``` 300mg loading dose of aspirin 12hrs - coronary angiography followed by PCI if indicated ```

Cardiac chest pain Flashcards by H Jalisi

Causes and types of stable angina

Atherosclerotic disease (most common)
Rarer types:
Decubitus angina - occurs when lying down
Prinzmental angina - occurs due to coronary vasospasm
Coronary syndrome X - angina sx despite normal exercise tolerance and normal coronary angiograms

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Mx of stable angina

Conservative
- stop smoking
- lose wt
- exercise
Medical
-  symptomatic: GTN spray
- anti-anginals: BBs, CCBs
- reduce RFs: ACEi, aspirin, statins

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Sx of ACS

Acute-onset central, crushing chest pain
Radiates to arms/neck/jaw
Pallor
Sweating
NOTE: silent infarcts in elderly and diabetics

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What are the mx steps to determine what type of ACS it is?

Hx
- sudden-onset central crushing pain
ECG
- changes => STEMI
- no changes
Troponin
- +ve => NSTEMI
- -ve => unstable angina

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What does an ECG show for

a) STEMI
b) NSTEMI?

a) hyperacute T waves, ST elevation, new onset LBBB

b) ST depression, T wave inversion

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What can ECG leads tell us about the site of the infarct?

II, III, aVF => inferior => right coronary artery

V1-V5 => anterior => left anterior descending

I, aVL, V5/6 => lateral => left circumflex

tall R wave + ST depression V1-3 => posterior => posterior descending

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Drug mx for ACS

M orphine
O xygen
N itrates
A ntiplatelets (aspirin+clopidogrel)
B eta-blockers
A CEi
S tatins
H eparins

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Mx of STEMI

300mg loading dose of aspirin
<12hrs
- PCI
>12hrs
- coronary angiography followed by PCI if indicated

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Mx of NSTEMI and UAP

Immediate
- aspirin: 300mg loading dose + other antiplatelet (clopidogrel)
- fondaparinux: if low bleeding unless coronary angiography planned within 24hrs
- UFH: if coronary angiography planned
Risk stratify using GRACE score
- HIGH: coronary angiography within 72hrs and GpIIb/IIIa inhibitor (tirofiban)
- LOW: conservative mx, control RFs

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What are potential complications of ACS?

D eath
A rrythmia
R upture
T amponade
H eart failure

V alve disease
A neurysm
D ressler's syndrome
E mbolism
R einfarction

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Compare use of anticoagulants and antiplatelets

Anticoagulants

inhibit coagulation factors
prevent venous thrombosis (DVT, PE)

Antiplatelets

inhibit platelets
prevent arterial thrombosis (MI, stroke)

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Possible causes of pericarditis

Idiopathic
Infective (Cox-Sackie B)
CTD (sarcoidosis)
Dressler syndrome (2-10 weeks post-MI)
Malignancy

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What is Beck’s triad?

‘Muffled’ heart sounds, raised JVP, low BP

- cardiac tamponade

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Presentation of pericarditis

Sharp, central chest pain
Pleuritic
Relieved by sitting forward
Fever/flu-like sx if viral
Pericardial friction rub
Tamponade (if pericardial effusion)

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Ix for pericarditis, incl. what they may show

ECG => widespread saddle-shapped ST elevation
Bloods (FBC, CRP) => raised CRP if infection
CXR => pleural effusion

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Pathognomonic for AF

Irregularly irregular pulse

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Causes of AF

PE
Pneumonia
Hyperthyroidism
IHD
Alcohol
Pericarditis

Ix for AF

ECG => irregularly irregular tachycardia and absent P waves
Test for underlying causes
- FBC, TFTs, glucose, lipids

Mx for AF

*TREAT CAUSE and
1) Rhythm control
<48hrs: DC cardioversion or chemical cardioversion
>48hrs: anticoagulate for 3-4 weeks before attempting cardioversion
2) Rate control
verapamil, BBs, digoxin
3) Stroke risk stratification
CHA2DS2-Vasc score
- low: nothing
- high: warfarin

Which drugs are used for chemical cardioversion?

Flecainide (contraindicated in IHD) or amiodarone

Break down the CHA2DS2-Vasc score

C ongestive heart failure/LV dysfunction (1)
H TN (1)
A ge>/=75 (2)
D iabetes mellitus (1)
S troke/TIA/TE (2)
V ascular disease, prior (1)
A ge 65-74 (1)
S ex female (1)

What are the two types of supraventricular tachycardias?

AVNRT (atrioventricular nodal reentry tachycardia)
- local circuit forms around AV node
AVRT (atrioventricular reentry tachycardia)
- reentry circuit forms between atria and ventricles due to presence of accessory pathway (Bundle of Kent)

What might show on an ECG after termination of a SVT?

AVNRT => normal

AVRT => ‘delta’ wave; slurred upstroke on QRS compex, indicative of Wolff-Parkinson-White syndrome

How does WPWS lead to AVRT?

Accessory pathway allows early depolarisation of ventricles
=>
Gives rise to slurred upstroke
=>
Wave of depolarisation travels retrograde back into atria, setting up a reentry circuit between atria and ventricles
=>
AVRT

How do you treat VT?

IV amiodarone if not haemodynamically uncompromised, otherwise DC cardioversion

Mx for SVTs

``` 1) Haem. stable? NO => synchronised DC cardioversion YES => 2) Vagal manouveres work? YES => yay NO => 3) IV adenosine 6mg work? YES => yay NO => 4) IV adenosine 12mg work? YES => yay NO => 5) IV adenosine 12 mg again? YES => yay NO => 6) Choose one of the following: - IV BB - IV amiodarone - IV digoxin - synchronised DC cardioversion ```

Causes of syncope

V asovagal - long time standing, sweaty/pale before collapse, increased vagal discharge (low BP and HR) A rrhytmia - low-output state, palpitations before collapse O utflow obstruction - HOCM, aortic stenosis P ostural hypertension - failure to compensate when you stand up, medication and dehydration common causes

Classic presentation of HOCM

FHx of sudden death at rel. young age (<65) Jerky carotid pulse Double apex beat Ejection systolic murmur( crescendo-decrescendo murmur)

What are other causes of someone fainting?

``` Niche syncopal - vertebrobasillar insufficiency - subclavian steal syndrome - aortic dissection Non-syncopal - intoxication - head trauma - metabolic (hypo); check for missed meals/insulin dose in diabetics - epileptic seizures ```

A 76-year-old woman is brought into A&E with central crushing chest pain that radiates to her jaw and left arm. An ECG is performed, which shows ST elevation in leads ll, lll and aVF. Her SaO2 is 89%. Before she is sent to the cathlab for percutaneous coronary intervention, she is started on a combination of drugs. Which of the following should not be given? A Morphine B Oxygen C Aspirin D Clopidogrel E Warfarin

E Warfarin

A 54-year-old man has been brought into A&E with a suspected acute coronary syndrome. An ECG is performed, which reveals ST elevation in leads I, aVL, V5 and V6. Which coronary artery has been occluded? A Left main stem B Left anterior descending coronary artery C Left circumflex coronary artery D Right coronary artery E Posterior descending artery

C Left circumflex coronary artery

A 54-year-old man is complaining of sharp, central chest pain that has arisen over the last 24 hours. On inspection, the patient is sitting forward on the examination couch. On auscultation, a scratching sound is heard – loudest over the lower left sternal edge, when the patient is leaning forward. He has a past medical history of a ST-elevation MI which was diagnosed, and treated with PCI, 6 weeks ago. What is the most likely diagnosis? A Viral pericarditis B Constrictive pericarditis C Cardiac tamponade D Dressler syndrome E Tietze syndrome

D Dressler syndrome

A 27-year-old man presents complaining of sharp chest pain. He mentions that he has taken a few days off work recently because of the flu. What would you expect to see on his ECG? A ST elevation in leads II, III and aVF B Widespread saddle-shaped ST elevation C ST depression D Tented T waves E Absent P waves

B Widespread saddle-shaped ST elevation

A 46-year-old man has been admitted to A&E after experiencing palpitations, which began about 4 hours ago. An ECG is performed, which reveals atrial fibrillation. He has no previous history of ischaemic heart disease. He refuses DC cardioversion. What is the next most appropriate treatment option? A Defibrillation B Low molecular weight heparin C Warfarin D Flecainide E Digoxin

D Flecainide

A 27-year-old man presents with palpitations and light-headedness. An ECG shows features consistent with a supraventricular tachycardia. Adenosine is administered and the SVT is terminated. A repeat ECG shows a short PR interval and a QRS complex with a slurred upstroke. What is the diagnosis? A Brugada syndrome B LBBB C Romano-Ward syndrome D Wolff-Parkinson-White syndrome E Complete heart block

D Wolff-Parkinson-White syndrome

A 52-year-old man was watching TV yesterday when he suddenly become very aware of his heart beating rapidly. This lasted for around 45 mins and then subsided spontaneously. It has happened several times over the past 2 months. An ECG reveals no abnormalities. However, due to the strong suspicion of atrial fibrillation, the patient is placed on a 24-hr tape, which confirms the diagnosis. Which scoring system should be used to determine the benefit of long-term anticoagulation in this patient? A QRISK2 score B ABCD2 Score C GRACE score D CHA2DS2 -VASc score E CURB-65 score

D CHA2DS2-VASc score

When is adenosine contraindiciated and what should you use instead for SVT mx?

Contraindicated in asthmatics so use verapamil instead

A 21-year-old woman has fainted 4 times in the past 3 months. She becomes sweaty and nauseous before she faints and is usually unconscious for a few seconds. Her friends have told her that she looks abnormally pale before she collapses. She doesn’t know if she jerks whilst unconscious, but has not lost control of her bladder or bitten her tongue. When she regains consciousness, she feels slightly dizzy but does not feel confused. What is the most likely cause of her fainting? A Hypoglycaemia B Epileptic seizure C Vasovagal syncope D Arrhythmia E Hypertrophic obstructive cardiomyopathy

C Vasovagal syncope

A 52-year-old man has collapsed 3 times in the past couple of months. His father died of a heart condition when he was 56 years old, although he cannot recall the details of the condition. On examination, a jerky carotid pulse is palpated and a crescendo-decrescendo murmur is heard over the carotid artery. What is the most likely diagnosis? A Aortic stenosis B Hypertrophic obstructive cardiomyopathy C Left heart failure D Mitral regurgitation E Constrictive pericarditis

B Hypertrophic obstructive cardiomyopathy

A 76-year-old man is found collapsed in the care home and has a suspected hip fracture. He says that he temporarily lost consciousness as he got up from his arm chair and came about, a matter of seconds later, on the floor. He has never experienced a fall before. He has a past medical history of a total knee replacement and heart failure which is treated with ramipril, furosemide and bisoprolol. What is the most likely cause of his collapse? A Vasovagal syncope B Medication side-effect C Arrhythmia D Anaemia E Dilated cardiomyopathy

B Medication side-effect