Angina, MI, Pericarditis, Pericardial effusion and cardiac tamponade, Myocarditis Flashcards
Angina
- core presentation (typical, atypical)
- confirming angina
Typical
1. worse on exertion
2. chest/neck/jaw/shoulder/arm pain
3. better with rest/GTN in 5mins
Atypical
2 typical + GI discomfort/SOB/nausea
Rapid access chest pain clinic => ECG
STEMI => PCI
NSTEMI => consider PCI
Typical/atypical/not angina with ECG changes => CTCA
Non angina pain, no ECG changes => alternative diagnosis
1st line - CTCA
2nd line - NIFT
Angina
- management (acute, maintenance)
- secondary prevention
All - aspirin + statin
Acute - GTN
-prophylactic before physical exertion
Maintenance - Bb/cardiac CC (verapamil/diltiazem)
2nd line - combine Bb with non cardiac CCB
3rd line - ISMN/nicorandil/ivabradine/ranolazine
DON’T GIVE CARDIAC CC and BB TOGETHER => HB
Angina mimics
Cardioresp
- exacerbation of asthma, COPD
- PE, PT
- CAP
- pulmonary edema
GI
-reflux
MSK
-costochondritis
Psych
-anxiety
ACS
- core features
- referral
- hospital management
Angina lasting for 15mins+ at rest
Not relieved by GTN
N+V, sweating, SOB
MONA (300mg aspirin)
12ECG
Don’t use nitrates in hypotension
A&E
-current pain
-pain in last 12hrs AND ECG changes/not available
Urgent day assessment
-pain in last 12hrs AND normal ECG
-pain in 12-72hrs
B
-12ECG (STelevation/depression, T inversion, Q waves)
B
-Tnt - high
-FBC, U&E, LFT, CRP, glucose, lipids
I
-CXR, echo
STEMI management
- immediate
- definitive
STAT MONA
U12hrs
PCI in 2hrs
✅ - prasugrel
-heparin during
❌- fibrinolysis + fondaparinux
- ticagrelor post-fibrinolysis
- ECG check in 60-90mins => PCI if needed
If presenting after 12hrs => PCI if still MI or cardiogenic shock
High bleed risk or on AC
-prasugrel => ticagrelor => clopidogrel
NSTEMI management
- immediate
- definitive
STAT MONA
Fondaparinux unless PCI
GRACE - predict 6month mortality, CV risk
U3% - ticagrelor
3%+ - PCI within 72hrs + prasugrel/ticagrelor + heparin
-immediately if unstable
If high bleed risk
-swab fondaparinux for alt antithrombin
-swap prasugrel => ticagrelor => clopidogrel
If on PO AC
-swap prasugrel/ticagrelor => clopidogrel
Secondary prevention
- medication
- lifestyle
- rehabilitation
GTN
DAPT - ticagrelor for 12 months
ACEi/ARB
Bb
Statin
Exercise, diet
Smoking, alcohol
Cardiac rehab
- started before discharge
- education on physical activity, lifestyle advice, stress management, health
Comparison of antiplatelets and their relative potency
Prasugrel
Ticagrelor
Clopidogrel
Management of all MI patients in hospital
ACS specific LMWH 5 days (heparin if PCI planned) => VTE prophylactic LMWH
Cardiac monitoring - 48hrs
Admit - 4-7 days
-daily examination
-2-3 days TnT
Correct electrolyes
Start ACEi, Bb - reduce cardiac remodelling, demand
Anteroseptal changes
ECG areas
Coronary artery affected
V1-4
LAD - ventricles, IV septum
Inferior changes
ECG areas
Coronary artery affected
II, III, aVF
RCA - RA, RV, SAN, AVN
Anterolateral changes
ECG areas
Coronary artery affected
V4-6, I, aVL
LAD - ventricles, IV septum
LCx - LA, LV
Lateral changes
ECG areas
Coronary artery affected
I, aVL, V5-6
LCx - LA, LV
Posterior changes
ECG areas
Coronary artery affected
Tall R waves, not Q waves
V1-３ ST depression, not ST elevation
LCx - LA, LV
RCA - RA, RV, SAN, AVN
Pericarditis
-etiology
MAJORITY - INFLAMMATION 2NDARY TO VIRAL INFECTION
Infectious - Coxsackie, TB
Post MI
- 3 days - fibrinous pericarditis
- weeks/months - AI pericarditis (Dressler)
RT
Connective tissue - Lupus, RA
Hypothyroid
Malignancy - lung, breast
Trauma
Pericarditis
-presentation, symptoms
Acute, sharp, pleuritic pain
Improved by sitting and leaning forward
Pericardial friction rub - differentiated from pleural rub when breath held
If infectious - fever, tired
Pericarditis
-investigations
B
-ECG - widespread ST elevation, PR depression most specific
B
-CRP - inflammation
-Troponin - myocardial involvement?
-Urea - uremic cause?
I
-GOLD STANDARD - Echo - pericardial effusion
-CXR - pericardial effusion, cardiomegaly
Pericarditis
-management
NSAID + colchicine, avoid strenuous physical activity until resolution and normalisation of inflammatory markers
High risk - high fever, high troponin => IP
Pericardial effusion
-presentation
-risk factors
-diagnosis
-management
SOB
DIscormfort when lying down
Retrosternal pain
Lightheaded
Muffled heart sounds
Low BP
Pericarditis
SLE/RA
Trauma
Mets
Gold standard - Echo
Depends on cause
-NSAIDs +/- colchicine
May need pericardiocentesis if unstable
Myocarditis
-causes
-presentation
-investigations
-management
-complications
Young children with chest pain
Acute
SOB, arrythmias
Viral - coxsackie B, HIV
Bacterial - diptheria
AI
High CRP, TnT, BNP
Tachycardia, arrythmia
ST changes
Treat underlying cause - ABx if bacterial
Supportive (heart failure/arrythmias)
Can lead to HF, arrythmias, dilated cardiomyopathy
Differentiating between STEMI, NSTEMI and unstable angina
TnT high
STEMI - ST elevation
-complete occlusion
NSTEMI - ST depression, T inversion
-partial occlusion => ischemia
Unstable angina
No cardiac markers => unstable angina
-can have ECG ischemic changes
Myocardial infarction complications timeline
Tachyarrythmia - VF, VT
=> Cardiac arrest
Bradyarrythmia - after inferior MIs
Cardiogenic shock
Left ventricular aneurysm - persistent ST elevation, LVF
Rupture of papillary muscle => mitral regurgitation (hypotension, pulmonary edema)
48hrs - pericarditis
2-6wks - Dresslers (fever, pleuritic, pericardiac effusion, ESR)
1st week - VSD (AHF, pansystolic murmur)
1-2wks - left ventricular free wall rupture (raised JVP, pulsus paradoxus, reduced heart sounds)
Long term complication
-chronic heart failure
