Cardio Flashcards
1
Q
Aortic stenosis
- pulse
- HS
- murmur
A
slow rising, narrow pulse pressure <30
HS:
soft S2 ± S4 (blood filling a non-compliant ventricle)
ejection systolic murmur
Right 2nd ICS, radiates to carotids
2
Q
Aortic stenosis Sx
A
SAD
syncope
angina
dyspnoea
3
Q
Aortic stenosis Ix
A
- ECG (LVH, arrhythmias)
- Bloods (FBC, U&E, BNP, lipids, glucose)
- CXR (calcified valves, LVH, pul. oedema)
- Echo ± doppler (severity, cause, LV function); severe AS:
- – Valve area <1cm2
- – Pressure gradient >40mmHg]
- – Jet velocity >4m/s
- Coronary angiography
4
Q
Aortic stenosis Mx
A
General:
- MDT (cardio, GP, specialist nurse, surgeon, dietician)
- RF modification (statin, anti platelet, manage HTN angina)
- regular f/u
Surgery
1) open replacement
(ix: symptomatic, non-symptomatic w/ low EF (<50%), severe undergoing CABG)
–> artificial
——Starr-Edwards / ball-in-cage (3 artificial sounds:)
Quiet click as valve opens
Rumbling as ball rolls in the cage
Loud thud as valve closes
——Tilting disc / bileaflet [1 artificial sound]
High-pitched click as valve closes
–> biological (normal HS)
2) TAVI (transcatheter AV implantation)
+ve = no bypass required, no large scars
-ve = higher risk of stroke compared to open
3) balloon valvuloplasty
4) sutureless AV replacement
5
Q
Aortic regurgitation
- peripheral signs
- pulse
- apex
- HS
- murmur
A
- all the peripheral signs e.g. Beckers, de musset, corrigans neck sign, quincke’s
- Corrigan’s pulse (water hammer), wide pulse pressure e.g. 180/45
displaced apex
HS: soft S2 + S3 (blood filling a compliant ventricle)
Murmur:
- Early diastolic murmur
- LLSE
6
Q
Becker’s sign
A
AR
Retinal artery pulsation
7
Q
Mueller’s sign
A
AR
systolic pulsations of the uvula
8
Q
De Musset’s sign
A
AR
nodding head
9
Q
Corrignan;s neck sign
A
AR
carotid pulsation
10
Q
Quincke’s sign
A
AR
pulsatile nail bed
11
Q
Traube’s sign
A
AR
pistol shot femoral pulses
12
Q
Duroziez’s sign
A
AR
femoral artery compression - systolic murmur on proximal compression, diastolic murmur on distal compression
13
Q
Severe AR S+S
A
collapsing pulse, wide PP, LVF
14
Q
AR Ix
A
- ECG (LVH, LV strain – lateral lead TWI)
- Bloods (FBC, U&E, NT-proBNP, lipids, glucose, ESR, HLA-B27, ANA)
- CXR (cardiomegaly, LVH, pul. oedema)
- Echo ± doppler (severity, cause, LV function); severe AR:
Jet width (>65% outflow tract)
Regurgitant jet volume
Premature closing of mitral valve - Coronary angiography
15
Q
AR Mx
A
General same as AS (MDT, RF modification, Regular FU)
Medical
- reduce afterload using ACEi, BB, diuretics
Surgical
- Vavle replacement before LV dilation and dysfunction:
- — Pulse pressure >100mmHg
- — ECG changes (TWI in lateral leads)
- — LV enlargement on CXR or EF <50%
16
Q
Mitral stenosis
- peripheral
- pulse
- apex
- HS
- murmur
A
malar flush
- irregular AF pulse
- tapping apex (palpable S1)
HS
- loud S1 (early diastolic opeining snap) + loud S2 if pulmonary HTN
Murmur
- mid diastolic murmur - in left lateral position at end expiration in apex
- radiated to axilla
17
Q
Severe MS S+S
A
malar flush, longer murmur, LVF
18
Q
Evidence of pulmonary HTN
A
malar flush
raised JVP with large V waves
RV heave
Loud S2
19
Q
MS Ix
A
- ECG (P-mitrale, AF)
- Bloods (FBC, U&E, NT-proBNP, lipids, glucose)
- CXR (LA hypertrophy (splaying of carina), calcified mitral valve, pul. oedema)
- Echo ± doppler (severity, cusp calcification, LV function, ? TOE); severe MS:
- – Valve orifice <1cm2
- – Pressure gradient >10mmHg
- – Pul. artery SBP >50mmHg
- Coronary angiography
20
Q
Mitral stenosis Mx
A
General
- MDT, RF modification, regular FU
Medical
- RhF prophylaxis (benxyylpenicillin)
- AF - rate control and DOAC
- diuretics for Sx relief
Surgical (indication = moderate severe MS symptomatic or non)
1st = balloon vavluloplasty
- valvotomy / commissutotomy (valve repair)
- valve replacement if repair not possible
21
Q
Mitral regurgitation
- pulse
- apex
- HS
- murmur
A
irregular pulse (AF)
Apex displaced
Sounds - Soft S1 (Loud S2 if pulmonary HTN)
Murmur
- pan systolic murmur
- left lateral position at end expiration in apec
- radiates to axilla
22
Q
Severe MR S+S
A
LVF, AF
23
Q
Mitral regurgitation Ix
A
- ECG (P-mitrale, AF, LVH)
- Bloods (FBC, U&E, NT-proBNP, lipids, glucose)
- CXR (LA/LV hypertrophy, calcified mitral valve, pul. oedema)
- Echo ± doppler (severity, cusp calcification, LV function); severe MR:
- – Jet width >0.6cm
- – Systolic pul. flow reversal
- – Regurgitant volume >60mL
- Coronary angiography
24
Q
Mitral regurgitation Mx
A
General
- MDT, RF mod, regular FU
Medical
- AF (rate and rhythm control, anticoagulation)
(AR and MR medical mx is to reduce afterload)
Surgical (symptomatic)
- valve replacement / repair
25
Heart failure New York Heart Association Classification
1 – no limitation of activity
2 – comfortable at rest, dyspnoea on ordinary activity
3 – marked limitation of ordinary activity
4 – dyspnoea at rest
26
Normal EF
45-60%
27
HF Mx
BASHIeD up heart
```
BB
ACEi
Spironolactone
Hydralazine / Ivabradine
Digoxin
```
1st line
BB + ACEi / ARB
(reduced EF - use BB or ACEi)
(preserved EF - use loop diuretic)
BB + Entresto (Sacubitril+valsartan) if ejection fraction <35%
2nd line
BB + ACEi/ ARB + spironolactone
-- monitor K
3rd line
Ivabradine - EF <35%, sinus rhythm HR >75
Hydralazine+ nitrate - best for afro-caribbean
Cardiac resynchronisation therapy if patient has widened QRS
Digoxin
Repeat echo in 3 months after starting treatment
Pneumococcal and flu vaccines
28
Contraindicated drugs in HF
Thiozoladinediones
Verapamil (-ve inotrope)
NSAIDs (fluid retention)
Glucocorticoids (fluid retention)
Flecainide (-ve inotrope, arrhythmogenic)
29
Angina S+S
Sharp chest pain
Precipitated by physical exertion
Relieved by GTN spray within 5 min
30
Criteria for stable, atypical and non-anginal pain
Stable 3/3
Atypical 2/3
Non <1/3
31
Stable angina Ix
1st - CTCA -- calcium score
2nd - non invasive functional imaging
- MPS SPECT (Myocardial Perfusion Scintigraphy with single photon emission CT)
- stress echo
- first pass contrast enhanced MR perfusion
- MR imaging for stress-induced wall motion abnormalities
3rd - coronary angiography
32
Stable angina Mx
Conservative
- stop smoking, weight loss, healthy diet
All receive aspirin + statin
1st
- GTN + BB / CCB
```
BB = atenolol 50-100mg OD
CCB = non-DHP, rate limiting e.g. verepamil, diltiazem
```
Increase to max dose
2nd
- GTN + BB + CCB
```
BB = Atenolol 50-100mg OD
CCB = DHP, non-rate limiting e.g. nifedipine, amlodipine
```
3rd- other options (instead of BB/CCB):
- long acting nitrate e.g. ISMN 20-40mg BD or slow release nitrate Imdur 60mg OD
- Ivabradine
- Nicorandil
- Ranolazine
if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG
33
Secondary prevention of Angina
- - aspirin 75mg OD,
- - atorvastatin 80mh ON
- - ACEi
- - antihypertensives
34
Why can't you give a BB with a non-DHP CCB
interacts with AVN conduction and can cause complete heart block
35
non-DHP CCB examples
Rate limiting
verapamil
diltiazem
36
DHP CCB examples
non rate limiting
amlodipine
nifedipine
37
BB CI
hypotension, bradycardia, asthma, HF
38
CCB CI
hypotension, bradycardia, peripheral oedema
| DHP/ non rate limiting better than non-DHP for peripheral oedema
39
AF causes
- ischaemic heart disease
- rheumatic HD (MR, MS)
- hyperthyroid
- infection
- PE
- cardiomyopathy
- alcohol
40
Types of AF
Acute <48h
Paroxysmal - self limiting, <7d, recurs
Persistent - >7d, may recur even after cardio version
41
Stroke + AF - medication
Anticoagulant e.g. apixaban
42
Stroke + no AF - medication
Antiplatelet e.g. clopidogrel / ticagrelor
43
AF Mx
use rhythm control if
reversible AF
coexistent HF
new onset AF
44
Rhythm control in AF
Acutely
Antgicoagulation required if onset 24-48 hours, for 4 weeks
1st - electrical cardio version (synchronised DC shocks)
2nd - pharmacological cardioversion
- - flecainide (young, no structural heart disease)
- - amiodarone (old, structural heart disease e.g. HF)
Long term:
1st - BB e.g. bisoprolol
Paroxysmal -- 'pill in pocket' flecainide (not in structural HD), amiodarone
BB failed/ CI --> amiodarone
Pacing
45
Rate control in AF
1st - BB e.g. bisoprolol or rate limiting CCB/ non DHP e.g. verapamil (CI in peripheral oedema)
2nd - digoxin
3rd - amiodarone
46
Anticoagulation in AF
remember that antiplatelets are used in arterial causes for clots e.g. atheroma
anticoagulation in venous causes
CHASVASC 1+ anticoagulate in men, 2+ in women
AF<48h - LMWH until assessemtn
AF >48h - Apixaban > dabigatran/rivoroxaban/warfarin
- - for 3w before cardio version
- - for 4w after cardio version if Chadvasc low/ for LIFE if chadvasc high or paroxysmal
47
Severe HTN BP
>180/110
48
Signs of severe HTN
Ix
```
retinal haemorrhage
pappiloedma
confusion
AKI
chest pain
```
ADMIT
ECG, urine dip, blood tests,
49
HTN algorithm
If T2DM or <55 and not black
1) ACEi / ARB
2) ACEi/ARB + CCB/ thiazide like diuretic (indapamide)
3) ACEi/ARB + CCB + thiazide-like diuretic (indapamide)
4) spironolactone if K<4.5
a-blocker or BB if K>4.5
55+ or black
1) CCB
2) CCB + ACEi/ ARB/ thiazide-like diuretic
3) ACEi/ARB + CCB + thiazide like diuretic
4) spironolactone if K<4.5
a-blocker or BB if K>4.5
50
Who should we measure standing and sitting BP in?
People with
T2DM
people with sx of postural hypotension
80y+
51
BP targets
| <80 and >80
<80
clinic BP <140/90
ABPM/HBPM <135/85
80 or more
clinic BP <150/90
ABPM/HBPM <145/85
52
What needs to be monitored before and during treatment with ACEi/ ARBs?
U+Es
increase up to 30% in creatinine is ok
increase in K up to 5.5mmol is ok
53
In which diseases are thiazides contradicted for use in HTN
```
CKD 4 5 (eGFR<30)
DM
gout
dyslipidaemia
SLE
```
54
primary prevention statin
Atorvastatin 20mg OD
if 10y risk 10%+ or T1DM or CKD eGFR <60
55
Secondary prevention statin
Atorvastatin 80mg OD
IHD or CVD or PAD
56
Risk factors for infective endocarditis
```
rheumatic heart disease
IVDU
Prostehtic valves
congenital heart defects
recent piercings
```
57
Valve affected in previously normal valves vs IVDU
normal -- mitral valve
IVDU -- tricuspid valve (first valve after venous circulation)
58
Organisms in IE
S aureus - IVDU, acute presentation
S epidermis - CoNS, prosthetic valves
S viridans - sub-acute presentation, developing world
59
culture negative organisms in IE and RF
RF
- prior abx, coxiella, bartonella, brucella, sub-acute presentation
HACEK
- H influenzae
- Actinobacillus
- Cariobacterium
- Eikenella corrodens
- Kingella
60
Criteria for IE
Dukes criteria - BE FEVEER
```
2 major
or
1 major 3 minor
or
5 minor
```
Major criteria
- Bacteraemia (2 cultures, 12 hours apart)
- Echo (vegetation, new murmur, abscess, dehisced prosthetic valve)
Minor criteria
- Fever >38
- Echo findings
- Vascular (embolus e.g. stroke PE, splinter haemorrhages, Janeway)
- Evidence of immunological involvement (Osler nodes, Rtoh spots, glomerulonephritis, RF)
- Evidence of microbiological involvement (1 culture +)
- RF e.g. IVDU, predisposing heart condition
61
IE S+S
FROM JANE
Fever
Roth spots
Osler nodes
Murmur
Janeway lesions
Anaemia
Nail haemorrhage (splinter)
Emboli
62
IE Mx
blind therapy native / prosthetic valve
blind therapy
native valve
- amoxicillin
± gentamicin (low dose)
prosthetic valve
- vancomycin + rifampicin + LD gentamicin
63
IE Mx
Native valve, staphylococci
Flucloxacillin
64
IE Mx
Prosthetic valve, staphylococci
Flucloxacillin + rifampicin + LD gentamicin
65
IE Mx
Streptococci (fully sensitive)
benzylpenicillin
66
IE Mx
Streptococci (not fully sensitive)
Benzylpenicillin + LD gentamicin
67
IE Mx
if pen allergic or MRSA
Amoxicillin --> vancomycin + LD gentamicin
Flucloxacillin --> vancomycin + rifampicin
68
rheumatic fever/ heart disease aetiology
Group A β-haemolytic streptococcus (S. pyogenes; GAS)
69
rheumatic fever/ heart disease
latent interval
2-6 weeks after pharyngeal infection
70
rheumatic fever/ heart disease
| S+S
```
poly arthritis (tender joints, swelling)
pericarditis (endocarditis, myocarditis, pericarditis)
erythema marginatum
```
synenham;s chorea 2-6 months later
71
rheumatic fever/ heart disease chronic progression
MS
chronic progression in 60-80%
72
rheumatic fever/ heart disease
| diagnostic criteria
Jones criteria
2 major or 1 major + 2 minor
Major = CASES
- carditis
- arthritis
- Subcutaneous nodules
- erythema marginatum
- syndenham's chorea
Minor = FRAPP
- fever
- raised ESR./ CRP
- arthralgia
- prolonged PR interbal
- previous RF
73
rheumatic fever/ heart disease Ix
Bloods FBC ESR ASOT
ECG
Echo
74
rheumatic fever/ heart disease Acute Mx
Acute
- bed rest until CRP normal for 2 weeks
- analgesia (NSAIDs, aspirin)
- phenoxymethylpenicillin (penicillin V QDS 10/7) or azithromycin if pen-allergic
CCF/ cardiomegaly or 3rd degree heart block -- corticosteroids
sydenhams chorea -- haloperidol, diazepam,
75
rheumatic fever/ heart disease prophylaxis
Once monthly IM benzylpenicillin or
BD PO 250mg phenozymethylpenicillin
± surgical valve repair/ replacement
76
Pericarditis causes
```
Viral - coxsackie
TB
uraemia (fibrinous pericarditis)
post MI, dressler's
hypothyroid
Trauma
Malignancy
CTD
```
77
Pericarditis S+S
```
pleuritic chest pain
non productive cough
dyspnoea
flu like sx
pericardial rub
tachypnoea
tachycardia
```
78
Pericarditis Ix
- ECG - widespread
PR depression > saddle-shaped ST elevation
- TTE
- troponin (may/ may not be raised)
79
Pericarditis Mx
Treat cause
1st - NSAIDs ± colchicine
80
Aortic stenosis
Murmur
Location
Radiation
HS
Murmur = ejection systolic murmur
Location = R 2nd ICS parasternal
Radiation = to carotids
HS = Soft S2 ± S4
81
Aortic regurgitation
Murmur
Location
Radiation
HS
Murmur = Early diastolic
Location = L 3rd ICS, parasternal, Erb's point
Radiation - displaced apex
HS = Soft S2 ±S3
82
Mitral stenosis
Murmur
Location
Radiation
HS
Murmur = mid diastolic murmur
Location = apex
Radiation = axilla
HS = loud S1
83
Mitral regurgitation
Murmur
Location
Radiation
HS
Murmur = pansystolic
Location = apex displaced
Radiation = axilla
HS = soft S1 ± loud S2 (if pulmonary HTN)
84
Cause of S1
mitral valve closure
85
Cause of S2
Aortic valve closure
86
Cause of S3
blood filling a compliant ventricle
| Kentucky
gallop rhythm
87
Normal causes of S3
young, athletes, pregnancy
88
Abnormal causes of S3
Heart failure
Aortic regurgitation
MR/TR
dilated CM
89
Cause of S4
blood filling a non-compliant ventricle
| Tennesse
90
Abnormal causes of S4
LVH - aortic stenosis or HTN
HOCM
restrictive cardiomyopathy
91
Split S1 cause
M1 and T1 closure at different times
92
Abnormal cause of split S1
RBBB
93
Split S2 cause
A1 and P1 closure at different times
94
Normal cause of split S2
Deep inspiration -non fixed
95
Abnormal cause of split S2
```
fixed
Atrial septal defect
Pulmonary HTN
RHF
BBB
```
96
Causes of collapsing pulse (4)
AR
thyrotoxicosis
pregnancy
anaemia
97
Causes of Absent radial pulse (5)
```
trauma
dead
coarctation
thromboembolic
Takayasu's arteritis
```
98
Causes of impalpable apex beat
COPD
Obese
pericardial effusion
dextrocardia
99
Features of Pulmonary HTN (5)
```
Raised JVP
Left parasternal heave (RVH)
Ascites/ peripheral oedema
Loud S2
Pulsatile hepatomegaly
```
100
Types of cardiomyopathy
2 genetic
2 mixed
2 acquired
2 genetic
- HOCM
- Arrhythmogenic right ventricular dysplasia
2 mixed
- dilated cardiomyopathy
- restrictive cardiomyopathy
2 acquired
- peripartum cardiomyopathy
- takostubo cardiomyopathy
101
Causes of dilated cardiomyopathy
alcohol
coxsackie B
wet beri beri
doxorubicin
102
Causes of restrictive cardiomyopathy
Amyloidosis
post radiotherapy
Loeffler's endocarditis
103
How does dilated cardiomyopathy present
HF - transplant, ACEi, BB, family screen
Arrhythmia - ICD
Sudden death
stroke
LV: reduced EF and contractility
Must rule out MR, AR, CAD
104
Primary cardiomyopathy must have absence of
```
CAD
HTN
valvular disease
congenital heart disease
systemic disease
```
105
Causes of secondary cardiomyopathy
Infective - coxsackie B, chagas disease
Infiltrative - amyloidosis
Storage - haemochromatosis
Toxicity - doxorubicin, alcohol
Inflammatory - sarcoidosis
Endocrine - DM, thyrotoxicosis, acromegaly
Neuromsucular - Friedrichs ataxia, Duchenne-Becker muscular dystrophy
Nutritional - beri beri
Autoimmune - SLE
106
CYP inducers
BS CRAP
Barbiturates
Sulphonylurea
Carbamazepine
Rifampicin
Alcohol (chronic excess)
Phenytoin
107
CYP inhibitors
ZAG DeViCES
```
Zoles - ketoconazole, fluconazole, omeprazole
Allopurinol
Grapefruit juice
Disulfiram
Valproate
Ciprofloxacin
Ethanol (acute excess)
Sulphonamides
```
108
Long QT causes
Congenital
- Jervell Lange Nielson syndrome (deafness)
- Romano Ward syndrome (no deafness)
Drugs METH CATS
- Methadone
- Erythromycin
- Terfenadine
- Haloperidol
- Chloroquine/ clarithromycin
- Amiodarone/ azithromycin
- TCAs
- SSRIs - citalopram
```
Other
- Hypocalcaemia
- Hypokalaemia
- Hypomagnesaemia
MI
Myocarditis
hypothermia
SAH
```
109
Torsades de Pointes Tx
IV magnesium sulphate
110
Pulsus paradoxus is...
Seen in
>10mmHg drop in systolic BP during inspiration causing faint or absent pulse in inspiration
severe asthma, cardiac tamponade
111
Pulsus alternans is...
seen in
Regular alternation of the force of arterial pulse
in severe left ventricular failure
112
slow rising pulse in
Aortic stenosis
113
Collapsing pulse is in
Aortic regurgitation
PDA
Hyperkinetic states e.g. anaemia, thyrotoxicosis, fever
114
Bisferiens pulse is
seen in
double pulse - two systolic peaks
in HOCM, mixed aortic valve disease
115
Jerky pulse seen in
HOCM
116
HOCM S+S
Asymptomatic
Sudden death (most commonly due to ventricular arrhythmias / VF), arrhythmias, heart failure, stroke, AF, VF (sudden cardiac death), VT (collapse)
Exertional: dyspnoea, angina, syncope (from hypertrophy of ventricular septum --> functional aortic stenosis)
Examination
- jerky pulse
- large 'a' waves
- double apex beat
- ESM (increases with Valsalva manoeuvre and decreases on squatting, PSM of mitral regurgitation from impaired mitral valve closure)
117
HOCM Ix
Echo (MR SAM ASH)::
Mitral regurgitation (MR)
Systolic anterior motion (SAM) of the anterior mitral valve leaflet
Asymmetric hypertrophy (ASH)
```
ECG:
LVH
Non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
Deep Q waves
AF (occasionally)
```
118
HOCM mx
```
ABCDE
o Amiodarone
o Beta-blockers / verapamil for symptoms
o Cardioverter defibrillator
o Dual chamber pacemaker
o Endocarditis prophylaxis
```
o Septal reduction therapies for NYHA 3-4: Myomectomy/ alcohol septal ablation
o Drugs to avoid = nitrates, ACEi, inotropes
119
What is coarctation of the aorta?
congenital narrowing of the aorta
120
Coarctation of the aorta features in children and adults
| General features
Children
Heart failure
Adults
HTN
Notching of the inferior border of ribs
General:
- Mid systolic murmur, maximal over back
- Apical click from aortic valve
121
Coarctation of the aorta
Associations
Male > Females
Turner's syndrome
Bicuspid aortic valve
Berry aneurysms
Neurofibromatosis
122
Difference between unstable angina, STEMI and NSTEMI
Unstable angina
- troponin normal
NSTEMI
- troponin raised
- no ST elevation on ECG
STEMI
- troponin raised
- ST elevation
123
PCI vs CABG
PCI
- for 1 or 2 vessel disease, NOT including LAD
CABG
- 2 or 3 vessel disease, including LAD
124
Leads in an anteroseptal MI
which artery
V1-V4
LAD
125
Leads in an inferior MI
which artery
II, III, aVF
Right coronary artery
126
Leads in an anterolateral MI
which artery
V4-6, I, aVL
LAD or LCx
127
Leads in a lateral MI
which artery
I, aVL ± V5-6
LCx
128
Leads in a posterior MI
which artery
Tall R waves V1-2
Usually LCx, also RCA
129
LAD leads
V1-4
130
RCA leads
II, III, aVF
131
Anterior leads
V3-4
132
Septal leads
V1-2
133
Inferior leads
II, III, aVF
134
Lateral leads
I, aVL, aVR, V5-6
135
Reversible causes of MI
4H and T
- Hypothermia
- Hypoxia
- Hypovolaemia
- Hypokaelamia, hyperkalaemia, hypoglycaemia, acideamie
- Thrombosis
- Tamponase
- Tension pneumothorax
- Toxins
136
Classification for predicting prognosis of MI
Killip classification
137
Complications of MI
DARTH VADER
Death
Arrhythmia
Rupture
Thrombus
Haemorrhage
Valvular heart disease
Aneurysm
Dressler's syndrome / pericarditis
Embolism
Re-infarction
138
types of arrhythmia post MI and Mx
o Heart block
- -----inferior MI = atropine
- ----anterior MI = temporary TC pacing --> permanent pacemaker
o Tachy/ Bradyarrhythmias
-----VF = most common cause of death post MI
Pacemaker
139
Types of rupture post MI
o Acute / 3-5 days
- acute mitral regurgitation (papillary muscle rupture; RCA)
in 15-60% of MIs
o Acute / 3-5 days - ventricular septal rupture (LAD or RCA)
1-2% of MIs
o 5 days - 2 weeks
- Left ventricular free wall rupture (LAD):
3% of MIs
140
MI Complication rupture:
Acute MR S+S, Mx
S+S
- pulmonary oedema
- hypotension
- new pan systolic murmur (no thrill, soft murmur)
Mx
- inotropes/ vasopressors, surgery
141
MI Complication rupture:
Ventricular septal rupture S+S, Mx
S+S
- chest pain
- biventricular failure (acute HF)
- shock
- new pan systolic murmur (thrill, harsh murmur)
Mx
- inotropes/ vasopressors, surgery
142
MI Complication rupture:
Left ventricular free wall rupture
S+S, Mx
S+S
- HF
- tamponade -- raised JVP, muffled HS, hypotension, pulses paradoxus (exaggerated fall of BP >10mmHg during inspiration)
Mx
- Pericardiocentesis + thoracotomy
143
MI Complication aneurysm:
which wall
which vessel
left ventricular wall
LAD involvement
144
MI Complication aneurysm:
S+S, Mx
S+S
- SOB
- persistent ST elevation
- no chest pain
- LVF --> thrombus
Mx
- anticoagulation
145
MI Complication Dressler's vs pericarditis time frames
pericarditis <48h
| Dressler's 2-6 weeks
146
MI Complication Dressler's and pericarditis
S+S, Mx
S+S
- Fever
- pleuritic pain
- pericardial effusion
- raised ESR
Mx
- NSAIDs
147
What to use to tell fi there is a re-infarction
CK-MB because it only stays raised for 3-4d post MI
re-infarcts happen 4-10d after initial MI
148
How long does troponin stay raised for
10d
149
General Mx of acute MI
D MONABASH
Dual antiplatelet therapy
-- aspirin and ticagrelor
Morphine
Oxygen
Nitrate
Anticoagulant
Beta blockers
ACEi (Longer term)
Statin (Longer term)
Heparin (enoxaparin or fondaparinux)
150
Morphine in acute MI dose
| + M....? dose?
- 5-10mg IV
- repeat after 5 min if needed
+ metoclopramide 10mg IV
151
when do you give oxygen in acute MI
- if <94%
152
when do you give nitrate in acute MI
- GTN if HTN or acute LVF
153
Anticoagulants given in acute MI
Angiography ± PCI <24h
--> enoxaparin (LMWH) or unfractionated heparin or bivalirudin
Fibrionlysis
--> enoxaparin or unfractionated heparin or fondaparinux
```
No intervention (low GRACE)
--> Fondaparinux
```
154
Do not give ? if PCI is possible
Fondaparinux
155
what do you always give in NSTEMI
Fondaparinux
156
Acute MI dual anti platelet therapy
Aspirin 300mg PO
+
Ticagrelor 180mg PO
157
Definitive Mx of STEMI
<12h
>12h
<12h
+ can give PCI <120min
--> PCI
<12h
+ cannot give PCI <120min
--> thrombolysis within 12h
-- do ECG 60-90min post thrombolysis - if ST elevation persisting, do PCI
>12h
- specialist advice + anticoagulation (fondaparinux or enoxaparin)
158
Long term management after MI
ABCDS
ACEi
- reduces RAAS cardiac remodelling
- if S+S HF after MI consider sprionolactone
Beta blocker or verapamil/ diltiazem
Cardiac rehab
- diet
- exercise 20-30min / day until slightly breathless
- sex after 4w
DAPT
- ACS medically managed --> aspirin + ticagrelor (stop after 12m)
- ACS PCI managed --> aspirin + prasugrel/ ticagrelor (stop after 12m)
Statin
159
Management of acute STEMI
DaM Beta blockers --> PCI/ thrombolysis
D = DAPT
- aspirin 300mg PO
- ticagrelor 180mg PO
M = Morphine
- 5-10mg IV
+ anti-emetic metoclopramide 10mg IV
B = Beta blockers
PCI or Fibrinolysis
160
Management of acute chest pain
MONA --> GRACE
M = Morphine 5-10mg IV + metoclopramide 10mg IV
O = Oxygen
N = GTN spray
A = aspirin 300mg PO
GRACE score
GRACE >3% >72h PCI
Haemodynamically unstable - immediate PCI
161
Acute pulmonary oedema S+S
SOB at rest
| acute onset
162
Causes of severe pulmonary oedema
Cardiovascular
- LVF (post MI, valvular heart disease) --> elevated PAWP
ARDS (trauma, malaria, drugs).--> elevated PAWP
Fluid overload
Neurogenic (head injury)
163
acute pulmonary oedema Mx
A-E --> AHF
1) Sit up. High flow O2
2) IV diamorphine 3mg + IV metoclopramide 10mg (careful in liver failure and COPD)
3) IV furosemide 40-80mg (larger dose in renal failure)
4) SL GTN spray x2 ( if SBP >100mmHg, use IV GTN)
5) further management:
- furosemide 40-80mg
- further nitrate infusion (maintain SBP >90)
- CPAP
164
Pulmonary oedema once stable Mx
- daily weight
- repeat CXR
- manage meds
- change to oral furosemide
- consider thiazide
- ACEi (LV EF <40%), BB (LV EF <35%), spironolactone
165
Causes of cardiogenic shock
```
MI
Arrhythmias
cardiac tamponade
PE
Tension pneumothorax
Myocarditis
Valve destruction
Aortic dissection
```
166
ECG of cardiogenic shock
electrical alternans
167
Cardiogenic shock S+S (triad)
Becks triad
- hypotension
- raised JVP
- muffled sounds
168
Ix/ Mx of cariogenic shock/ cardiac tamponade
- senior review
- pericardiocentesis
ECG, ABG, CXR, Echo
U+E, troponin, BNP, UO (catheterise)
consider CVP + arterial lines
Swan Gantz catheter / pulmonary artery catheter
169
Swan Gantz catheter / pulmonary artery catheter can measure
- RA and RV pressure
- PAWP
- filling LA pressure
- Cardiac output
170
Normal central venous pressure
0-6mmHg
171
Complications of CV line
NOW
- pneumothorax, arrhythmia, failure, air embolus, bleeding, perforation
Early
- bruise, infection, occlusion
Late
- thrombosis, Horners, phrenic nerve damage, sepsis, venous stenosis
172
broad complex tachycardias
VT including Torsades de pointes
173
narrow complex tachycardias
sinus tachycardia
SVT
AF/ flutter
atrial tachycardia
174
Mx of VF
non synchronised DC shock
175
Mx of VT (including TdP)
synchronised DC shock (synch to R waves)
Drugs
- amiodarone
- lidocaine
- procainamide
176
Mx of Torsades de points
Congenital - high dose beta blockers
Drug-induced - magnesium sulphate
177
Mx of broad complex tachycardias (stable, regular rhythm)
IV amiodarone 300mg + 900mg over 24h, central line
178
Mx of narrow complex tachycardias
vagal manoeuvres
IV adenosine 6mg, 12mg, 12mg
179
When to use adrenaline and how much
PEA/ asystole = immediately
VF/pVT = after 3 shocks
1mg adrenaline / 10ml 1 in 10,000 IV
180
Causes of bradycardia
- physiological
- cardiac e.g. post MI, sick sinus syndrome, aortic valve disease, cardiomyopathy, sarcoid
- non-cardiac: vasovagal, hyperkalaemia, hypothermia, raised ICP, hypothyroid
- drug induced e.g. BB, amiodarone, verapamil , diltiazem, digoxin
181
Bradycardia Mx
atropine 500mcg / 0.5mg IV
If no satisfactory response, do one of:
- repeat atropine every 3-5 min. Max = 6 doses (3mg)
- transcutaneous pacing (pads on chest giving small shocks) --> interventional radiology thread a catheter into the heart --> transvenous pacing
- isoprenaline 5mcg/ min IVI
- adrenaline 2-10mcg/ min IVI
