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Meded Flashcards 2020 > cardiac conditions: chest pain > Flashcards

cardiac conditions: chest pain Flashcards

1
Q

What types of cardiac conditions can cause chest pain?

A
  • Ischaemic Heart disease
  • Infection- pericarditis/endocarditis
  • Arrhythmia
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2
Q

What are associated symptoms that can accompany cardiac chest pain?

A
  • Palpitations
  • Syncope
  • SOB
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3
Q

SBA 1

76 year old female

Central crushing chest pain- radiates to jaw

ECG= ST elevation in leads II, II, and aVF

SaO2= 89%

Started on drugs before PCI

Which 4 drugs should she be given?

  • A) Morphine*
  • B) Oxygen*
  • C) Aspirin*
  • D) Clopidogrel*
  • E) Warfarin*
A
  • A) Morphine*
  • B) Oxygen*
  • C) Aspirin*
  • D) Clopidogrel*
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4
Q

SBA 2

54 year old man

Suspected ACS

ECG- ST elevation in aVL, I, V5. V6

What type of MI is this and which coronary artery has been occluded?

A

Lateral MI

Left circumflex

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5
Q

What are the conditions that make up acute coronary syndrome (ACS)?

A
  • Unstable angina pectoris
  • STEMI
  • NSTEMI
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6
Q

Stable angina

Definition

Aetiology

Types

Epidemiology

Symptoms + Signs

Investigations

Management

A

Stable angina

Definition

Aetiology

Epidemiology

Symptoms + Signs

Investigations

Management

Definition

Chest pain caused by triggers such as exertion due to myocardial ischaemia + that is relieved by rest

Aetiology

Blood supply to the heart is less than demand= ischemia

Usually due to atherosclerosis of coronary arteries,

OTHER TYPES

Decubitus angina- triggered by lying down

Coronary syndrome X= Symptoms of angina with no ECG changes

Prinzmetal angina- Coronary vasospasm

Epidemiology

Common

Symptoms + Signs

Central chest pain

Better on resting

Investigations

Gold standard = ECG exercise stress test

FBC
U + E

TFT
Echo?

Management

Conservative: Stop smoking, lose weight/diet, exercise

Medical: Beta blockers/CCBs

GTN spray- when symptoms happen, PRN

+

manage risk factors- aspirin, statins, antihypertensives

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7
Q

Acute coronary syndrome

Definition

Types (and definition of each type)

Aetiology

Symptoms and signs

Epidemiology

Investigations

Management

Complications

A

Acute coronary syndrome

Definition

Types (and definition of each type)

Aetiology

Epidemiology

Investigations

Management

Complications

Acute coronary syndrome

Definition

Constellation of symptoms- sudden reduced blood flow to myocardium

Types (and definition of each type)

Unstable angina- chest pain at rest due to ischemia, no infarction or cardiac injury

NSTEMI- Non ST elevation myocardial infarction [high troponin]

STEMI- ST elevation myocardial infarction [ST elevation on ECG + high troponin]

Aetiology

Myocardial oxygen demand exceeds supply= ischemia= infarction

Epidemiology

Symptoms and Signs

Acute, sudden onset

Central crushing chest pain

Radiates to arm, neck, jaw

Pallor

Sweating

Dizziness

[Silent/asymptomatic in elderly]

Investigations

1st line: ECG

Troponin (elevated in MI)

Echocardiogram

_____________

ECG findings

Unstable angina/NSTEMI- ST depression, T wave inversion

STEMI= ST elevation, LBBB, hyperacute T waves

Old infarction= pathological/deep Q waves

Management

ACS in general:

Immediate: MONAC

Morphine, Oxygen, Nitrates (short and long acting), Aspirin and Clopidogrel

Long term:

Conservative- diet, exercise, weight

Medical: Beta blockers, + {Risk factors}- hypertensives (ACEi), statins

STEMI

Immediate

  • PCI (Percutaneous coronary intervention)
  • Fibrinolysis/thrombolysis

If <12 hr from symptom onset:

Can do PCI within 2hr of time that fibrinolysis could be adminstered (within 30 mins of hospital arrival)

If >12 hr:

Do coronary angiogram first to check if can do PCI

NSTEMI/Unstable Angina

MONAC +

  • Fondaparinux (factor Xa inhibitor, similar to heparin)- if low bleeding risk or coronary angiography planned in 24hr of admission
  • Unfractionated heparin- if coronary angiography planned

Risk factors using GRACE score

If

High risk

GlpIIb/IIIa inhibitor- tirofiban +

Coronary angiography

Low risk

Conservative = control risk factor

Complications

DARTH VADER

Death
Arrhythmia
Rupture of heart muscles
Tamponade
Heart failure

Valve disease
Aneurysm
Dressler’s syndrome
Embolism
Reinfarction

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8
Q

What are antiplatelets used for?

A

Arterial thrombosis:

MI

Stroke

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9
Q

What are types of disease are anticoagulants used for?

A

Venous thrombus related disease:

DVT

PE

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10
Q

SBA 3

54 year male

Sharp central chest pain- 24hr

Auscultation- scratching sound- pericardial rub= loudest lower left sternal edge

PMH- STEMI, treated with PCI- 6 weeks ago

A Viral pericarditis

B Constrictive pericarditis

C Cardiac tamponade

D Dressler syndrome

E Tietze syndrome

A

A Viral pericarditis

B Constrictive pericarditis

C Cardiac tamponade

D Dressler syndrome

E Tietze syndrome

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11
Q

SBA 4

27 year old man

Sharp chest pain

Flu like symptoms

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

A
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12
Q

Pericarditis

Definition

Aetiology

Risk Factors

Epidemiology

Symptoms

Signs

Investigations + Results

(Management)

A

Pericarditis

Definition

Inflammation of the pericardium membrane surrounding the heart

Aetiology

Infection- viral -> Coxsackie B, Mumps etc

  • Connective tissue disease- sarcoidosis*
  • MI (Dressler’s syndrome)*
  • Malignancy*
  • Idiopathic*

Risk Factors

Recent flu/viral symptoms

Young age???

Post MI- Dressler’s Syndrome

Epidemiology

Young

Male???

Symptoms

Sharp chest pain

Pleuritic pain- worse on inspiration

Alleviated when sittting forward, worse on lying down

Fever/flu-like symptoms (if viral)

Signs

Pericardial rub on auscultation- scratching sound

Tamponade

Investigations + Results

FBC, CRP

ECG- widespread saddle shaped ST elevation (in all leads)

CXR- pericardial effusion may be visible

Management

Broad spectrum antibiotics [if purulent] + NSAIDS

[If viral/idiopathic]- NSAIDS + colchicine [+ anti viral if needed]

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13
Q

SBA 5

46 year old man

Palpitations, since 4hr

ECG shows AF

No PMH of IHD

Refuses DC cardioversion

Next most appropriate step?

A Defibrillation

B Low molecular weight heparin

C Warfarin

D Flecainide

E Digoxin

A

D Flecainide

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14
Q

SBA 6

27 year old man

Palpitations and lightheadedness

ECG shows SVT

Adenosine given, stops SVT

Repeat ECG shows: Short PR interval + slurred upstroke in QRS complex

Diagnosis?

A Brugada syndrome

B LBBB

C Romano-Ward syndrome

D Wolff-Parkinson-White syndrome

E Complete heart block

A

D Wolff-Parkinson White syndrome

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15
Q

SBA 7

52 year old man

Palpitations- 45 mins then stopped spontaneously

Several occurences over 2 months

ECG: normal

24 hour tape done: confirms AF

Which scoring system should be used to decide whether long term anti coagulation should be given?

A QRISK2 score

B ABCD2 Score

C GRACE score

D CHA2DS2 -VASc score

E CURB-65 score

A

D CHA2DS2 -VASc score

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16
Q

Atrial Fibrillation

Definition

Aetiology

Risk factors

Epidemiology

Symptoms

Signs

Investigations + results

Management

Complications (of AF + of AF management)

Prognosis

A

Atrial Fibrillation

Definition

Irregular, rapid and ineffective atrial contraction- due to uncoordination of electrical impulse conduction in atrial fibres

Aetiology

Many causes

Mitral regurgitation/ stenosis

PIRATES

Pe, pneumonia

Ischemic heart disease

Rheumatic heart disease

Alcohol/ anaemia

Thyrotoxicosis

Electrolyte, endocarditiss

Sepsis, sick sinus syndome
Leukocytosis- ie infection

Risk factors

IHD

Male

Epidemiology

Young

Male

Symptoms

Palpitations

Light headedness??

Syncope

Symptoms of underlying causes of AF

Signs

Irregularly irregular heartbeat

Investigations + results

ECG/24 hour tape= irregularly irregular tachycardia + no p waves (fast AF= tachycardia, slow AF=

Tests for possible underlying causes

Management

  1. Rhythm control
  2. Rate control
  3. Stroke risk management
  4. Treat underlying cause

Rhythm control

Immediate

If less than 48 hours since AF occured, OR if pt is haemodynamically unstable (SBP<90)

  • DC cardioversion
  • Chemical cardioversion (flecainide or amiodarone)

If more than 48 hours:

Warfarin/DOAC

+ then DC/chemical cardioversion

Rate controlling medication:

Beta blockers

Verapamil

Digoxin

Long term:

If CHA2DS2 VASC score >2 : Anticoagulate with warfarin/DOAC to decrease stroke risk

Complications (of AF + of AF management)

AF management

Prognosis

17
Q

When is flecainide contraindicated?

A

If PMH of ischaemic heart disease

18
Q

Supraventricular tachycardia

Types

Aetiology/risk factors

Epidemiology

Symptoms

Signs

Investigations + results

Management

A

Supraventricular tachycardia

Types

AVRT (Atrioventricular reentry tachycardia)- eg. Wolff Parkinson White
AVNRT (Atrioventricular nodal re-entrant tachycardia)
Atrial flutter

Aetiology/risk factors

Infiltrative disease- eg sarcoidosis, amyloidosis- can cause scar tissue in AV node

Epidemiology

Male

Symptoms

Signs

Investigations + results

ECG (+ 24 hour tape)

= regularly irregular, regular tachycardia, no p waves,

Management

1) Haemodynamically stable?

If no = DC cardioversion

If yes=

a) Vagal manoeuvres
b) IV adenosine - 6mg
c) IV adenosine - 12mg
d) IV adenosine- 12mg
d) IV digoxin/beta blockers/amiodarone/DC cardioversion

Verapamil if adenosine contraindicated eg. asthmatics

19
Q

Wolff Parkinson White

A
20
Q

Syncope

Definition

Aetiology/Risk factors

Types/Causes of syncope- Differential diagnosis for presentation

Epidemiology

Symptoms

Signs

Investigations + results

A

Syncope

Definition

Collapse/transient loss of consciousness due to hypoperfusion of the brain

Aetiology/Risk factors

Vasovagal

= Increased vagal discharge- low HR + CO + BP

Standing for a long time

Fear

Sight of blood

Types/Differential diagnosis for presentation (if cardiac)

VAOP

Vasovagal (nb. only one that is on Sofia)

Arrhythmia

Outflow obstruction- aortic stenosis, HOCM

Postural hypotension (failure to compensate for decrease in blood pressure- due to medications {antihypertensives} + dehydration)

Other rare causes of syncope

Subclavian steal syndrome

Vertebrobasilar insufficiency

Aortic dissection

Non syncopal causes of collapse

Seizures

Head trauma

Metabolic- hypoglycemia, DKA?

Drugs- intoxication

Epidemiology

Young

Symptoms

Before LOC: dizziness, lightheadness, sometimes vision changes- blurring, blackness, sweating

During LOC: Sometimes jerky movements

After LOC: no confusion

Arrhythmia= Palpitations

Signs

Before LOC: going pale

Investigations + results

ECG

Lying- standing blood pressure

Cardio exam- pulse rate and rhythm, + auscultation

Neurological exam

If MI suspected= troponin + cardiac enzymes

(If seizures = creatine kinase also high)

21
Q

HOCM- Hypertrophic Obstructive Cardiomyopathy

Definition + Aetiology

Risk factors

Symptoms

Signs

Investigations + results

A

HOCM- Hypertrophic Obstructive Cardiomyopathy

Definition + Aetiology

Hypertrophy of cardiac muscle causes outflow obstruction by blocking the aortic valve

Risk factors

FH of sudden cardiac death aged <65 years old

Symptoms

Palpitations?

Syncope?

Signs

Jerky carotid pulse

Ejection systolic murmur

Double apex beat

Investigations + results

Echo

22
Q

(Extra card) What is the diagnostic criteria for orthostatic hypertension?

A

Drop in SBP of 20 mmHg or in DBP of 10 mmHg within 3 minutes of standing

23
Q

SBA 8

21 year old female

Fainted 4 times in 3 months

Sweating, nauseous and pale before fainting

LOC for few seconds

No loss of control of bladder or tongue biting

After LOC: No confusion, but slight dizziness

What is the most likely cause of her fainting?

A Hypoglycaemia

B Epileptic seizure

C Vasovagal syncope

D Arrhythmia

E Hypertrophic obstructive cardiomyopathy

A

C Vasovagal syncope

24
Q

SBA 9

52 year old man

Collapsed 3 times in past couple of months

Father died of cardiac condition at 56 years old

O/E:
Jerky carotid pulse

Crescendo-decrescendo murmur

What is the most likely diagnosis?

A Aortic stenosis

B Hypertrophic obstructive cardiomyopathy

C Left heart failure

D Mitral regurgitation

E Constrictive pericarditis

A

B Hypertrophic obstructive cardiomyopathy

25
Q

SBA 10

76 year old man

Collapsed in care home

Suspected hip fracture

LOC on getting up from arm chair

Became consciousness a few seconds later, on floor

Never had a fall

PMH= total knee replacement, heart failure

DH= ramipril, furosemide, bisoprolol

What is the most likely cause of his collapse?

A Vasovagal syncope

B Medication side-effect

C Arrhythmia

D Anaemia

E Dilated cardiomyopathy

A

B Medication side-effect

26
Q

SBA 11

A 52-year-old patient is recovering on the cardiology ward after undergoing a valve replacement.

A routine blood test reveals the following results:

Na+ : 135 mmol/L (135 – 145)

K + : 8.7 mmol/L (3.5 – 6.0)

Ca2+ : 0.3 mmol/L (2.2 – 2.6)

An ECG is performed which shows no obvious abnormalities.

Past medical history of hypertension which is treated with ramipril.

Given the above information, what should be the next step in the management of this patient?

A Urgently draw another blood sample

B 10 mL 10% calcium gluconate

C 20 mL 20% calcium gluconate

D 50 mL 50% dextrose + 10 U insulin

E IV salbutamol

A

A Urgently draw another blood sample

Because

Hyperkalaemia that bad WOULD cause ECG abnormalities

27
Q

What does this ECG show?

How would you proceed?

Talk it through

A

tachycardia with regular RR but no p waves with narrow QRS

YOUR differentials:

  • Atrial flutter - No flutter visible - so not this one
  • Supra ventricular tachycardia - could be
  • Sinus tachycardia (maybe P waves hidden) - could be

To distinguish between SVT and ST- do vasovagal manoeuvres and then adenosine- if improves SVT if not ST

28
Q

What does this ECG show talk through it

Explain the pathology

A

ECG: normal rate (84 bpm), sinus rhythm, broad QRS, delta wave and short PR interval

(SPECIFIC of Wolf parkinson white syndrome (T wave inversion + ST depression))

Explanation:

  • Bundle of KENT conducts impulse down to ventricles - fast tansduction of signal - short PR interval
  • Ventricle don’t contract at same time- wide QRS
29
Q

What drug do you give to Wolff parkinson white patients?

What drug can you not give EVER?

Why not?

A

What drug do you give to Wolff parkinson white patients? Amiodarone

What drug can you not give EVER?

Adenosine

Beta blocker

  • *C**alcium channel blocker
  • *D**igoxin

Why not?

lead to VF or VT - because reduce AV node activity - only VT node active and can lead to circuit

30
Q

What is the pathology in AVRT and AVNRT?

What is the ECG changes that can be seen?

What is their treatment?

A

AVRT- there is an accessory pathway between the ventricles and the atria

AVNRT- there is circuit within the AV node (most common slow fast)

ECG- tachycardia- p wave can be burried in QRS

AVNRT- try vasovagal moneuvre

BUT otherwhise radiocatheter ablation

  • AVRT- destroy accesory pathway
  • AVNRT- destroy slow pathway in the AV node
31
Q

FIll out the table

A
32
Q

What is the use of flecainide contraindicated in

A

Ischaemic heart disease

Meded Flashcards 2020 (36 decks)

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