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cardiology > ACS**** > Flashcards

ACS**** Flashcards

1
Q

3 types

A

STEMI
NSTEMI
Unstable angina

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2
Q

STEMI:

Marker in blood for change

A

Rise of troponin

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3
Q

NSTEMI:

Troponin is the obvious marker for change.

What 2 other features need to be present?

A

Rise of troponin

ECG changes and ischamuic symptoms

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4
Q

Unstable angina:

Features - 2

A

Prolonged, severe angina

Usually at rest

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5
Q

Pain Hx:

What would you find in SOCRATES?

A 
S - central 
O - usually sudden but can be more gradual 
C - tight, crushing but not sharp 
R - left arm, neck, jaw
A - sweating, clamminess, SOB, dizziness, faint
T - >15 minutes
E - Exertion, emotion, eating
S - high but can be low
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6
Q

Who tend to have more atypical presentations? -2

What symptoms do they have in these atypical presentations?

A

Elderly or diabetic patients

High blood sugar, high blood pressure and cholesterol problems raise risk for heart events, but nerve damage can make warning signs of an attack impossible to feel. “People with diabetes may have an impaired perception of chest pain, a key symptom that compels people to go to the hospital,” he says.

Little or no chest pain 
SOB 
Sweating 
N&V
Silent MI - not symptoms at all
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7
Q

Signs

HR
BP
Colour
Heart sounds

A

Can be high or low

Pallor

S3 AND S4 heart sounds

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8
Q

Investigations:

ECG changes in STEMI

Acute
Within days
Long term

A

Peaked T waves
THEN ST elevation

Elevated Q wave
THEN T wave inversion

Elevated Q wave + ST changes

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9
Q

What else can cause ST elevation?

  • infection of what surrounds the heart
  • heart tissue gets bigger and which side
  • aorta
  • bundle block
  • lungs
  • potassium
A 
Pericarditis
LVH 
Aortic dissection 
LBBB, RBBB
PE 
Hyperkalaemia
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10
Q

Investigations:

ECG changes in NSTEMI and unstable angina

What may be seen in a posterior MI?

A

ST depression and/or T-wave inversion

ST depression and Tall R waves in anterior leads

A good way to think about reciprocal change is an ‘upside down’ ST elevation seen in leads opposite to the site of infarction.

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11
Q

Investigations:

Troponin:

  • how long after admission should it be tested?
  • when does it peak?
  • over what centile is acute MI diagnosed?

Other causes of raised troponin - HEART DIES

A

3-6 hrs

12-24 hrs

99th centile

HF
AF
Embolus
Renal failure 
Thrombus

Dissection
Inflammation
Exercise
Sepsis

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12
Q

Investigations:

Why are:

  • FBC
  • U&E
  • Glucose
  • Lipids
  • CXR
  • Exercise tolerance test

DONE

A

Low Hb may exacerbate heart strain and baseline Hb and PLT needed before anticoagulation

Baseline before anticoagulants and ACEi given
Screens for co-morbid renal disease from HTN

Tight control improves outcomes

Check on admission as cholesterol
Can dip 24 hours post-MI

Rule out other causes and check for signs of HF

Considered in lower risk patients

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13
Q

Management:

Symptom management - MONA

A

Morphine IV
Oxygen
Nitrates - GTN spray/sublingual
Aspirin 300mg PO

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14
Q

Management:

What is added for dual antiplatelet therapy?

What can be added to oxygen therapy if tachycardic/hypertensive?

A

P2Y12 inhibitors - clopidogrel, ticagrelor or prasugrel

Beta blockers

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15
Q

Management:

What anticoagulation is used?

A

Unfractionated heparin IV

Enoxaparin SC
Fondaparinux SC

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16
Q

Reperfusion:

STEMI presenting within 12 hr of onset:

Immediate (within 90-120 mins) - PCI is done - what does ti stand for and what is it?

What if above is not available in 120 mins?

What is beyond 12 hrs?

A

Primary PCI - percutaneous coronary intervention
Dilation of artery with balloon catheter +/- stents

Thrombolysis - alteplase, reteplase, tenecteplase and transfer to PCI centre

Manage like NSTEMI

17
Q

Reperfusion for NSTEMI and unstable angina - 1

What is the GRACE score?

What else is considered on top of that if GRACE score is high?

What is given if they are unstable, they have refractory chest pain or acute severe HF?

A

The GRACE Score is a prospectively studied scoring system to risk stratifiy patients with diagnosed ACS to estimate their in-hospital and 6-month to 3-year mortality.

Angiography +/- revascularisation within 48 hrs

Immediate PCI

18
Q

Management:

Another mneumonic that is used is BATMAN. What does it stand for?

Others issues:
What happens to the anticoagulation?
What are they discharged with?
What med should be avoided?

A 
Beta-blocker
Aspirin
Thrombolysis
Morphine
ACE inhibitors 
Nitroglycerin

Glucose maintenance <11 mmol/L - may require insulin infusion
Statin

Stopped post-PCI or continued until discharge - continued for 3 months for anterior MI
Secondary prevention meds and offer cardiac rehab
NSAID’s

19
Q

Complications:

Electrical - 4

A

Heart block
Sinus bradycardia
Bundle branch block
Ventricular fibrillation

20
Q

Complications:

Structural - 5

A 
Acute mitral regurgitation 
Papillary muscle rupture 
Ventricular free wall rupture leading to haemopericardium
Ventricular septal rupture 
Ventricular aneurysm
21
Q

Complications:

Inflammatory - 1

What is Dresslers syndrome?

Long term

A

Peri-infarction pericarditis

Pericarditis weeks post MI

Myocyte death
Low SV, low HR and low BP 
Sympathetic response to try and compensate 
LV changes
HF
22
Q

Right sided HF

2 big features:

  • supply to body
  • see on neck

Rx - 1

What should be avoided?

A

Low cardiac output
Raised JVP

Fluids

Vasodilators or diuretics

23
Q

Pericarditis

What type of pain would you have?

How is the pain relieved?

What would you see on ECG?

How painkiller is given to Rx?

A

Central chest pain
Relieved by sitting forward

Saddle shaped ST elevation

NSAID’s

24
Q

Systemic embolism:

Where might it come from?

Rx - 2 choices and you are on one of them for 3 months?

A

LV mural thrombus

Anticoagulation
Warfarin for 3 months

25
Q

Cardiac tamponade:

What happens to CO?

You can get Kussmaul’s sign. What is it?

A

Drops

A paradoxical (weird/absurd) rise JVP on inspiration, or a failure in the appropriate fall of the JVP with inspiration due to reduced RV filling

26
Q

Cardiac tamponade?

You get pulses paradoxus with this. What is this?

What happens to the heart sounds?

How is it diagnosed?

What is needed to treat it?

A

Paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus.

Muffled heart sounds

Echocardiogram

Pericardial aspiration - pericardiocentesis

27
Q

Mitral regurgitation:

What feature would you find in the lungs?

Rx?

A

Pulmonary oedema

Valve replacement
Treat left ventricular filling problems first

28
Q

Ventricular septal defect:

What type of murmur would you hear?
Other sign on neck?

Diagnosis?

Rx

A

Pansystolic murmur
Raised hVP

Echo

Surgery

cardiology (36 decks)

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