Cardiac Flashcards
Why is it important to determine the duration of the angina that the patient has been experiencing?
angina lasting <20 minutes = myocardial ischemia angina
> 20 minutes = acute coronary syndrome (i.e. unstable angina or myocardial infarction)
CCS classification of angina
class 1 = no limitation of ordinary activity; angina with strenuous, rapid or prolonged exertion
class 2 = slight limitation of ordinary activity; angina with ordinary activity (walking stairs, walking uphill) after meals, in cold, in wind or under emotional stress
class 3 = marked limitation of ordinary activity; angina on walking or climbing short distances under normal condition and at normal pace
class 4 = inability to carry on ordinary activity; angina at rest
Stable angina pathophysiology
atherosclerotic plaque narrowing of coronary artery plus endothelial dysfunction decrease blood supply to heart causing ichemia
Stable angina clinical presentation
typical angina for <20 minutes
Stable angina management
lifestyle
anti-anginal therapy: nitrates PRN, beta blocker
anti-platelet therapy: aspirin or clopidogrel
lipid lowering therapy: statin
if decreased quality of life despite medication or high risk feature on stress testing or significant angina or acute change in angina, mechanical revascularization: percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG)
ACS pathophysiology
unstable angina: rupture of atherosclelrotic plaques of coronary arteries causing increased ischemia
STEMI & NSTEMI: disruption of atherosclerotic plaque of coronary arteries causing platelet aggregation and clot formation, causing high grade stenosis or occlusion of coronary artery with or without associated emboli entering microciriculation downstream, resulting in ischemia and infarction of myocardium
ACS clinical presentation
typical angina that is severe and prolonged (>20 minutes)
unstable angina can present with any of the following ways
- crescendo pattern with increase in frequency, duration or intensity
- angina at rest without provocation
- new onset of severe angina (CCS class 3) without previous angina
Diagnosis of different ACS types
ECG: no ST elevation
Enzyme test: normal
= unstable angina
ECG: no ST elevation
Enzyme test: elevated
= NSTEMI
ECG: ST elevation
Enzyme test: elevated
= STEMI
STEMI management
PCI or tPA
Non ST elevated (unstable angina and NSTEMI) ACS management
- Everyone gets ASA, statin and nitro
- Risk stratify
Low Risk Group:
ECG normal
TIMI score 0-2
Intermediate Risk Group
ECG: Normal or T wave inversion
TIMI 3-4
Previous CABG or PCI
High Risk Group
ECG ST shift or deep T wave inversion
TIMI 5-7
Refractory ischemia, heart failure or hypotension
- Treatment
Low Risk
Beta blocker
early discharge with follow up
Intermediate risk
Heparin
Clopidogrel
Observation
High risk Beta blocker Heparin GPIIb/IIIa inhibitor or bivalirudin with clopidogrel Early cath
How to calculate the TIMI score
age >65
> 3 CAD risk factor
prior stenosis
ST depression
elevated cardiac markers
multiple angina within 24 hours
aspirin in last 7 days
Aortic dissection diagnosis
Chest CT
What is Tietze syndrome
pain accompanied by inflammation (swelling, erythema, heat) is named Tietze syndrome, which is a more severe case of costochondritis
What is dead space
Ventilation but no perfusion (ex. PE)
Pretest probability of PE based on Well’s score
+1
Active cancer
Hemoptysis
+1.5
Past history of DVT or PE
Recent Immobilization or surgery
Tachycardia >100
+3
Signs or symptoms of DVT
No alternative diagnosis as or more likely than PE
If total points 0-4 then PE is unlikely
Investigations based on Well’s score
Unlikely --> D dimer If negative = no PE If positive --> CTPA If negative = no PE If positive = PE
Likely
–> CTPA
If negative = no PE
If positive = PE
PE management
LMWH short term while starting warfarin or DOAC long term
CXR in PE
band atelectasis
decreased lung volume on affected side
pulmonary infarct/hemorrhage
edema
ECG in PE
Tachycardia
A fib
RV strain (inverted T wave, ST depression in V1-V3)
S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign. A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain
ABG in PE
Hypoxemia
Hypocapnia
High Aa gradient
Respiratory alkalosis
Pneumonia management
Outpatient
Previously well and no abx use in last 3 months -
Macrolide OR doxycyline
Comorbidities or abx use in last 3 months -
Respiratory fluoroquinolone OR beta lactam + macrolide
Inpatient
Ward - resp fluoroquinolone
ICU - beta lactam + (macrolide OR resp fluoroquinolone)
Resp fluoroquinolone - (moxi, femi, levofloxacin)
beta lactam - (cefotaxime, ceftriaxone)
Macrolide - (azithro, clarithro, erythro)
Pneumothorax risk factors
asthma, COPD, lung procedures
Panic attack clinical presentation
panic attack is an abrupt surge of intense fear of intense discomfort that
1. peaks within minutes and
2. is time limited with
3. 4+ of the following symptoms
palpitation / heart pounding
sweating
trembling / shaking
sensation of shortness of breath or smothering
feeling of choking
chest pain or discomfort
nausea or abdominal distress
feeling dizzy, unsteady, lightheaded or faint
chills or heat sensation
paresthesia (numbness or tingling sensation)
derealization (feeling of unreality) or depersonalization (being detached from one self)
fear of losing control or going crazy
fear of dying
Panic attack management
Benzo PRN
Causes of secondary hypertension
renovascular hypertension: renal artery stenosis, fibromuscular dysplasia
renal hypertension: chronic kidney disease including polycystic kidney disease and diabetic nephropathy, kidney transplant
endocrine: hypothyroidism, hyperthyroidism, hyperaldosteronism, Cushing’s syndrome, pheochromocytoma, hyperparathyroidism
Guidelines for diagnosis of HTN
- Elevated BP reading at office, home or pharmacy
- Hypertension visit 1
BP 180/110 + = hypertension
AOBP 135/85 +
OBPM 140/90 +
NO = no hypertension, annual BP measurement recommended
YES = out of office assessment (ABPM preferred or HBPM diagnostic series or OBPM alternate method)
- Hypertension visit 2 (within 1 month)
Daytime ABPM or HBPM 135/85+ 24h ABPM 130/80+ NO = white coat hypertension (complete HBPM or ABPM to confirm and if still below then no hypertension and annual BP measurement recommended) YES = hypertension
- OBPM Hypertension visit 2
140+ or 90+ then go to step 4 - Hypertension visit 3
160+ or 100+
YES = hypertension
NO = go to step 5 - Hypertension visit 4-5
140+ or 90+
YES = hypertension
NO = no hypertension (annual BP measurement recommended)
Hypertensive urgency
asymptomatic and BP >180/110
Hypertensive emergency
BP > 180/110 with end organ damage
How often should follow up occur for patients with hypertension
hypertensive patients with lifestyle modification alone should be followed up at 3-6 months interval
patients on antihypertensive medication treatment should be followed up every 1-2 months until readings on 2 consecutive visits are below target, then follow up at 3-6 months interval
Physical exam components for a patient with hypertension
weight, waist circumference, height vitals: blood pressure, heart rate
neurological:
cognitive assessment for dementia
look for signs of stroke including gait, cranial nerves, speech, motor, sensory, reflexes
eye: fundoscopy for signs of hypertensive retinopathy including papilledema, hemorrhage, AV nicking
cardiovascular: signs of heart failure or left ventricular dysfunction including elevated JVP, displaced apex, peripheral edema, auscultate for S3, S4, loud A2, heart murmur
peripheral vascular: palpate peripheral pulses for peripheral vascular disease, auscultate for bruit at renal arteries
Indications for investigation for hypertension due to renovascular disease
patients with >2 of the following should be investigated for renovascular hypertension:
sudden onset or worsening of hypertension at age <30 years or >55 years
presence of abdominal bruit
hypertension resistant to >3 antihypertensive medications
increase in serum creatinine >30% with use of ACE inhibitor (ACEI) or ARB
atherosclerotic vascular disease (coronary artery disease, peripheral vascular disease), particularly in patients who smoke or have dyslipidemia
recurrent pulmonary edema associated with hypertensive surges
Indications for investigation for hypertension due to hyperaldosteronism
patients with any of the following should be investigated for hyperaldosteronism
hypertensive patients with spontaneous hypokalemia (K < 3.5 mmol/L)
hypertensive patients with marked diuretic induced hypokalemia (K < 3 mmol/L)
patients with hypertension refractory to >3 antihypertensive medication
hypertensive patients with incidental adrenal adenoma
Indications for investigation for hypertension due to pheochromocytoma
patients with any of the following should be investigated for pheochromocytoma
paroxysmal or severe (blood pressure >180/110)
sustained hypertension refractory to usually anti-hypertensive therapy
patients with hypertension and multiple symptoms suggestive of catecholamine excess (headaches, palpitations, sweating, panic attacks, pallor)
hypertension triggered by beta-blockers, MAO inhibitors, micturition or changes in abdominal pressure
patients with incidentally discovered adrenal mass or multiple endocrine neoplasia (MEN2A, MEN2B, von Recklinghausen’s neurofibromatosis, von Hippel-Lindau disease)
Investigations for pheochromocytoma
screening for pheochromocytoma include 24 urinary
total metanephrine and urinary metanephrine-to-creatinine ratio
high 24 urinary total metanephrine and urinary metanephrine-to-creatinine ratio should be followed up with MRI to visualize adrenal tumors
Investigations for renal vascular hypertension
captopril-enhanced radioisotope renal scan - contraindicated in patients with chronic kidney disease GFR<60
Doppler sonography
MR angiography
CT angiography - contraindicated in patients in renal failure (i.e. abnormally high creatinine)
Investigations for hyperaldosteronism
screening for hyperaldosteronism include plasma aldosterone and plasma renin activity
high plasma aldosterone and plasma renin activity followed up with maneuvers for autonomous hyper-secretion of aldosterone (saline loading test, fludrocortisone suppression test, plasma aldosterone to plasma renin activity ratio or captopril suppression test)
Indications for antihypertensive use
1) average diastolic blood pressure >100mmHg or systolic blood pressure >160mmHg even if without any target organ damage or other cardiovascular risk factors
2) average diastolic blood pressure >90mmHg with macro vascular target organ damage or cardiovascular risk factors (other than hypertension)
3) average systolic blood pressure >140mmHg with macro vascular target organ damage
Antihypertensives medication guidelines
1st line anti-hypertensives
- thiazide and thiazide-like diuretics, which have the most evidence
- beta blocker (in patients age <60 years)
- ACEI) (in non-black patients)/ARB
- long acting calcium channel blocker (CCB)
1) initial mono therapy with any of 1st line
if systolic blood pressure is 20mmHg above target or diastolic blood pressure is 10mmHg above target, consider start combination therapy
2) if not achieve target blood pressure with mono therapy, add on medications from another class of 1st line anti-hypertensives
recommended combinations =
(thiazide / thiazide-like diuretics or CCB) + (ACEI or ARB or beta blocker)
combinations NOT recommended =
(non-dihydropyridine CCB + beta blocker)
(ACEI + ARB)
3) if hypertension still not at target with >2 anti-hypertensives from 1st line classes, may add other anti-hypertensive drugs not from 1st line classes
e.g. alpha blockers - Doxazosin, Prazosin, Terazosin
centrally acting agents - clonidine, guanfacine, methyldopa
non-dihydropyridine CCB - verapamil, diltiazem
HTN management for hypertensive patients with coronary artery disease
ACEI, ARB and beta blocker preferred over other 1st line therapies
preferred combination = ACEI + dihydropyridine CCB
HTN management for hypertensive patients with recent myocardial infarction (MI)
initial therapy = (ACEI or ARB) + (beta blocker or dihydropyridine CCB)
HTN management for hypertensive patients with heart failure
initial therapy = (ACEI or ARB) + beta blocker
aldosterone antagonist (e.g. Spironolactone) may be added
HTN management for hypertensive patients with stroke
blood pressure control usually not indicated in setting of acute stroke unless very high post stroke
preferred combination = ACEI + thiazide / thiazide-like diuretics
Management for hypertensive patients with non-diabetic chronic kidney disease
ACEI and ARB preferred over other 1st line therapies
thiazide / thiazide-like diuretics preferred as additive anti-hypertensive therapy
Management for hypertensive patients with renovascular disease
ACEI or ARB used with caution due to risk of acute renal failure or unilateral kidney disease
consider intervention (angioplasty & stunting or surgery) if hypertension despite >3 anti-hypertensive combination therapy, deteriorating kidney function, bilateral renal artery lesion or recurrent episode of flash pulmonary edema
Management for hypertensive patients with diabetes
ACEI and ARB preferred for patients with cardiovascular or kidney disease
preferred combination = ACEI + dihydropyridine CCB
non-dihydropyridine CCB contraindication
heart failure
blood pressure equation
blood pressure = cardiac output (stroke volume x heart rate) / peripheral vascular resistance (inversely proportional to vascular diameter)
Thiazide diuretic MOA
thiazide diuretics block Na-Cl symporter, decreasing Na reabsorption in distal convoluted tubule, which result in increased Na & H2O renal excretion to decrease stroke volume
ACEi MOA
ACEI inhibits ACE to decrease renin-angiotensin-aldosterone (RAA) system and increased bradykinin
decreased RAA increase Na and H2O renal excretion, resulting in decreased stroke volume and vasodilation
increased bradykinin cause vasodilation, decreasing peripheral vascular resistance
ACEi side effects
electrolyte abnormalities: hyperkalemia
acute renal failure with decreased GFR
angioedema
interaction with K sparing diuretics, ARB and NSAID cough
ARB MOA
ARB block angiotensin AT1 receptors, which cause vasodilation
decreased aldosterone to increase Na and H2O renal excretion, resulting in decreased stroke volume
decreased sympathetic activity
BB MOA
block beta 1, beta 2 and / or alpha adrenergic receptors
beta 1 selective blocker most commonly prescribed
beta 1 blockade “1 heart” = decrease heart rate, decrease heart contractility and decrease RAA, thereby decreasing cardiac output and causing vasodilatation
beta 2 blockade “2 lungs” = bronchoconstriction and increased vascular resistance
CCB types and examples of each
dihydropyridine (DHP) CCB end with “-dipine” including Amlodipine, Nifedipine
non-dihydropyridine (NDHP) CCB including Verapamil, Diltiazem
Indication for DHP CCB
DHP CCB may be indicated in patients with comorbidities that could also be treated with DHP CCB including Raynaud’s and migraine
CCB MOAs
DHP CCB decrease Ca influx in vascular smooth muscle, causing vasodilatation to decrease peripheral vascular resistance
NDHP CCB decrease Ca influx in cardiomyocyte, decreasing heart contraction to decrease cardiac output
K sparing diuretic indication in hypertension
2nd line antihypertensive diuretic
Amiloride and Triamterene usually used in mild to moderate hypertension with normal renal function
Spironolactone usually used in hypertensive patients with severe heart failure
K sparing diuretic MOAs
Amiloride & Triamterene: inhibit ENaC sodium channel in collecting duct, leading to Na & H2O renal excretion to decrease stroke volume
Spironolactone: block aldosterone receptor in collecting duct, leading to Na & H2O renal excretion to decrease stroke volume
Loop diuretics indication in hypertension (Lasix)
2nd line antihypertensive diuretic
usually indicated in hypertensive patients with volume overload (from renal failure, heart failure or cirrhosis)
Loop diuretic contraindication
sulfa allergy
Thiazide diuretic contraindication
sulfa allergy
Loop diuretic MOA
inhibit Na-K-2Cl symporter on thick ascending limb, decreasing Na reabsorption leading to increased Na & H2O renal excretion to decrease stroke volume
What is malignant hypertension
hypertensive emergency
What is hypertensive crisis
hypertensive urgency
Malignant hypertension management
- Admit to ICU
- Stabilize
- Treat underlying cause
- usually reduce blood pressure slowly to prevent ischemic damage
usually reduce mean arterial pressure 10-20% in first hour and then reduce by 25% gradually over next 23 hours compared to baseline
target blood pressure <170/110 mmHg
1st line = IV Labetalol (beta blocker) or IV Nitroprusside (vasodilator)
5) Address target organ damage and symptoms
6) after 24 hours of blood pressure control, then discharge from ICU and start on oral anti-hypertensive medication
Acute target organ damage in hypertensive emergency can include what?
hypertensive encephalopathy including papilledema
acute ischemic stroke
intracranial hemorrhage
acute left ventricular failure
acute coronary syndrome
acute aortic dissection
acute kidney injury
eclampsia of pregnancy
5 big risk factors for ischemic heart disease
1) dyslipidemia (high total cholesterol, high LDL, low HDL)
2) smoking
3) diabetes
4) hypertension
5) family history of premature cardiovascular disease (1st degree relative with CVD at <55 years for men or <65 years for women) – this doubles your Framingham risk score
What is the definition of metabolic syndrome
central obesity based on waist circumference (>101cm for men; >88cm for women)
plus 2+ of following:
hypertriglyceridemia (>1.7)
low HDL cholesterol (<1 for men, <1.3 for women)
hypertension (>130/85 or treatment for hypertension)
high fasting glucose (>5.6 mmol/L) or diabetes
What is the Framingham risk score
Framingham risk score used to calculate 10 year future risk of cardiovascular disease for patients with NO history of cardiovascular disease
How often should screening for dyslipidemia occur
every 3-5 years if Framingham risk score <5%
every year if Framingham risk score >5%
Statin indications
High risk (FRS >20%) start statin in all patients
Intermediate risk (FRS 10-19%) start statin if LDL cholesterol is high (>3.5) or apoprotein B >1.2 or non-HDL cholesterol >4.3 if do not satisfy treatment threshold but higher risk based on secondary testing, then start statin
Low risk (FRS <10%) start statin if LDL cholesterol >5 or familial hypercholesterolemia if do not satisfy treatment threshold and FRS 5-9% but higher risk based on secondary testing, then start statin
LDL target
LDL cholesterol <2 or >50% decrease in LDL cholesterol
What does non invasive cardiac testing include
1) non-invasive stress testing
2) rest echocardiogram for left ventricular ejection fraction
Indications for non invasive cardiac testing
patients satisfying any of the criteria below should undergo both non-invasive stress testing and rest echocardiogram:
adults age >30 with >2 angina criteria
male age >40 and female age >60 with 1 angina criteria
male age <40 and female <60 with 1 angina criteria and other cardiovascular risk factors
Requirements to be able to complete exercise stress test
ECG normal
Ability to exercise to 85% heart rate
What is the strongest prognostic factor in ischemic heart disease
left ventricular ejection fraction
Indications for invasive angiography
high pre-test likelihood of ischemic heart disease (male >50 with 3 angina criteria)
high risk features on non-invasive stress test or left ventricular ejection fraction on echocardiogram
history of sudden cardiac arrest
life-threatening arrhythmia on ECG
Long term angina relief
1st line = beta blockers
beta blocker recommended for patients with MI or reduced ejection fraction or heart failure
dose of beta blocker usually titrated to target resting heart rate of 55-60 BPM
2nd line = dihydropyridine calcium channel blocker
3rd line = long acting nitrate
vessels used for cabg
saphenous vein or internal mammary artery
what is secondary prevention of ischemic heart disease
intervention for patients with history of ischemic heart disease to slow worsening of coronary artery disease or prevent cardiovascular event (myocardial infarction, stroke)
What does secondary prevention of ischemic heart disease include
- surveillance
- all of the primary prevention interventions (see above)
- anti-platelet agents
ASA 81 mg or Clopidogrel 75 mg
Post ACS or PCI with stent placement, P2Y12 receptor antagonist should be added to Aspirin for at least 12 months
P2Y12 receptor antagonist can be any of the following Clopidogrel, Prasugrel, Ticagrelor
Post CABG aspirin 100-325mg daily started within 6 hours after surgery for 1 year
- Renin-Angiotensin-Aldosterone system blockers
ACEI indicated in all patients with ischemic heart disease, especially if left ventricular ejection fraction <40%, hypertensive, diabetic or chronic kidney disease
for patients intolerant to ACEI, ARB can be used as a substitute
aldosterone blocker (Spironolactone) indicated in post-MI patients with all of the following:
on therapeutic dose of ACEI and beta blocker
left ejection fraction 0-40%
have diabetes or heart failure
- beta blockers
beta blockers indicated in all patients with ischemic heart disease, especially if patient has any of the following
left ventricular ejection fraction 0-40%
history of MI or ACS
heart failure - cardiac rehabilitation
- Statin
statin for all patients with ischemic heart disease (even if normal lipid profile)
