Hypertension & Acute Coronary Syndrome Flashcards by Imogen Smedley

What are the big 3 causes of chest pain?

Acute coronary syndrome
Pulmonary embolism
Acute aortic syndrome

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What is acute aortic syndrome?

AAA
Dissection
Rupture
Penetrating ulcer

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What is acute coronary syndrome?

STEMI, NSTEMI, unstable angina

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What are the main types of hypertension?

Essential and secondary hypertension

Essential hypertension = cause unknown

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What endocrine syndrome is a common cause of secondary hypertension?

Conn’s syndrome

Hyperaldosteronism

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What is stage 1, 2 and 3 hypertension

-give the clinic and the ABPM/HBPM readings

1 clinic >140/90, home >130/85
2 clinic >160/100, home >150/95
3 clinic sBP >180 or dBP >120 = severe

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What is masked hypertension?

Clinic less than 140/90 but home readings higher

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What is accelerated AKA malignant hypertension?

> 180/20 plus hypertensive retinopathy or papilledema

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What is the white coat effect?

> 20 systolic or 10 diastolic difference between clinic and average home readings

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In basic terms, why does hypertension predispose heart failure?

Heart strain due to pumping against increased resistance

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When do you offer ABPM?

If clinic >140/90

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What test would you do if you suspected Conn’s syndrome?

Renin aldosterone ratio blood test

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What is the 1st and 2nd line management of hypertension?

1st: If aged under 55 years ACEI or ARB
If aged over 55 years or black skin CCB

2nd: aged under 55: (ACEI or ARB) + (CCB or thiazide diuretic)
aged >55 or block skin: CCB + (ACEI or ARB or thiazide)

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What is the 3rd line management of hypertension?

ACEI/ARB + CCB + thiazide diuretic

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What is the 4th line management of hypertension?

Confirm elevated BP with ABPM
If K <4.5 add low dose spironolactone
If K >4.5 add alpha blocker or beta blocker

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What stage of hypertension management is considered resistant hypertension?

4th line management

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If blood pressure is uncontrolled on X number of drugs at optimal doses, seek expert help.. how many is X?

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Which antihypertensive causes angioedema as a SE?

ACEI

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Which antihypertensive causes urticaria as a SE?

ARB

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Which antihypertensive causes bronchospasm as a SE?

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Which antihypertensive causes gout as a SE?

Diuretics

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Which antihypertensive causes gingival hypertrophy as a SE?

CCB

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Which antihypertensive causes ankle edema as a SE?

CCB

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Which antihypertensive causes is also an antiandrogen?

Spironolactone

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Which antihypertensive is contraindicated in bilateral renal artery stenosis?

ACEI | Also contraindicated in pregnancy and severe CKD

What is the mechanism of labetalol?

Alpha and beta blocker

What is the mechanism of prazosin?

A1 alpha blocker

What is the BP targets in hypertension?

Age under 80 clinic <140/90 | Age over 80 clinic <150/90

What is the effect of spironolactone and thiazide diuretics on potassium?

Thiazide diuretics case hypokalaemia | Spironolactone is potassium sparing - hyperkalaemia

What group of antihypertensives should be used with caution in heart failure

Out of LDL and HDL, which is the good and bad cholesterol

LDL bad, HDL good

What is name of the scoring system for cardiovascular risk? At what cut off should you start primary prevention?

ASSIGN >20 (Primary prevention is to prevent an event, secondary prevention is after an event to prevent recurrence)

What is the mechanism of statins?

HMG Co-A reductase inhibitor

Xanthomata, xanthelasma and xanthoma are all presentations of dyslipidaemia - which body parts do each refer to?

Xanthomata - fingers Xanthelasma - eyes Xanthoma - joints

What sign can be seen in the iris of the eye in severe dyslipidaemia?

Corneal arcus

What food interacts with statins?

Grapefruit juice | Also alcohol, St Johns wort, clarithromycin

Name 4 side effects of statins

Myalgia Rhabdomyolisis Raised CK Transient raise in ALT and AST

What is the 1st line statin?

Atorvastatin (second line simvastatin) (statins are taken at night)

What blood tests should you monitor when initiating statins? And when?

At 3 months check LFTs and lipids (total cholesterol, triglycerides, HDL) Recheck at 1yr

In high cholesterol, what percentage reduction are you aiming for in non-HDL? What do you do if not achieved?

40% reduction in non-HDL cholesterol | If not titrate dose up

What is the second line management of high cholesterol?

Ezetimibe

Put the stages of atherosclerosis in the correct order: - Atherosclerotic plaque - Normal - Fibrous plaque - Plaque rupture + thrombosis - Fatty streak

``` Normal Fatty steak Fibrous plaque Atherosclerotic plaque Plaque rupture + thrombosis ```

Here are the stages of atherosclerosis: normal > fatty streak > fibrous plaque > atherosclerotic plaque > plaque rupture + thrombosis Which stages are clinically silent? At which stages do you see stable angina or intermittent claudication? At which stages to do see ACS, CVAs or leg ischaemia?

Normal / fatty streak both clinically silent Fibrous plaques and atherosclerotic plaques cause stable angina and intermittent claudication Plaque rupture causes ACS, CVAs and leg ischaemia

How would you clinically differentiate stable and unstable angina - in terms of triggers and relief

Stable angina is relieved by rest and GTN and provoked by exercise or the cold Unstable angina occurs at rest and the pain is more intense

What are troponins in unstable angina?

Normal

How could you clinically differentiate an NSTEMI and unstable angina?

Unstable angina typically lasts under 15 minutes unlike a NSTEMI

What test is diagnostic of stable angina?

None - it is a clinical diagnosis | Though perform an ECG, FBC, U+Es, LFTs, a lipid profile, HbA1C and fasting glucose for the work up

GTN vasodilates or vasoconstricts

Vasodilates

During angina symptoms, after how many minutes could you repeat a dose of GTN?

After 5 minutes repeat | If pain still present 5 minutes after the repeat dose, call an ambulance

What is the basic pathology of unstable angina?

Plaque rupture - with a platelet rich clot on top

What scar does a CABG leave? What scar does percutaneous coronary intervention with balloon angioplasty leave? What vein is harvested in a CABG?

CABG - median sternotomy scar CABG harvest great saphenous vein in the leg PCI - scar at site of entry at brachial/ femoral artery

What 3 drugs comprise 1st line management of angina

GTN + 75mg aspirin + BB eg bisoprolol 5mg (2nd line switch BB to or add CCB eg amlodipine) (3rd line nicorandil) (Also a statin)

What is the difference between an STEMI and NSTEMI in terms of basic pathophysiology?

``` NSTEMI = artery open but severe narrowing STEMI = lumen blocked causing ischemia (time = muscle) ```

How long do symptoms last in an acute MI?

Longer than 20 mins

What are the ECG features of an NSTEMI?

ST segment depression T wave inversion May be normal

What are the ECG features of a STEMI?

>1mm elevation in 2 adjacent limb leads or >2mm elevation in 1 chest lead New LBBB T wave inversion

A lateral MI is due to occlusion of which vessel and where would it be seen on an ECG?

Lateral = left circumflex | aVL, I, v5, v6

An inferior MI is due to occlusion of which vessel and where would it be seen on an ECG?

Inferior = right coronary | aVF, II, III

An anterior MI is due to occlusion of which vessel and where would it be seen on an ECG? BIT CONFUSED IF LEFT CORONARY OR LAD

LEFT CORONARY OR LAD

When to troponins peak? When should they be measured? Why do you need to interpret troponins with caution?

Peak 12-24hr Measure at onset + repeat at 12hr Non-specific myocardial damage (also raised by PE, CKD, sepsis, myocarditis, aortic dissection)

What is the biggest cause of death in acute MI?

Go into v-fib

What is the 1st line Ix for an MI, how quickly should it be given?

12 lead ECG within 10 min of arrival | patients admitted to CCU, HDU or telemetry bed

What is reperfusion therapy for a MI?

PCI or fibrinolysis

If patients with an acute STEMI are not deemed eligible for reperfusion therapy (PCI or thrombolysis) what should they be given?

180mg ticagrelor antiplatelet + aspirin antiplatelet

What are the indications for angiography with PCI (cath lab) for STEMI?

If under 12hr since symptom onset and PCI available within 120mins

What are the indications for thrombolysis for STEMI?

If under 12hr since symptom onset and PCI not available within 120mins

What drugs are given adjuvant to PCI?

Prasugrel and aspirin

What 3 drugs is given for thrombolysis?

Streptokinase 300mg aspirin 180mg ticagrelor

What is initial Mx of an NSTEMI?

``` BATMAN BB Aspirin 300mg ASAP Ticagrelor Morphine Anticoagulant LMWH fondaparinux 2.5mg (not if going for angiograpy) Nitrate GTN ```

How do you decide if NSTEMI patients get angiography?

Use scoring system eg GRACE to predict 6 month mortality. If risk >3% angiography (immediate if clinically unstable, within 72hr if stable) If risk <3% conservative Mx without angiography unless younger patient

What is the conservative management for NSTEMI without angiography?

Ticagrelor + aspirin + fondaparinux

What is the long term management secondary prevention post heart attack?

Cardiac rehab + ACEI + dual antiplatlet therapy + statin (ACEI rampipril continue indefinitely) (Dual antiplatelet aspirin + another for 12mth) (Statin 80mg atorvastatin)

What are the exercise recommendations for cardiac rehab?

20-30 minutes a day to the point of slight breathlessness

What is the mechanism of Dressler's syndrome? How long post MI does it occur? How would it appear on an ECG?

Autoimmune 2-6wk Global ST elevation

Management of Dressler's syndrome?

NSAIDs

How soon after an MI does a VSD present? What murmur does it cause? How is it diagnosed? What is the management?

In 1st week Pan-systolic murmur Echo Surgical

3 wk after an MI a patient presents with fever, pleuritic chest pain and a pericardial rub - what is the diagnosis?

Dressler's syndrome | with associated pericardial effusion

How soon after an MI does LV free wall rupture present? What is the management

After 1-2 weeks | Urgent pericardiocentesis + thoracotomy

Persistent ST elevation and left ventricular failure following an MI could be caused by what?

LV aneurysm

An early-to-mid systolic murmur following an inferoposterior MI is caused by what?

Acute mitral regurgitation

Hypertension & Acute Coronary Syndrome Flashcards

(80 cards)