AMI

Question 1

What is the initial management of AMI?

Answer 1

Get help, aspirin 300mg, clopidogrel 300mg, IV access + bloods (troponin, CKMB, EUC, glucose, FBC), GTN 400mcg every 5 mins as required for pain (unless sys < 94%, continuous ECG, ready defibrillator + adrenaline 1mg ampules + saline 1L

Question 2

What are the indications for fibrinolysis?

Answer 2

1. symptoms > 20minutes and 1mm in 2 contiguous limb leads or > 2mm in 2 contiguous chest leads or new LBBB

Question 3

What are some possible adverse reactions to fibrinolysis?

Answer 3

haemorrhage, decreased blood pressure, arrhythmia, allergic reaction

Question 4

In which patients should streptokinase not be used and why?

Answer 4

1. previous streptokinase use: potential allergic reaction 2. ATSI: likely to have high levels of neutralising antibodies

Question 5

What are the absolute contraindications for using thrombolysis?

Answer 5

1. increased risk of bleeding: bleeding disorder, active bleeding, closed head or facial trauma within 3 months, suspected aortic dissection 2. increased risk of intracranial haemorrhage: prior haemorrhage, stroke < 3months, brain tumour

Question 6

What are the relative contraindications for using thrombolysis?

Answer 6

1. increased risk of bleeding: current anticoagulants, active PV bleeding, internal bleeding within the last 4 months 2. increased risk of intracranial haemorrhage: very high blood pressure, stroke > 3months, prgnancy

Question 7

What is the ongoing management of an AMI?

Answer 7

• troponin + CKMB + ECG 6 hourly for 24 hours then daily for 2 days - FBC, EUC, fasting lipids, fasting sugars - ECG if any symptoms or arrhythmias - CXR - echocardiogram - within 24 hours start aspirin +/- clopidogrel, ACE-I, statin, B-blocker - short acting nitrate PRN - written chest pain action plan - patient education re coronary heart disease, lifestyle, driving, work - refer for coronary angiogram - if fibrinolysis used then needs f/u assessment for PCI or bypass. Must be within 12 hours of symptoms and within 90minutes if not reperfusing - cardiac rehab (light exercise first 2 weeks post PCI, HR< 220- age, stop with chest pain) - 500mg/ day omega 3 polyunsaturated fatty acids (= 2-3 serves of oily fish per week) - 2-3g phytosterols per day - i clove garlic per day

Question 8

Why is garlic beneficial in cardiovascular disease? What is the recommended dose?

Answer 8

• reduces blood pressure by up to 5% and lowers cholesterol by up to 9% - 1 clove per day

Question 9

What are some causes of chest pain and what are their typical symptoms/ signs?

Answer 9

1. musculoskeletal: aggravated by cough/sneeze, sharp/ stabbing + aching pain 2. Angina/ AMI: radiation differentiates from pericarditis. central, crushing chest pain associated with nausea + diaphoresis 3. Aortic dissection: sudden, severe, midline pain. Tearing, retrosternal, radiates to abdomen, flank and legs, unequal pulses 4. PE: dyspnoea =/- syncope, pleuritic chest pain, haemoptysis, ECG- rBBB, right axis deviation, right ventricular strain, tachycardia 5. neoplasia: lung or spinal cord 6. pericarditis: pain can be pleuritic, like MI or synchronous with heartbeat and felt over praecordium and left shoulder. ECG: low voltage + saddle shaped ST elevation 7. pneumothorax: pleuritic pain + dyspnoea. Seen on expiration film 8. mitral valve prolapse: think of this in unwell female, prone to palpitations who has chest pain. Fleeting, non exertional, near cardiac apex 9. GORD: retrosternal pain precipitated by bending, lifting, lying down 10. herpes zoster: rash appears where pain is 11. fractured rib: pleuritic pain worse with deep inspiration and coughing 12. spinal dysfunction: dysfunction of facet joints of neck and upper thoracic spine

Question 10

What are some potential end organ results of hypertension?

Answer 10

1. heart: failure, LVH, ischaemic disease 2. kidney: insufficiency 3. retina: retinopathy 4. blood vessels: peripheral vascular disease, dissection 5. brain: cerebrovascular disease

Question 11

What common antihypertensive classes can cause dyslipidaemia?

Answer 11

b-blockers and diuretics

Question 12

At what lipid level should you begin treatment for a patient with existing cardiac disease, and what should their target total LDL, HDL and TG be?

Answer 12

• lipid level: total >4mM - target total: 1 - target TG: <1.5