscle damage – check the creatine kinase in patients with muscle pain)
which antibiotics interact with statins
Several common medications interact with statins. One key interaction to remember is with macrolide antibiotics. Patients being prescribed clarithromycin or erythromycin should be advised to stop taking their statin whilst taking these antibiotics.
1.what is the inheritance pattern of familial hypercholestrolemia
2. three important features for diagnosis?
3. management?
Familial hypercholesterolaemia is an autosomal dominant genetic condition causing very high cholesterol levels. Several genes have the potential to cause the disorder.
3 criterias for diagnosis
-FHX of CVD
-VERY High cholesterol - above 7.5
-Tendon xanthomata (hard nodules in the tendons containing cholesterol, often on the back of the hand and Achilles)
Management
-Specialist referral for genetic testing and testing of family members
-Statins
what is the Q- RISK score and threshold for treatment?
he percentage risk that a patient will have a stroke or myocardial infarction in the next 10 years.
if above 10%, they should be offered a statin, initially atorvastatin 20mg at night.
why should you monitor renal patients on ACE inhibitors and aldosterone antagonists.
Both can cause hyperkalaemia (raised potassium). The MHRA issued a safety update in 2016 that using spironolactone or eplerenone (aldosterone antagonists) plus an ACE inhibitor or angiotensin receptor blocker carries a risk of fatal hyperkalaemia.
what is dressler’s syndrome, how does it present and how is it managed?
AKA POST MI SYNDROME
happens 2-3 weeks after an MI, caused by local inflammatory response. Resulting in inflammation of the pericardium - pericarditis.
presentation:
pleuritic chest pain, low grade fever, pericardial rub on auscultation (rubbing and scratching sounds)
- it can causes a pericadial effusion and rarely a cardiac tamponase
A diagnosis can be made with an ECG (global ST elevation and T wave inversion), echocardiogram (pericardial effusion) and raised inflammatory markers (CRP and ESR).
Management is with NSAIDsand, in more severe cases, steroids (e.g., prednisolone). Pericardiocentesis may be required to remove fluid from around the heart, if there is a significant pericardial effusion.
complications post MI an be remembered with the “DREAD” mnemonic:
D – Death
R – Rupture of the heart septum or papillary muscles
E – “oEdema” (heart failure)
A – Arrhythmia and Aneurysm
D – Dressler’s Syndrome
You are starting a patient on sublingual glyceryl trinitrate (GTN) for angina.
What should you tell them before commencing treatment?
you may get a headache and dizziness after using it
what are the reversible causes of cardiac arrest 4 Ts 4 Hs?
T- Thrombosis, Tension pneumothorax, tamponade, toxins
H-Hypoxia, hypovoalemia Hypothermia, Hyperkalemia/Hypoglycaemia (and other metabolic abnormalities),
what are the shockable rhythms? defibrilation
Ventricular tachycardia
Ventricular fibrillation
How to treat sinus tachycardia ?
treat underlying cause
How to treat supraventricular tachycardia ?
FIRST vagal manoeuvres- massage carotid and blowing against force into tube
IF UNSUCCESSFUL
adenosine
How to treat Atrial Fibrilation? - atrial flutter basically the same
treated with rate control or rhythm control.
Options for rate control:
Beta blocker first-line (e.g., atenolol or bisoprolol)
Calcium-channel blocker (e.g., diltiazem or verapamil) (not preferable in heart failure)
Digoxin (only in sedentary people with persistent atrial fibrillation, requires monitoring and has a risk of toxicity)
Rhythm control aims to return the patient to normal sinus rhythm. This can be achieved through:
Cardioversion
Long-term rhythm control using medications
e.g. Flecainide, Amiodarone (the drug of choice in patients with structural heart disease)
Most patients will end up on a beta blocker for rate control, often bisoprolol, plus a DOAC for anticoagulation. If you remember one thing about the treatment of atrial fibrillation, remember this combination.
what is the CHA2DS2-VASc score and opposite scoring systems?
CHA2DS2-VASc is a mnemonic for the factors that score a point:
C – Congestive heart failure
H – Hypertension
A2 – Age above 75 (scores 2)
D – Diabetes
S2 – Stroke or TIA previously (scores 2)
V – Vascular disease
A – Age 65 – 74
S – Sex (female)
NICE (2021) recommends, based on the CHA2DS2-VASc score:
0 – no anticoagulation
1 – consider anticoagulation in men (women automatically score 1)
2 or more – offer anticoagulation
bleeding risk score - ORBIT (also HAS BLED) which is less accurate.
what is the criteria for a narrow complex tachycardia and name the 4 main types ?
A QRS complex duration of less than 0.12 seconds or 3 small squares.
-Sinus tachycardia
-Supraventricular tachycardia
-Atrial fibrillation
-Atrial flutter
In both broad and narrow complex tachycardia’s how do you treat patients with life-threatening features, such as loss of consciousness (syncope), heart muscle ischaemia (e.g., chest pain), shock or severe heart failure ?
synchronised DC cardioversion under sedation or general anaesthesia. Intravenous amiodarone is added if initial DC shocks are unsuccessful.
Difference between cardioversion and defibrillation ?
C- ELECTIVE D- EMERGENCY
C- Synchronised D- Unsyncronised
C- lower energy D-high energy
Unlike defibrillation, which is used in cardiac arrest patients, synchronized cardioversion is performed on patients that still have a pulse but are hemodynamically unstable.
what is the criteria for a broad complex tachycardia and name the 4 main types and treatment
Ventricular tachycardia or unclear cause (treated with IV amiodarone)
Polymorphic ventricular tachycardia, such as torsades de pointes (treated with IV magnesium)
Atrial fibrillation with bundle branch block (treated as AF)
Supraventricular tachycardia with bundle branch block (treated as SVT)
cause of atrial flutter ?
Atrial flutter is caused by a re-entrant rhythm in either atrium. The electrical signal re-circulates in a self-perpetuating loop due to an extra electrical pathway in the atria.
what is Paroxysmal atrial fibrillation and how it it investigated ?
Paroxysmal atrial fibrillation refers to episodes of atrial fibrillation that reoccur and spontaneously resolve back to sinus rhythm. These episodes can last between 30 seconds and 48 hours.
Patients with a normal ECG and suspected paroxysmal atrial fibrillation can have further investigations with:
- 24-hour ambulatory ECG (Holter monitor)
- Cardiac event recorder lasting 1-2 weeks
what are the 3 key causes of pancreatitis?
gallstones
alcohol
post-ERCP
causes of pancreatitis IGET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion bite
Hyperlipidemia
ERCP
D (furosemide, thiazide diuretics and azathioprine)
Glasgow score - PANCREAS NUEMONIC
The criteria for the Glasgow score can be remembered using the PANCREAS mnemonic (1 point for each answer):
P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)
What is the most common cause of chronic pancreatitis and what are the symptoms?
alcohol
and same as acute but longer lasting and less intense
Key complications are:
-Chronic epigastric pain
-Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract
-Loss of endocrine function, resulting in a lack of insulin, leading to diabetes
-Damage and strictures to the duct system, resulting in obstruction in the -excretion of pancreatic juice and bile
Formation of pseudocysts or abscesses
Management of chronic pancreatits
-Stop alcohol and smoking
-Replacement pancreatic enzymes (Creon) may be required if there is a loss of pancreatic enzymes (i.e. lipase). Otherwise, a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins. (A,D,E,K)
Subcutaneous insulin regimes may be required to treat diabetes.
ERCP with stenting can be used to treat strictures and obstruction to the biliary system and pancreatic duct.
Surgery may be required by specialist centres to treat:
Severe chronic pain (draining the ducts and removing inflamed pancreatic tissue)
Obstruction of the biliary system and pancreatic duct
Pseudocysts
Abscesses
What type are the majority of pancreatic cancers? and where are they mostly?
adenocarinomas
head of pancreas
TOM TIP: It is worth noting that a new onset of diabetes, or a rapid worsening of glycaemic control type 2 diabetes, can be a sign of pancreatic cancer. Keep pancreatic cancer in mind if a patient in your exams or practice has worsening glycaemic control despite good lifestyle measures and medication.
only cancer where u can refer directly for ct - not everyone though
Courvoisier’s law
Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.
what do these tumour markers relate to?
CA 125
CA 19-9
CA 15-3
Alpha-feto protein (AFP)
Carcinoembryonic antigen (CEA)
CA 125 - Ovarian cancer
CA 19-9 - Pancreatic cancer
CA 15-3 - Breast cancer
Alpha-feto protein (AFP) Hepatocellular carcinoma, teratoma
Carcinoembryonic antigen (CEA) Colorectal cancer
