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bookmarked qns medicine > ACS and hypertension > Flashcards

ACS and hypertension Flashcards

1
Q

What are the signs and symptoms of ACS?

A

Signs: distress, anxiety, pallor, sweatiness, low grade fever, signs of heart failure (raised JVP, basal crepitations, 3rd heart sound)

Symptoms: acute central crushing chest pain lasting >20 minutes, nausea, sweating, dyspnoea, palpitations

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2
Q

What can cause false positive elevation of hs-TnI, meaning the patient is not having an MI?

A

Common: advanced renal failure, PE, CPR, ablation therapy

Less common: severe congestive heart failure, myocarditis, prolonged tachyarrhythmia

Rare: aortic dissection, aortic stenosis, hypertrophic cardiomyopathy, malignancy, stroke, severe sepsis

ALWAYS TAKE SERIAL MEASUREMENTS AND LOOK AT THE TREND NOT THE VALUE OF TEST

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3
Q

What are the sequential ECG changes following an MI?

A

Within hours: ST elevation and hyperacute T waves or LBBB

24 hrs: T wave inversion, ST normal

Few days: pathological Q waves that persist

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4
Q

What is T wave pseudonormalisation?

A

NSTEMIs often have T wave inversion that represents reperfusion of the area

On repeat ECG T waves may appear back to normal after firstly being inverted but this just means the artery is reoccluded

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5
Q

Apart from an ECG and cardiac enzymes, what other investigations should you carry out for a patient who presents with cardiac chest pain ?MI?

A

CXR: look for cardiomegaly, pleural effusion, widened mediastinum

Bloods: FBC, U+Es, random glucose, lipid profile, HbA1c, cardiac enzymes (2 tests 3 hours apart)

ECHO: regional wall abnormalities

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6
Q

What are some differential diagnoses for ACS?

A

Stable angina
Pericarditis
Myocarditis
Takotsubo cardiomyopathy
Pneumothorax
PE
Oesophageal spasm/reflux
MSK pain

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7
Q

What are some contraindications for treating a STEMI with thrombolysis?

A

Previous intracranial haemorraghe
Ischaemic stroke <6months ago
Recent major head trauma/surgery
Known bleeding disorders
Liver biopsy or LP in past 24 hours
Pregnancy
GI bleeding
Cerebral malignancy

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8
Q

What blood tests are essential for a patient with a STEMI?

A

Cardiac enzymes (TropI)
FBC
Lipid profile
Random blood glucose
HbA1c

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9
Q

What medications are patients started on after an MI and for how long?

A
  • Aspirin 75mg for life
  • Ticagrelor (or another antiplatelet e.g Clopidogrel/Prasugrel) for 12 months
  • ACEi or ARB for hypertension (checking renal function)
  • Beta-blocker to lower heart rate (e.g Bisoprolol)
  • Statin (e.g atorvastatin 80mg or rosuvastatin 5mg). Use ezetimibe if all statins have side effects

ATABS (also consider PPI for gastric protection with antiplatlets)

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10
Q

What are some complications of a STEMI and how are they managed?

A
  • Heart failure: diuretics e.g Epleronone
  • Cardiogenic shock: need inotropes and balloon pumps]
  • Valve damage e.g Mitral Regurg: may present with pulmonary oedema, needs valve replacement
  • Ventricular Septal Defect: pansystolic murmur that is diagnosed on ECHO and needs surgery
  • Pericarditis: give NSAIDs
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11
Q

What are some associated symptoms with angina if it is severe, and what symptoms make the diagnosis of angina less likely?

A

Associated symptoms: fear, sweating, nausea, dyspnea

Less likely to be angina: pain that is continuous, pleuritic or worse with swallowing, palpitations, dizziness, tingling

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12
Q

Apart from exercise, what are some other things that can precipitate angina?

A

Emotion
Cold weather
Heavy meals

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13
Q

Angina is usually due to atheromas in the coronary arteries (coronary artery disease). What are some other conditions that can cause symptoms of angina in the absence of coronary artery disease?

A

Aortic stenois
Hypertensive heart disease
Hypertrophic cardiomyopathy

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14
Q

Patients who have angina like pain are scored based on their estimated likelihood of CAD. What investigations should you offer for different likelihood scores?

A
  • 61-90%: Invasive coronary angiography
  • 30-60%: Functional imaging e.g stress MRI, echo or myoview
  • 10-29%: CT calcium scoring. If zero likelihood is minimal. If 1-400 consider CTCA or stress perfusion imaging. If >400 CTCA
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15
Q

How do the following drugs act as anti-anginal medicine and when are they used?

Nicorandil
Ivabradine
Ranolazine

A

Used 1st line as monotherapy if CCB and BB contraindicated or used in conjunction with one of them as 2nd line

Nicorandil: K+ channel activator. Can’t use in pulomary oedema or hypotension

Ivabradine: Reduces HR without lowering BP by blocking sinus node. Do not give if HR<70 or not in sinus rhythm, and do not coprescribe with CCB

Ranolazine: Inhibits late Na current. Caution in heary failure, elderly, <60kg, eGFR<30

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16
Q

what is the managment for angina?

A

B-Blockers: Atenolol or bisoprolol
or
NDHP CCB if above Cx: Diltiazem or Verapamil

2nd Line
- BB + CCB
If one of the above is Cx give one with long acting nitrate isosorbibe mononitrate, nicorandil or ranolazine

surgical management: PCI or CABG

17
Q

When should BB and CCB not be used in the acute setting?

A

BB: acute pulmonary oedema or heart failure

CCB: as negative inotrope in acute setting

18
Q

What is malignant hypertension?

A

Rapid rise in blood pressure to over 200/130, leading to vascular and organ damage

Can causes bilateral retinal haemorrhages, headache, visual disturbances

Needs urgent treatment (BB or CCB)

19
Q

What other tests apart from BP are performed when a patient is newly diagnosed with hypertension?

A

Urine dip
Bloods
Retinopathy
ECG
ECHO

20
Q

What are target blood pressures to bear in mind when treating hypertension?

A

Low-moderate risk: <140/90
- Diabetic/Previous Stroke: <130/80 (keep below 85)

  • Elderly >80: <150/90

Reduce slowly, can be fatal if lower too rapidly!

21
Q

Why should you drop hypertension slowly?

A

Any sudden drops in BP increases stroke risk as cerebral autoregulation is poor

22
Q

What is the definition of a hypertensive emergency?

A

Increase in BP which if sustained over the next few hours will cause irreversible end organ damage (encephalopathy, LV failure, aortic dissection, unstable angina, renal failure)

23
Q

What is the difference between a hypertensive emergency and urgency?

A

Emergency - High BP with critical illness (AKI,MI, Encephalopathy). Will cause damage over hours

Urgency - High BP without critical illness at the moment, often accompanied by retinal damage. Will cause damage over days

24
Q

How is hypertensive urgency managed?

A

Reduce diastolic gradually to <100 over 48-72 hours using PO drugs

Usually a combination of ACEi and CCB or Nifedipine AND Amlodipine for 3 days and then continue Amlodipine alone

Amlodopine
Diltiazem
Lisinopril

25
Q

What is the classic triad of symptoms for patients with a phaeochromocytoma?

A

Episodic headache
Sweating
Tachycardia
with sustained/paroxysmal hypertension

26
Q

How is phaeochromoctyoma diagnosed?

A

24h urine collection: measure urinary and plasma metanephrines and catecholamines

Can do MRI or CT abdo/pelvis to detect adrenal tumours

27
Q

how do you manage phaeochromocytoma

A

surgical resection
in between this period, use alpha blockers eg (phenoxybenzamine) first then add beta blockers

28
Q

What are the causes of the following pulses:

Bounding pulse
Collapsing waterhammer pulse
Slow rising anacrotic pulse
Jerky pulse
Pulsus paradoxus

A

Bounding: sepsis, CO2 retention, liver failure

Collapsing pulse: aortic regurgitation, AV malformation, PDA

Slow rising: aortic stenosis

Jerky pulse: HCM

Pulsus paradoxus: severe asthma, pericardial constriction, cardiac tamponade

29
Q

When do you hear an opening snap?

A

Mid diastolic murmur of mitral stenosis usually due to calcification

30
Q

which murmurs radiate and to where?

A

Aortic stenosis: carotids

Mitral regurgitation: axilla

31
Q

Which murmurs can be heard best when leaning forward, left lateral positioned, expiring?

A

Leaning forward: aortic regurg

  • Left lateral: mitral stenosis
  • Expiring: left sided murmurs as expiring increases blood follow to left side of heart
32
Q

Why are transoesophageal echos better than transthoracic and what are they used for?

A

Closer to the heart so more sensitive

Cardiac emboli
Aortic dissections
Assessing prosthetic valves

33
Q

Which valve is the most commonly affected in infective endocarditis?

A

mitral valve

34
Q

What medication do you need to give a patient before PCI?

A

Dual antiplatelet therapy with aspirin and a P2Y12 antagonist

PLUS

Unfractionated Heparin

35
Q

What is the difference between a STEMI and an NSTEMI?

A

STEMI is complete occlusion of the coronary artery but NSTEMI is only partial

Both result in tissue necrosis

36
Q

How is hypertensive retinopathy graded?

A

1 - Tortuous arterterues with thick shiny walls

2 - AV nipping where arteries cross veins

3 - Flame haemorraghes and cotton wool spots

4 - Papilloedema

37
Q

How should cocaine induced MI be managed?

A

Benzodiazepine plus GTN

bookmarked qns medicine (7 decks)

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