ACT Cardiovascular Flashcards
Investigation of suspected Acute Coronary Syndrome
A to E
B - CXR ?cardiomegaly ?pulmonary oedema
C - ECG then continuous cardiac monitoring
Troponin - Take at 3h and 6-12h
FBC – anaemia, inflammation (?pericarditis)
U&Es – Potassium
Glucose – DM, ensure BM kept low (improves outcomes)
Lipids – optimise statin therapy
TFT – cause of arrhythmias
Immediate management of Acute Coronary Syndrome
Risk - TIMI for STEMI, GRACE for NSTEMI Oxygen? only if sats <95% Morphine + Metoclopramide 10mg Aspirin 300mg dispersed in water Nitrates - 2 GTN sprays sublingual Ticagrelor 180mg or Clopidogrel 300mg
PCI or Fondaparinux
Long term management of Acute Coronary Syndrome
Patient education
Smoking cessation, Alcohol reduction
Weight loss if overweight
Diet - less fat, sugar, salt. More vegetable
Exercise - Cardiac rehab
DVLA - 4 weeks (Grade 2 = 6 weeks + assessment)
ACEi - Ramipril up to 10mg B-blocker - Bisoprolol up to 10mg Cholesterol - Atorvastatin 80mg Nocte Dual antiplatelet - Aspirin 75mg - Clopidogrel 75mg for 1 year Echocardiogram - follow up with cardiology Follow up GP for bloods + Influenza immunisation annually Manage comorbidities - DM
Investigations for acute ventricular failure
A to E B - ABG + CXR - Alveolar oedema, Kerley B lines, Cardiomegaly, Dilated upper lobe vessels, Pleural Effusion C - ECG Bloods: BNP + Troponin FBC - exclude anaemia U&Es - check renal perfusion TFTs - cause of arrhythmia lipids - optimise glucose - optimise Echocardiogram within 48hrs
Immediate management of Acute Ventricular Failure
Position - sit up Oxygen - Diuretics - Furosemide 40-80mg IV Morphine - 5mg Antiemetic - Metoclopramide 10mg Nitrates - 2 GTN sprays sublingual Fluid balance - restriction + daily weights
Assessment of suspected Chronic heart failure
Arrange admission if severe symptoms If previous MI - urgent 2 week referral No previous MI - measure BNP BNP > 400 pg/mL = Urgent 2 week referral BNP 100-400 pg/mL = 6 week referral BNP < 100 pg/mL = Heart failure unlikely ECG for all patients Consider other tests for causes or differentials
Management of chronic heart failure with reduced ejection fraction
Patient education, Screen mental health
Smoking cessation,
Low salt diet
Supervised exercise programme
Furosemide when symptomatic 1st ACEi + Bisoprolol one at a time Refer if symptoms aren't controlled Consider Statin + Aspirin if CAD pneumococcal + annual influenza vaccine
Cardiac resynchronise therapy
Assessment of suspected stable angina
Clinical diagnosis based on Hx
ECG - may or may not have evidence of ischaemia
Manage stable angina in Primary care
Refer to a cardiologist for angiography if:
- evidence of extensive ischaemia on ECG
- Angina persists despite optimal drug treatment and lifestyle interventions.
Admit to hospital if unstable angina
Management of stable angina
Patient eduction, Screen mental health
Smoking cessation, Alcohol reduction
Diet, Exercise
GTN + Atorvastatin 80mg + Aspirin 75mg
1st: Betablocker or CCB
2nd: Dual therapy with BB and CCB
if CI then a long-acting nitrate, ivabradine, nicorandil
If pain persists despite medical management
Percutaneous Coronary Intervention
Coronary Artery Bipass Graft
Review every 6/12 or 1yr
Management of new Atrial Fibrillation
- Rate or Rhythm control?
Rhythm: if new onset, reversible cause, if worsening HF
Amidoarone -> Electrocardioversion
?Prophylaxis with 1st: Bisoprolol
Rate: 1st Bisoprolol
2nd Diltizem if active, Digoxin if sedentary - Anticoagulation + Risk factors
CHA2DS2 VASc - risk of stroke
HAS-BLED - risk of bleeding
Apixaban or Warfarin life long
Aetiology of Atrial Fibrillation
Ischaemic heart disease
Hypertension
Thyrotoxicosis
Signs, description and aetiology of aortic stenosis
Slow rising pulse
Low volume pulse with low pulse pressure
JVP not elevated
Apex beat forceful but not displaced (pressure overload)
Ejection systolic murmur - carotid radiation
Narrowing of the valve orifice due to fusion of the commissures, causes pressure overload in the left ventricle
Degenerative calcification of normal valve
Congenitally bicuspid valve with degenerative changes
Rheumatic heart disease
Causes of pressure overload on the left ventricle
Hypertension
Aortic stenosis
Coarctation of the aorta
Hypertrophic cardiomyopathy with subvalvular stenosis
Management of aortic stenosis
Symptoms guide to severity
Valve replacement
Transcatheter aortic valve insertion (TAVI)
if unfit for cardiopulmonary bypass
Manage comorbidities
Describe aortic sclerosis
Normal pulse and normal apex beat.
An ejection systolic murmur heart loudest over the aortic area with no carotid radiation.
Signs and causes of mitral regurgitation
Apex beat usually displaced (volume overload)
Pansystolic murmur radiates to axilla
Leaflet: Congenital, Endocarditis, Degenerative
Papillary muscles + Chordae: MV prolapse, ACS, Marfans
Annular dilation: cardiomyopathy, IHD with HF
