Acute Care- Cardio Flashcards
Mx of STEMI
- Aspirin 300mg
- PCI possible within 120 mins?
Y: Prasugrel, radial access, UFH with bailout glp IIb/IIIa inhibitor
N: Alteplase + Enoxaparin + DAPT (Aspirin + Ticagrelor) + repeat ECG
How should Mx of STEMI change if patient already on anticoagulants?
Swap Prasugrel for Clopidogrel
Mx of NSTEMI/ unstable angina
- Aspirin 300mg
+ Fondaparinux (no immediate PCI planned)
OR
+ UFH (immediate angiography planned) - GRACE score
,<3%: Ticagrelor or Clopidogrel
>3%: Prasugrel + Angiography with UFH +/- PCI
Mx following ACS
DAPT
= Medically managed: Aspirin (lifelong) + Ticagrelor (12m)
= PCI: Aspirin (lifelong) + Ticagrelor/ Prasugrel (12m)
ACEi / ARB
BB or CCB
Statin
ACS Ix
ECG
Cardiac markers e.g. Troponin
3 non-modifiable RFs for ACS
Age
Male
FH
5 modifiable RFs for ACS
Smoking
DM
HTN
Hypercholesterolaemia
Obesity
Counselling patient with ACS
Chest pain because of a heart attack. Happened because a blood vessel to your heart has been blocked.
4w off driving
4 Sx of acute heart failure
SOB
Reduced exercise tolerance
Fatigue
Oedema
6 signs of acute heart failure
Cyanosis
Tachycardia
Raised JVP
Displaced apex beat
Bibasal crackles +/- wheeze
S3 heart sound
Ix for acute HF
Bloods: ?anaemia, electrolytes, infection
ECG: normal
CXR: pulmonary venous congestion, interstitial oedema, cardiomegaly
Echo
BNP
LVF on CXR
Alveolar oedema (bats wing shadowing)
Kerley B lines
Cardiomegaly
Upper lobe Diversion/ Dilated prominent upper lobe veins
Pleural Effusion
Mx of acute HF
IV Furosemide
+/- O2
Mx of respiratory failure in acute HF
CPAP
When should nitrates be used in acute HF? What is the major side effect/ contraindication to their use?
If concomitant myocardial ischaemia, severe HTN, AR or MR
Major SE/ CI: hypotension
Mx of acute HF with hypotension/ cardiogenic shock
Inotropes e.g. Dobutamine
Vasopressors e.g. Norepinephrine
Mechanical circulatory assistance: intra-aortic balloon counterpulsation or ventricular assist devices
In which circumstances should BB be stopped in acute HF?
HR < 50 beats per minute
2nd or 3rd degree AV block
Shock
What is the first line management for chronic heart failure?
ACEi + BB
Start one drug at a time
What is second line management of chronic heart failure? What needs to be monitored and why?
Aldosterone antagonist e.g. Spironolactone/ Eplerenone
Monitor K+ as ACEi + aldosterone antagonists can cause hyperkalaemia
What drug can be used second line in management of chronic heart failure with reduced ejection fraction?
SGLT-2 inhibitors: dapagliflozin, empagliflozin, canagliflozin
Reduce glucose reabsorption + increase urinary glucose excretion
What third line therapy can be initiated by a specialist for chronic HF?
Hydralazine + Nitrate
Entresto: Sacubitril-valsartan
Digoxin
Ivabradine
Cardiac resynchronisation therapy
Paroxysmal AF
AF lasting >30s but <7 days (often <48h).
Self-terminating + recurrent.
Persistent AF
AF >7 days (spontaneous termination unlikely to occur after this time)
or <7 days but requiring cardioversion.
Permanent AF
AF that:
failed to terminate with cardioversion
OR
terminated but relapsed within 24h
OR
longstanding AF (>1y) in which cardioversion is CI or not been attempted
4 most common causes of AF?
Coronary artery disease
HTN
Valvular heart disease
Thyrotoxicosis
3 lifestyle factors can cause AF
Caffeine intake
Excessive alcohol intake
Obesity
Describe an ECG in AF
Chaotic baseline
Absent p waves
Irregular intervals between QRS complexes
4 life-threatening features of tachycardias
Shock (Hypotension)
Syncope
Signs of myocardial ischaemia
Signs of Heart failure
Once AF is identified on ECG, what investigations are performed?
Bloods
Echo (TTE/ TOE)
What investigations can be performed to aid identification of underlying cause of AF?
FBC (Infection, Anaemia)
U+Es (Electrolyte imbalance)
TFTs (Thyrotoxicosis)
Cardiac enzymes
When should rhythm control be tried first line in AF?
Haemodynamically unstable
New onset AF <48h
Heart failure (primarily caused by AF)
Reversible cause.
Describe management of haemodynamically unstable patient with AF
DC cardioversion
If rhythm control is indicated in a haemodynamically stable patient, describe management?
<48h: Heparinise + cardioversion
>48h: rate control + anti-coagulate for >,3w OR TOE to exclude a left atrial appendage thrombus then proceed
Describe ongoing management if AF is confirmed as being less than 48h and resolved with DC cardioversion
Further anticoagulation unnecessary
If onset of AF was more than 48 hours ago, why must a patient be anti-coagulated for at least 3 weeks prior to cardioversion?
High risk of cardioversion induced thromboembolism as clot likely to have formed in atria
What is used in pharmacological cardioversion?
Structural heart disease: Amiodarone
NO structural heart disease: Flecainide
Describe electrical cardioversion
Synchronised to R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when VF can be induced.
Which drugs are used for rate control in AF?
B-blockers e.g. Atenolol, Metoprolol, Propranolol
Rate limiting CCB e.g. Diltiazem
Digoxin (2nd line)
Name a common contraindication to B-blockers in AF. What should be used first line?
Asthma
Use CCB e.g. Diltiazem
In which patients with should nondihydropyridine CCBs be avoided?
Acute decompensated HF
What non-pharmacological method can be used for rate control in AF?
Catheter ablation
(percutaneous, via groin)
ablates faulty electrical pathways resulting in AF
Describe the use of anticoagulation with catheter ablation
Anticoagulate for 4w prior + during procedure
Catheter ablation controls rhythm but doesn’t reduce stroke risk
Continue anticoagulation as per CHADSVASc
4 complications of catheter ablation for AF
Cardiac tamponade
Stroke
Pulmonary vein stenosis
Recurrence of AF
What tool is used to assess and manage stroke risk in AF?
CHA2DS2-Vasc Score
elements of CHA2DS2VASc?
Congestive HF 1
HTN (inc. treated HTN) 1
Age >= 75y (2), 65-74y (1)
Diabetes 1
S2 Prior Stroke, TIA or thromboembolism 2
Vascular disease (inc. IHD + PAD) 1
Sex (F) 1
Describe the anticoagulation strategy based on CHA2DS2VASc score
0: No Tx
1: M: Consider anticoagulation
F: No Tx (because score 1 only due to their gender)
>,2: Offer anticoagulation
If CHA2DS2VASc score suggests no need for anticoagulation, what must be performed?
TTE
to exclude valvular heart disease
Vavular heart disease in combination with AF is an absolute indication for anticoagulation.
What scoring system is used to calculate risk of bleeding in patients with AF considering anticoagulants?
ORBIT
Old (age >75)
Red cells (anaemia)
Bleeding hx
Impairment (renal)
Treatment (anti platelet Tx)
What class of drug is used first line for anticoagulation in AF? Give 4 examples
DOACs
Apixaban
Dabigatran
Edoxaban
Rivaroxaban
What drug is used for anticoagulation in AF when DOACs are contraindicated?
Warfarin
What should be used for long term stroke prevention in patients with AF once haemorrhage has been excluded?
Following TIA: DOAC (or warfarin) immediately
Following acute stroke: DOAC (or warfarin) after 2w (anti-platelet in the interim)
