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Finals RP > Cardio > Flashcards

Cardio Flashcards

1
Q

What is the cardinal symptom of Stable Angina?

What is typical and atypical Angina?

A

RESTRICTIVE chest pain upon EXERTION that gets better with REST/GTN.
Typical is all three present. Atypical is 2 or less.

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2
Q

What investigations for Stable Angina and what would they show?

A

ECG - ST depression
Bloods - check haem, lipids, glucose and TFTs for risk of angina.
Check LFTs for statin therapy benchmark, and U+Es for ACEi benchmark.

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3
Q

What is Gold standard Ix for Stable Angina?

A

CT Coronary Angiography

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4
Q

What is “Variant Angina” and what is the test for it?

A

Variant Angina is caused by artery spasm - Test is Angiography with Provocation.

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5
Q

What is the general management for Stable Angina?

A

1) Refer to cardiologist
2) Lifestyle Education - lower risk factors
3) Drugs
4) Surgery - particularly in left sided/ 3 vessel/ 2 vessel and diabetes disease

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6
Q

What drugs are used to treat Stable Angina?

A

Immediately: GTN spray - repeat once after 5 minutes, then wait 5 mins. If pain continues, call Ambulance.

Long term: Beta blocker (e.g. Bisoprolol 10mg) +- Calcium Channel blocker (e.g. Amlodipine 5mg)
- Increase dose of monotherapy before adding the other.

Secondary prevention: Beta blocker + Aspirin + Atorvastatin (or ezetimibe) + Acei

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7
Q

What makes up “Acute Coronary Syndrome”?

A

STEMI
NSTEMI
Unstable Angina

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8
Q

What are the general symptoms of ACS?

A

“Crushing chest pain” +- SOB, Nausea, Sweating
In women, atypical pain in neck and shoulders
In elderly, delirium

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9
Q

What investigations for ACS?

A 
ECG:
        - STEMI = ST elevation
        - NSTEMI = ST dep or T changes 
Troponin:
        - STEMI = increased
        - NSTEMI = increased

If no ST elevation, and low troponin but N-STEMI still suspected - take another trop at 1h then another at 3h - if Trop low at 3h, NSTEMI can be ruled out.

CXR
Bloods: FBC, U&Es and creatinine (for GRACE score)

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10
Q

What other things can cause raised Troponin?

A

Myocarditis, Aortic Dissection, Acute PE, Sepsis

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11
Q

What is the level Glucose should be at in an ACS event?

A

< 11 mmol

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12
Q

What is the immediate management for ACS in general?

A

1) ASPIRIN! 300mg stat
2) Start DAPT with:
- Prasugrel 60mg
or - Ticagrelol 180mg
or - Clopidogrel 300mg
3) Oxygen if O2 < 90%
4) GTN sublingual - not if systolic <90 or used P5 inhibitor for erectile dysfunction in last 48h
5) IV morphine
6) IV anti-emetic - Ondansetron 4mg/ Met 10mg x3/ Cyclizine 50mg x3

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13
Q

What is the specific management of a STEMI?

A

Remember DAPT (Aspirin + Prasugrel/Ticagrelol/Clopidogrel) for all ACS!

If symptom onset <12h + PCI available within 2h–> PCI

If symptom onset <12h + PCI not available within 2h –> Fibrinolysis + Anti-coagulation –> Repeat ECG within 90 mins: If there is still 50% ST elevation, transfer for Rescue PCI

NOTE: If fibrinolysing, start DAPT and anti-coagulation AFTER fibrinolysis

If symptom onset >12h + Ischaemia –> consider PCI
If symptom onset >12h + No ischaemia –> Just meds

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14
Q

What drugs can be used for fibrinolysis and anti-coagulation?

A
  • Tenecteplase - one time bolus of 50mg - most ideal outside of the hospital
  • Alteplase - 15mg bolus then IV infusion
  • Streptokinase - 1.5m units per hour
    ~Note: Do not give STK if given before, will have antibodies~

Anti-coagulation options:

  • Enoxaparin
  • Unfractionated Heparin
  • Fondaparinux - only if STK given
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15
Q

What are some contra-indications to Fibrinolysis?

A 
Neoplasm of the CNS
Pessure puncture in the last 24 hours - LP, biopsy 
Ischaemic stroke < 6m
Haemmorhagic stroke (not trauma) ever
Trauma/surgery <1m
GI bleed <1m
Blood disorders
Aortic dissection
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16
Q

What is the long-term management of a STEMI?

How does this differ from long-term management of NSTEMI?

A

Continue DAPT for 12 months
Beta Blocker or Calcium Channel Blocker
Ace-inhibitor
Atorvastatin

NSTEMI: Same, but no Ca-channel blocker

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17
Q

What is the immediate management of a N-STEMI?

A

Same drugs as STEMI:

  • DAPT with Aspirin + Prasugrel/Ticagrelol/Clopi
  • GTN
  • Oxygen if <90%
  • IV Morphine
  • IV anti-emetics

+ Fondaparinux 2.5mg for 8 days
+ Risk evaluate with GRACE score

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18
Q

Complications of ACS?

A 
DREAD
Death
Rupture of muscles
Edema
Arryhthmia/aneurysm
Dressler's Syndrome
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19
Q

What are the different types of muscle ruptures after a MI?

A

Ventricular Septal Rupture - associated w Anterior MI

Ventricular Free Wall Rupture - causes tamponade!

Papillary Muscle rupture - associated w Inferior MI

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20
Q

What is Dressler’s Syndrome and what is the management?

A

Dressler’s = complication 2-6 weeks post MI –> Pericarditis! Pain worse when lying down, better on sitting forward.

Mx: Aspirin and Colchicine

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21
Q

What kind of bradycardias can be caused by MI?

A

Bradycardia caused by Anterior MI = Pacing

Bradycardia caused my Infrior MI = self-limiting

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22
Q

What are the causes of Left sided heart failure?

A

Cardiomyopathies
Ischaemia
HTN

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23
Q

How does left sided HF cause pulmonary oedema?

A

Increased pressure in Pulmonary Vein = leaky vein = fluid in lungs = pulm. oedema

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24
Q

What are some signs of Left sided HF?

A

Displaced apex beat, S3, pulmonary oedema

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25
Q

What causes Right sided HF?

A

Main cause is left sided heart failure where the right side pumps blood to every resistant lungs –> initially hypertrophy then dilation of right ventricle.

Cor Pulmonale = Right sided HF caused by Lung disease such as COPD/PE.

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26
Q

What are some signs of Right sided HF?

A

Raised JVP, hepatomegaly, ascites, peripheral oedema

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27
Q

What is the difference between Systolic and Diastolic HF?

A

Systolic HF - Problem during systole where ventricles don’t contract properly - means not all of the blood is ejected out = reduced EF HF (<40%)

Diastolic HF - Problem during diastole where the ventricles are stiff and don’t fill properly - but the limited blood that comes in is adequately ejected out = preserved EF HF (>50%)

28
Q

What are come causes of Acute HF?

A

Iatrogenic! - too many fluids
Sepsis
MI

29
Q

What are the investigations for Heart Failure?

A 
Bloods 
B-type BNP
CXR
TTEcho
ECG
30
Q

What are the hallmarks on a CXR with heart failure?

A 
Alveolar oedema 
B lines (Kerley)
Cardiomegaly
Diversion of upper lobe
Effusion
31
Q

How does management differ with BNP hormone result in HF?

A

If BNP > 100, refer in 6 weeks

If BNP > 400, refer + Echo in 2 weeks

32
Q

What management for HF?

A

1) Lifestyle changes - restrict fluid and salt

33
Q

What are the stages of Hypertension?

A

Stage 1) Clinic >140/90
ABPM >135/80

Stage 2) Clinic 160/100
ABPM >150/95

Severe) Systolic >180
Diastolic >120

34
Q

Investigations for suspected hypertension?

A

Clinic BP:

  - If near 140/90, recheck within 5Y
  - If between 140/90 and 179/119, do home/ ABMP
  - If >180 or >120, check end organ damage immediately + maybe start anti-hypertensive + recheck in clinic in 7 days

ABPM: 2 readings each hour

Home monitoring: 2 readings each day - each reading must be an average of two taken one minute apart

35
Q

When should you start treatment for HTN?

A

Start treatment for all Stage 2 HTN (i.e. BP > 160/100)

Start treatment for Stage 1 if there is end organ damage, or CVD or Renal or Diabetes or >10% CVD risk

36
Q

What is the management algorithm for HTN?

A

1) If <55 / T2DM: ACEi/ARB
If >=55 / black: CCB

2) If <55 / T2DM: ACEi/ARB + CCB or Thiazide
If >=55 / black: CCB + ACEi/ARB or Thiazide

3) ACEi/ARB + CCB + Thiazide

4) If K <4.5, add Spironolactone
If K >4.5, add Alpha/Beta blocker

37
Q

What are some examples of each class of HTN drugs?

A

ACE inhibitors: Ramipril, Lisonopril, Enalapril - prils
ARBs: Candesartan, Losartan - tans

Calcium Channel blockers: Amlodipine, Nifedipine, + Verapamil, Diltiazem

Thiazide- like dieuretics: Indapamide, Chlorothiazide, Chlorthalidone

Potassium-sparing dieuretic: Spironolactone

Alpha-blockers: Doxazosin, Alfusozin, Labetolol

38
Q

What are the common causes of Pericarditis?

A

Post MI
Auto-immune: SLE
Viruses: Coxsackie, EBV, Echovirus
Drugs: Hydralazine, Isoniazid, Procainamide, Penicillin

39
Q

What is the cardinal symptom of Pericarditis?

A

Left sided chest pain that gets better when sitting up

40
Q

Investigations for Pericarditis?

A

ECG - ST Elevation/PR depression
Bloods: WBC, CRP, Troponin up
CXR/Echo

41
Q

Management for Pericarditis?

A
  • Aspirin / other NSAIDs - specifically Aspirin if post MI
  • Colchicine for 3 months - prevents recurrence
  • Restrict exercise until no symptoms + CRP normal (+ ECG and Echo normal in athletes)
  • Consider Prednisolone if definitely NON-infective

If bacterial pericarditis, consider antibiotics and pericardiocentesis

42
Q

What is Constrictive Pericarditis, what are the causes, and the cardinal signs?

A

Constrictive Pericarditis is thickening of the Pericardium, caused by surgery or MI, and it causes a KNOCK and KUSSMAUL sign

Kussmaul sign = JVP rises on inhalation

43
Q

What is Rheumatic Fever?

A

Autoimmune reaction to Group A strep infection

44
Q

What is the diagnostic criteria for Rheumatic Fever called?

A

Duckett-Jones criteria

45
Q

What is the Duckett-Jones criteria?

A 
5 Majors: Carey's Red Nodules ruined Arthur's Career
Carditis
Rash (Erythema Marginatum) 
Skin nodules 
Artheritis
Chorea
7 Minors: 
Fever >38.5
Raised ESR >60 
Raised CRP >3.0
Raised WCC
PR prolonged ECG
Joint pain
Previous RF
46
Q

Investigations for Rheumatic Fever?

A

Anti-ASO/DNAase antibodies
Strep A throat culture
Bloods: WCC, ESR, CRP, Cultures to rule out IE
ECG + Echo

47
Q

Management of Rheumatic Fever?

A

1) Reduce movement
2) Antibiotics for Group A strep –> Benzathine Benzylpenicillin 900mg IM
- If Arthritis, Aspirin 1000mg 4x day
- If Carditis leading to Heart failure, Furosemide
- If Chorea, usually self-limiting but if it’s really bad,
Sodium Valproate or Carbemazepin

48
Q

What is the drug for secondary prophylaxis of Rheumatic Fever?

A

Benzathine Benzylpenicillin given every 4 weeks

49
Q

How long should secondary prophylaxis of Rheumatic Fever last?

A

Benzathine Benzylpenicillin given every 4 weeks
No carditis and no valve disease = 5 y / until 18Y
Yes carditis and no valve disease = 10 y / until 21Y
Yes carditis and yes valve disease = 10 y / unitl 40Y

If valve surgery, forever

50
Q

What are the two main causative organisms for infective endocarditis?

A

Staph Aureus - if IVDU

Strep Viridians - if teeth (on previously damaged valves)

51
Q

What kind of endocarditis does SLE cause?

A

SLE causes LSE - Liebman Sach’s Encdocarditis

52
Q

What are some signs of IE?

A

Fever
Changing heart murmur

Emboli, causing:
Janeway lesions / Osler nodes = painful!
Roth spots
Splinter haemmorhages

53
Q

What criteria is used to diagnose Infective Endocarditis?

A

Duke’s criteria for Infective Endocarditis

54
Q

What is the Duke’s criteria?

A

Criteria for Infective Endocarditis.

2 Majors:
Positive blood cultures
Echo

5 minors:

  • Vascular involvement
  • Immunological involvement
  • Microbiological involvement
  • Fever >38.5
  • Pre-disposing factor to IE
55
Q

How many majors and minors do you need in Duke’s for a definitive IE diagnosis?

A

All 2 Majors - Blood cultures and Echo
1 Major + 3 minors
All 5 minors

56
Q

What are the investigations for IE?

A

Blood cultures - xthree 12 hours apart each
Echo - TTE
Bloods + urinanalysis - proteinuria and haematuria

57
Q

What is the management for IE?

A

If Native valves, vancomycin and gentamycin 4-6 weeks
If Prosthetic valves, vanco + gent + rifampicin 6 weeks
If Fungal, IV Flucytosine + oral flucanozole

Straight surgery if acute AR/MR w heart failure

58
Q

What is a wacky bacteria that can cause IE and what extra investigation should you do if it is that?

A

Strep gallolyticus can cause IE –> also do colonoscopy, as it’s associated with colorectal tumours

59
Q

What is the management for sinus bradycardia (<60bpm)?

A

Atropine 0.5mg IV - repeat every 5 mins until 3mg reached

or Isoprenaline
or Adrenaline

60
Q

What can bradycardia caused by Beta blockers be reversed by?

A

Glucagon

61
Q

What can bradycardia caused by Calcium channel blockers be reversed by?

A

Calcium or Adrenaline

62
Q

What is the management for Narrow Complex Tachycardia?

A

1) Vasovagal manouvers
2) IV Adenosine 6mg –> 12mg –> 18mg - remember saline flush with it

or Digoxin 500 mcg/30 mins
or Amiodarone 300 mg/1 hour
or Verapamil 10mg

63
Q

What can you not give to patients w a tachycardia who have asthma, and what is an alternative?

A

No Adenosine, give Verapamil instead

64
Q

What is the management for Broad Complex Tachycardia?

A

IV Amiodarone 300 mg/1hr (which is also an option in Narrow complex, but after Adenosine)
or lidocaine

65
Q

What is characteristic on an ECG of Wolff-Parkinson-White syndrome?

A

Delta waves

66
Q

What are some causes of AF?

A

AGE

Cardiac conditions:
HTN, atherosclerosis, congenital heart disease, cardiomyopathy, pericarditis

Others:
Hyperthyroidism, Pneumonia, asthma, COPD, lung cancer, T2DM, PE, CO poisoning

Finals RP (11 decks)

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