Cardiac Emergencies Flashcards
What is ACS?
Acute coronary syndrome
In pts with ischaemic heart disease
Chest pain at rest
Acute partial or total coronary artery occlusion
Plaque rupture coronary artery thrombosis/embolism/dissection
What are the three diagnosis that comprise ACS?
STEMI
NSTEMI
Unstable angina
What are the main features of STEMI’s?
Complete coronary occlusion
Transmural infarction
Troponin rise
Diagnosed on ECG
Urgent transfer for PCI
What are the main features of NSTEMI’s?
Partial coronary occlusion Sub-endocardial infarction Ischaemic ECG changes e.g. ST Depression Troponin rise Diagnosed on ECG and bloods
What are the main features of unstable angina?
Partial coronary occlusion without infarction
Ischaemic ECG changes
Normal troponin
RARE
What are adverse features of tacharrythmias?
Shock
Syncope
Myocardial ischaemia
Heart failure
What is the treatment for tachyarrhythmias with adverse features?
DC cardioversion
What are the causes of bradycardias?
Fibrosis of conductive tissue (age related) - most common
Drugs MI Hypothermia Electrolyte imbalance Increased vagal tone
60 yr old man Chest pain Tight, 4 hrs Nausea Sweating Breathlessness HTN DH: amlodipine
Most likely diagnosis?
Myocardial Infarction
What investigations for MI?
ECG (Need to know if ST elevated or not) Troponin \+ve: coronary angiography -ve: Exercise Tolerance Test 3. Echocardiography
What are the cardiac DD for chest pain?
IHD
Aortic Dissection (sudden)
Pericarditis (pain worst on inspiration, better when leaning forward, ask about recent infection)
What are the resp DD for chest pain?
PE
Pneumonia (cough, sputum, fever)
Pneumothorax (sudden onset, breathlessness, sharp pain)
What are the GI DD for chest pain?
Oesophageal spasm
Oesophagitis (chest pain)
Gastritis, abdominal pain (history of steroids)
What are the MSK DD for chest pain?
Costochondritis
What would you see in and ECG in anteriolateral STEMI?
V1, aVL, V5 and V6
ST elevation
Lateral
V2,3,4
ST Elevation
Anterior
What would you see on and ECG in an inferior STEMI?
V2, V3 and aVF
Where will there be ST elevation in an anterior MI?
V1-V4
Blockage of which coronary artery causes anterior MI?
LAD
Blockage of which coronary artery causes lateral MI?
Circumflex
Blockage of which coronary artery causes inferior MI?
RCA
ST elevation in II,III and aVF
What is the shorthand for normal heart sounds?
S1 + S2 + 0
What are the differential diagnosis for collapse?
Hypoglycaemia Cardiac - Vasovagal - Arrhythmia - Outflow obstruction - Postural hypotension Seizure
What is DNEFG?
Do Not Ever Forget Glucose
What are causes of outflow obstruction LHS of the heart?
Aortic stenosis
HOCAM
(hypertrophic obstructive cardiomyopathy)
What are causes of outflow obstruction RHS of the heart?
PE
What are the two types of arrhythmia?
Tachy
Brady
What investigations do you do for arrhythmias?
ECG (? Long QT), cardiac monitor, 24 hour tape
What investigation do you do when suspecting outflow obstruction?
What findings OE?
Low volume/slow rising pulse, ESM, Echocardiogram
What is ESM?
Ejection systolic murmur
What investigation do you do when suspecting postural hypotension?
Lying/Standing BP
What are the main features of long QT syndrome?
Abnormal ventricular repolarization
Congenital e.g. mutations in K+ channels
FH of sudden death
Acquired: low K+/ Mg2+, drugs
45 year old man Fever Malaise IV drug use Temp: 38oC
Raised JVP to earlobes
HS: S1 + S2 + PSM (louder on inspiration)
Hepatomegaly
Infective endocarditis
Tricuspid regurg
IV drug use exposing right sided valves to bacteria
Hepatomegaly caused by back flow of blood (liver congestion)
What is PSM?
Pan systolic murmur Either tricuspid or mitral regurg But differentiate between where the murmur is loudest TR - louder on inspiration MR - louder on expiration
What are the differences between Janeway lesions and Oslers nodes?
Janeway lesions - palms and painless
Oslers nodes - tops of fingers and painful
What are the differential diagnoses for raised JVP?
R heart failure
Tricuspid regurg
Constrictive pericarditis
What would cause infective endocarditis on the LHS?
Dental infection
Why might RHS HF cause raised JVP?
Secondary to L heart failure (CCF) Pulmonary HTN (PE, COPD etc.)
Why might tricusp regurg cause increased JVP?
Valve leaflets
R ventricle dilatation (left parasternal heave) Since the R ventricle needs to work against pulmonary hypertension
Why might constrictive pericarditis cause increased JVP?
Infection e.g. TB
Inflammation: CTD
Malignancy
What are differentials for systolic murmur?
Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
How do you differentiate between systolic murmurs?
Where is it loudest?
Where does it radiate to?
What conditions has a murmur louder at the aortic area? Where would it radiate?
Aortic stenosis
Radiates to neck
Associated with slow rising pulse
What conditions has a murmur louder at the apex area? Where would it radiate?
Mitral regurg
Radiates to axilla
Associated with a displaced apex beat
What conditions has a murmur louder at the tricuspid area? Where would it radiate?
Triscuspid regurg
Louder on inspiration
Associated with raised JVP
65 year old man Breathlessness Palpitations PMH: HTN DH: Bendroflumethiazide Temp: 38oC PR: 160, irregular BP: 110/80 mmHg Dull percussion note & coarse crackles L base
What would you expect to see on his ECG?
AF
What is SVT?
Supraventricular tachycardia
What are the causes of sinus tachycardia?
Sepsis, hypovolaemia, endocrine
(thyrotoxicosis, phaeochromocytoma)
Anxiety/Stress
What are causes of SVT?
Re-entry circuit
What are causes of AF?
Thyrotoxicosis, ischaemia, chest infection, alcohol
Heart: muscle, valve, pericardium
Lungs: Pneumonia, PE, cancer
What are causes of VT?
ischaemia, electrolyte abnormality, long QT
What are the differences between sinus tachy and SVT on ECG?
No p-waves in SVT
What is re-entry circuit? (do not need to know detail)
AVNRT (node)
- Impulses go down septum and up via accessory pathways
AVRT
- Impulses go up and down septum
How do you tell the difference between AF and SVT when both have no p-waves?
SVT is irregular
How do you tell the difference between AF and atrial flutter?
Saw-tooth pattern on ECG in flutter
BUT treat as same
How would you manage a pt. with an SVT and BP of 110/80?
Vagal maneuvers
Adenosine (cardiac monitor)
DC cardioversion if evidence of haemodynamic compromise
Write down the management plan for a patient with acute fast AF & BP: 120/80
Rhythm control
If onset > 48hours, anticoagulate for 3-4 weeks before cardioversion
Rate control
- beta blocker
- digoxin
What is the management of VT?
If no haemodynamic compromise: IV Amiodarone
Look for & treat underlying cause
ICD (implantable cardioverter defibrillator)
Pulseless VT: defibrillate
How does htn show up on ECG?
Deep S waves
Tall R waves
How can you identify LVH by voltage criteria?
Deep S in V1/2
Tall R in V5/6
S in V1 + R in V5 or V6 (whichever is larger) ≥ 7 large squares
How does 1st degree heart block present on ECG?
Prolonged QR
More than one large square
How does 2nd degree heart block present on ECG?
Missing QRS complexes
How does 3rd degree heart block present on ECG?
No relation between QRS and P waves
Broad QRS
What pathologies can be suggested by ECG?
Ischaemia
ST, T, Q
Arrhythmia or conduction defects
Rate, Rhythm
PR, QRS, QT
Ventricular strain or hypertrophy
Axis, R, S
What is S3?
S3 = rapid ventricular filling
Immediately after S2
What is S1?
Closure of mitral valve
What is S2?
Closure of aortic valve
What would Fixed wide splitting of S2 be?
Atrial septal defect
What heart sound is associated with ventricular filling?
S3
What heart sound is associated with ventricular hypertrophy?
S4
What is the management for acute heart failure?
Sit up
Oxygen
Furosemide (IV)
(GTN infusion)
Treat the underlying cause
What is the ALS algorithm for VF/pulseless VT?
Shock CPR (2 min) Assess rhythm Adrenaline every 3-5 min Amiodarone after 3 shocks Treat reversible causes
What is the ALS algorithm for asystole?
CPR (2 min)
Adrenaline every 3-5 min
Correct reversible causes
30 yr old woman URTI Pleuritic chest pain Better when leaning forward Diagnosis?
Pericarditis PE Pneumonia Pneumothorax Pleural pathology 5Ps
What causes angina?
Insufficient oxygen reaching myocardium at times of increased demand
What are RFs for ACS?
Increasing age
Male gender
Family history
Smoking Diabetes mellitus Hypertension Hypercholesterolaemia Obesity
What would ST elevation in Lead II, III and aVF mean?
Occlusion of the right coronary artery
Inferior STEMI
Where would you see ST elevation in a lateral STEMI?
I, aVL
V5, V6
Left circumflex artery
Where would you see ST elevation in an anterior STEMI?
V1-V4
Left anterior descending
Where would you see ST elevation in a septal STEMI?
V1
V2
What does ST depression signify?
Severe ischaemia usually LAD
Deep and widespread ST depression is associated with high mortality
How do you treat ACS?
MONA Morphine Oxygen if sats <94% Nitrates Aspirin
What is the treatment of STEMI?
Asptin
2nd anti-platelet e.g. Clopidogrel
Unfractionated heparine
Urgent PCI if cannot be done within 120 mins consider fibrinolysis
What is PCI?
Percutaneous coronary intervention
Balloon opens up blocked arteries
Stent may be deployed
Done via catheter insertion into radial or femoral artery
How is management for a NSTEMI decided?
Risk stratification e.g. GRACE
If high risk or unstable - coronary angiography
Surgical:
PCI if neccesary w/ unfractionated heparin
Further drug therapy e.g. clopidogrel
Conservative:
Further drug e.g. clopdiogrel if at high risk of bleed
What secondary prevention is used lifelong in patients who have has an ACS?
aspirin a second antiplatelet if appropriate (e.g. clopidogrel) a beta-blocker an ACE inhibitor a statin
What should be done in patients who have had fibrinolytic therapy rather than PCI?
ECG repeat 60-90 mins to see if changes have resolved
If not consider PCI
What is GRACE and what does it take into account?
Global registry of acute coronary events used for NSTEMI risk stratification
age heart rate, blood pressure cardiac (Killip class) and renal function (serum creatinine) cardiac arrest on presentation ECG findings troponin levels
GRACE > 3% 6 month mortality: coronary angiography within 72 hours
What happens to T-waves in acute MI?
Become inverted indicating ischaemia
What is different in a posterior MI?
ST depression
Why do you get reciprocal changes in an anterior STEMI?
LAD blocked
RCA has to compensate to provide blood flow to the LHS
So there is ischaemia but not due to primary occlusion there
Why is PCI urgent and done?
Life-saving
Risk reduction is 50% with PCI
What is the difference between aspirin and rivaroxiban?
Asprin - antiplatelete
Rivaroxiban - anticoagulant
What are some thiazide diuretics?
Indapamide
Bendroflumethiazide
