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Year 3 Cardio > Cardiac Emergencies > Flashcards

Cardiac Emergencies Flashcards

1
Q

What is ACS?

A

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

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2
Q

What are the three diagnosis that comprise ACS?

A

STEMI
NSTEMI
Unstable angina

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3
Q

What are the main features of STEMI’s?

A

Complete coronary occlusion
Transmural infarction
Troponin rise
Diagnosed on ECG

Urgent transfer for PCI

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4
Q

What are the main features of NSTEMI’s?

A 
Partial coronary occlusion
Sub-endocardial infarction
Ischaemic ECG changes e.g. ST Depression
Troponin rise
Diagnosed on ECG and bloods
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5
Q

What are the main features of unstable angina?

A

Partial coronary occlusion without infarction
Ischaemic ECG changes
Normal troponin
RARE

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6
Q

What are adverse features of tacharrythmias?

A

Shock
Syncope
Myocardial ischaemia
Heart failure

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7
Q

What is the treatment for tachyarrhythmias with adverse features?

A

DC cardioversion

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8
Q

What are the causes of bradycardias?

A

Fibrosis of conductive tissue (age related) - most common

Drugs
MI
Hypothermia
Electrolyte imbalance
Increased vagal tone
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9
Q 
60 yr old man
Chest pain
Tight, 4 hrs
Nausea
Sweating
Breathlessness
HTN
DH: amlodipine

Most likely diagnosis?

A

Myocardial Infarction

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10
Q

What investigations for MI?

A 
ECG (Need to know if ST elevated or not)
Troponin
	\+ve: coronary angiography
	-ve: Exercise Tolerance Test 
3. Echocardiography
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11
Q

What are the cardiac DD for chest pain?

A

IHD
Aortic Dissection (sudden)
Pericarditis (pain worst on inspiration, better when leaning forward, ask about recent infection)

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12
Q

What are the resp DD for chest pain?

A

PE
Pneumonia (cough, sputum, fever)
Pneumothorax (sudden onset, breathlessness, sharp pain)

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13
Q

What are the GI DD for chest pain?

A

Oesophageal spasm
Oesophagitis (chest pain)
Gastritis, abdominal pain (history of steroids)

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14
Q

What are the MSK DD for chest pain?

A

Costochondritis

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15
Q

What would you see in and ECG in anteriolateral STEMI?

A

V1, aVL, V5 and V6
ST elevation
Lateral

V2,3,4
ST Elevation
Anterior

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16
Q

What would you see on and ECG in an inferior STEMI?

A

V2, V3 and aVF

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17
Q

Where will there be ST elevation in an anterior MI?

A

V1-V4

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18
Q

Blockage of which coronary artery causes anterior MI?

A

LAD

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19
Q

Blockage of which coronary artery causes lateral MI?

A

Circumflex

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20
Q

Blockage of which coronary artery causes inferior MI?

A

RCA

ST elevation in II,III and aVF

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21
Q

What is the shorthand for normal heart sounds?

A

S1 + S2 + 0

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22
Q

What are the differential diagnosis for collapse?

A 
Hypoglycaemia
Cardiac 
- Vasovagal
- Arrhythmia
- Outflow obstruction
- Postural hypotension
Seizure
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23
Q

What is DNEFG?

A

Do Not Ever Forget Glucose

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24
Q

What are causes of outflow obstruction LHS of the heart?

A

Aortic stenosis
HOCAM
(hypertrophic obstructive cardiomyopathy)

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25
Q

What are causes of outflow obstruction RHS of the heart?

A

PE

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26
Q

What are the two types of arrhythmia?

A

Tachy

Brady

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27
Q

What investigations do you do for arrhythmias?

A

ECG (? Long QT), cardiac monitor, 24 hour tape

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28
Q

What investigation do you do when suspecting outflow obstruction?
What findings OE?

A

Low volume/slow rising pulse, ESM, Echocardiogram

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29
Q

What is ESM?

A

Ejection systolic murmur

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30
Q

What investigation do you do when suspecting postural hypotension?

A

Lying/Standing BP

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31
Q

What are the main features of long QT syndrome?

A

Abnormal ventricular repolarization
Congenital e.g. mutations in K+ channels
FH of sudden death
Acquired: low K+/ Mg2+, drugs

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32
Q 
45 year old man
Fever
Malaise
IV drug use
Temp: 38oC

Raised JVP to earlobes
HS: S1 + S2 + PSM (louder on inspiration)
Hepatomegaly

A

Infective endocarditis
Tricuspid regurg
IV drug use exposing right sided valves to bacteria
Hepatomegaly caused by back flow of blood (liver congestion)

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33
Q

What is PSM?

A 
Pan systolic murmur
Either tricuspid or mitral regurg
But differentiate between where the murmur is loudest
TR - louder on inspiration
MR - louder on expiration
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34
Q

What are the differences between Janeway lesions and Oslers nodes?

A

Janeway lesions - palms and painless

Oslers nodes - tops of fingers and painful

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35
Q

What are the differential diagnoses for raised JVP?

A

R heart failure
Tricuspid regurg
Constrictive pericarditis

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36
Q

What would cause infective endocarditis on the LHS?

A

Dental infection

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37
Q

Why might RHS HF cause raised JVP?

A 
Secondary to L heart failure (CCF)
Pulmonary HTN (PE, COPD etc.)
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38
Q

Why might tricusp regurg cause increased JVP?

A

Valve leaflets

R ventricle dilatation (left parasternal heave) Since the R ventricle needs to work against pulmonary hypertension

39
Q

Why might constrictive pericarditis cause increased JVP?

A

Infection e.g. TB
Inflammation: CTD
Malignancy

40
Q

What are differentials for systolic murmur?

A

Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect

41
Q

How do you differentiate between systolic murmurs?

A

Where is it loudest?

Where does it radiate to?

42
Q

What conditions has a murmur louder at the aortic area? Where would it radiate?

A

Aortic stenosis
Radiates to neck
Associated with slow rising pulse

43
Q

What conditions has a murmur louder at the apex area? Where would it radiate?

A

Mitral regurg
Radiates to axilla
Associated with a displaced apex beat

44
Q

What conditions has a murmur louder at the tricuspid area? Where would it radiate?

A

Triscuspid regurg
Louder on inspiration
Associated with raised JVP

45
Q 
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?

A

AF

46
Q

What is SVT?

A

Supraventricular tachycardia

47
Q

What are the causes of sinus tachycardia?

A

Sepsis, hypovolaemia, endocrine
(thyrotoxicosis, phaeochromocytoma)
Anxiety/Stress

48
Q

What are causes of SVT?

A

Re-entry circuit

49
Q

What are causes of AF?

A

Thyrotoxicosis, ischaemia, chest infection, alcohol
Heart: muscle, valve, pericardium
Lungs: Pneumonia, PE, cancer

50
Q

What are causes of VT?

A

ischaemia, electrolyte abnormality, long QT

51
Q

What are the differences between sinus tachy and SVT on ECG?

A

No p-waves in SVT

52
Q

What is re-entry circuit? (do not need to know detail)

A

AVNRT (node)
- Impulses go down septum and up via accessory pathways

AVRT
- Impulses go up and down septum

53
Q

How do you tell the difference between AF and SVT when both have no p-waves?

A

SVT is irregular

54
Q

How do you tell the difference between AF and atrial flutter?

A

Saw-tooth pattern on ECG in flutter

BUT treat as same

55
Q

How would you manage a pt. with an SVT and BP of 110/80?

A

Vagal maneuvers
Adenosine (cardiac monitor)
DC cardioversion if evidence of haemodynamic compromise

56
Q

Write down the management plan for a patient with acute fast AF & BP: 120/80

A

Rhythm control
If onset > 48hours, anticoagulate for 3-4 weeks before cardioversion

Rate control

  • beta blocker
  • digoxin
57
Q

What is the management of VT?

A

If no haemodynamic compromise: IV Amiodarone
Look for & treat underlying cause
ICD (implantable cardioverter defibrillator)

Pulseless VT: defibrillate

58
Q

How does htn show up on ECG?

A

Deep S waves

Tall R waves

59
Q

How can you identify LVH by voltage criteria?

A

Deep S in V1/2
Tall R in V5/6

S in V1 + R in V5 or V6 (whichever is larger) ≥ 7 large squares

60
Q

How does 1st degree heart block present on ECG?

A

Prolonged QR

More than one large square

61
Q

How does 2nd degree heart block present on ECG?

A

Missing QRS complexes

62
Q

How does 3rd degree heart block present on ECG?

A

No relation between QRS and P waves

Broad QRS

63
Q

What pathologies can be suggested by ECG?

A

Ischaemia
ST, T, Q

Arrhythmia or conduction defects

Rate, Rhythm
PR, QRS, QT

Ventricular strain or hypertrophy
Axis, R, S

64
Q

What is S3?

A

S3 = rapid ventricular filling

Immediately after S2

65
Q

What is S1?

A

Closure of mitral valve

66
Q

What is S2?

A

Closure of aortic valve

67
Q

What would Fixed wide splitting of S2 be?

A

Atrial septal defect

68
Q

What heart sound is associated with ventricular filling?

A

S3

69
Q

What heart sound is associated with ventricular hypertrophy?

A

S4

70
Q

What is the management for acute heart failure?

A

Sit up
Oxygen
Furosemide (IV)

(GTN infusion)

Treat the underlying cause

71
Q

What is the ALS algorithm for VF/pulseless VT?

A 
Shock
CPR (2 min)
Assess rhythm
Adrenaline every  3-5 min
Amiodarone after 3 shocks
Treat reversible causes
72
Q

What is the ALS algorithm for asystole?

A

CPR (2 min)
Adrenaline every 3-5 min
Correct reversible causes

73
Q 
30 yr old woman 
URTI
Pleuritic chest pain
Better when leaning forward
Diagnosis?
A 
Pericarditis
PE
Pneumonia
Pneumothorax
Pleural pathology
5Ps
74
Q

What causes angina?

A

Insufficient oxygen reaching myocardium at times of increased demand

75
Q

What are RFs for ACS?

A

Increasing age
Male gender
Family history

Smoking
Diabetes mellitus
Hypertension
Hypercholesterolaemia
Obesity
76
Q

What would ST elevation in Lead II, III and aVF mean?

A

Occlusion of the right coronary artery

Inferior STEMI

77
Q

Where would you see ST elevation in a lateral STEMI?

A

I, aVL
V5, V6
Left circumflex artery

78
Q

Where would you see ST elevation in an anterior STEMI?

A

V1-V4

Left anterior descending

79
Q

Where would you see ST elevation in a septal STEMI?

A

V1

V2

80
Q

What does ST depression signify?

A

Severe ischaemia usually LAD

Deep and widespread ST depression is associated with high mortality

81
Q

How do you treat ACS?

A 
MONA
Morphine
Oxygen if sats <94%
Nitrates
Aspirin
82
Q

What is the treatment of STEMI?

A

Asptin
2nd anti-platelet e.g. Clopidogrel
Unfractionated heparine
Urgent PCI if cannot be done within 120 mins consider fibrinolysis

83
Q

What is PCI?

A

Percutaneous coronary intervention
Balloon opens up blocked arteries
Stent may be deployed
Done via catheter insertion into radial or femoral artery

84
Q

How is management for a NSTEMI decided?

A

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

85
Q

What secondary prevention is used lifelong in patients who have has an ACS?

A 
aspirin
a second antiplatelet if appropriate (e.g. clopidogrel)
a beta-blocker
an ACE inhibitor
a statin
86
Q

What should be done in patients who have had fibrinolytic therapy rather than PCI?

A

ECG repeat 60-90 mins to see if changes have resolved

If not consider PCI

87
Q

What is GRACE and what does it take into account?

A

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

88
Q

What happens to T-waves in acute MI?

A

Become inverted indicating ischaemia

89
Q

What is different in a posterior MI?

A

ST depression

90
Q

Why do you get reciprocal changes in an anterior STEMI?

A

LAD blocked
RCA has to compensate to provide blood flow to the LHS
So there is ischaemia but not due to primary occlusion there

91
Q

Why is PCI urgent and done?

A

Life-saving

Risk reduction is 50% with PCI

92
Q

What is the difference between aspirin and rivaroxiban?

A

Asprin - antiplatelete

Rivaroxiban - anticoagulant

93
Q

What are some thiazide diuretics?

A

Indapamide

Bendroflumethiazide

Year 3 Cardio (12 decks)

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