Cardio Flashcards
ACS mx
Morphine - if severe pain
Oxygen - If So2 <92%
Nitrates - useful if chest pain or HTN. Careful if hypotensive
Aspirin - 300mg
STEMI
- 2nd anti platelet: prasugral (clopidogrel if high bleeding risk)
- PCI - w/in 12hrs of onset and w/in 120 of potential fibrinolysis.
— Radial access preferred: give unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
- OR Fibrinolysis: w/in 12hrs
— give an antithrombin drug (heparin/ LMWH/ fondaparinux/ bivalirudin)
— repeat ECG after 60-90mins , if persistent STEMI-consider PCI
NSTEMI
- immediate coronary angiography (+/- PCI) if: GRACE score >3% OR clinically unstable. Give
- antithrombin treatment - fondaparinux if not immediate PCI. Heparin if PCI
- 2nd anti platelet: prasugral or ticagrelor if PCI/ ticagrelor if conservative (clopidogrel if high bleeding risk)
DAPT summary: aspirin &…
- prasugrel if primary PCI
- ticagrelor if medically managed
- Clopidogrel - if high bleed risk (e.g. oral anticoagulant)
———–
Secondary prevention
- ACEi
- Beta clocker
- Statin
- DAPT (aspirin lifelong, 2nd for 12 months)
STEMI criteria
clinical symptoms & ECG changes in >=2 or more contiguous leads:
V2-3 ST elevation:
>= 2.5mm in men under 40
>= 2mm in men over 40
>= 1.5mm in women
All other leads ST elevation:
>= 1mm
new LBBB
Pericarditis mx
(ECG: saddle shaped widespread STelevation, PR depression)
tx underlying cause
- idiopathic or viral: 1st-
- NSAIDS & colchicine combination
- avoid strenuous activity
ALS algorithm for cardiac arrest
chest compression - 30:2
Defib - a single shock for shockable rhythm (VF/pulseless VT) , then 2 mins CPR
- if cardiac arrest happens in cardiac monitored pt-> up to 3 successive shocks
Adrenaline 1mg
- ASAP for non-shockable
- shockable - start after 3rd shock, repeat every 3-5mins
Amiodernone (/ lidocaine)
- NOT in non-shockable
- shockable - 300mg after 3rd shock, repeat 150mg after 5 shocks
Thrombolytic drugs
- If PE suspected
- CPR should be continued for another 60-90mins if given
Reversible causes of cardiac arrest:
H
- hypoxia
- hyper/hypo-kalaemia , hypoglycaemia, hypocalcaemia, acidaaemia
- hypothermia
T
- Thrombosis
- tension pneumothorax
- Tamponade
- Toxins
Angina pectoris mx
(stable angina)
aspirin
statin
sublingual GTN
1st: B blocker OR CCB (rate-limiting: verapamil/ diltiazam)
2nd: increase to maximum tolerated dose
3rd: B blocker AND CCB (dihydropyridine - amlodipine)
If 3rd is contraindicated: a long-acting nitrate, ivabradine, nicorandil, ranolazine
4rth: only add 3rd drug whilst a patient is awaiting assessment for PCI or CABG
( Nitrate - isosorbide mononitrate - stop nitrate tolerance: asymmetric dosing interval w nitrate-free time of 10-14 hours)
Antiplatelet secondary prevention: MI, TIA, stroke, PAD
Acute coronary syndrome (medically treated) 1st: Aspirin (lifelong) & ticagrelor (12 months)
2nd: clopidogrel (lifelong)
Percutaneous coronary intervention
1st: Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)
2nd: clopidogrel (lifelong)
TIA/ ischemic stroke
1st: Clopidogrel (lifelong)
2nd: Aspirin (lifelong) & dipyridamole (lifelong)
Peripheral arterial disease
1st:Clopidogrel (lifelong)
2nd: Asprin (lifelong)
Features of Aortic stenosis
Clinical
- chest pain
- dyspnoea
- syncope / presyncope (e.g. exertional dizziness)
- ESM - radiates to carotids, decreased following valsalva
Features of severe aortic stenosis
- narrow pulse pressure
- slow rising pulse
- delayed ESM
- soft/absent S2
- S4
- thrill
- left ventricular hypertrophy or failure
Aortic stenosis mx
symptomatic or valvular gradient > 40 mmHg - valve repair
otherwise - observe
Choice of aortic valve replacement (AVR)
- surgical AVR - young, low/medium operative risk patients
- transcatheter AVR (TAVR) - high risk
Baloon valvuloplasty
- children with no aortic valve calcification
- adults w critical aortic stenosis not fit for AVR
Features of aortic regurgitation
early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
collapsing pulse
wide pulse pressure
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)
mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams
Arrhythmogenic right ventricular cardiomyopathy ECG
ECG abnormalities in V1-3, typically T wave inversion.
An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex
AF mx
haemodynamically unstable -> electrical cardioversion
rate control unless: coexistent heart failure / first onset AF / obvious reversible cause.
Rate
1st: beta blocker or rate-limiting calcium channel blocker (e.g. diltiazem)
2nd: combination of 2- betablocker/ diltiazem/ digoxin
Rhythm
- either symptom onset <48hrs or anti coagulated for 3weeks/ TOA to exclude a left atrial appendage thrombus
- electrical DC synchronised cardioversion/ flecainide or amiodarone
Anticoagulation if indicated by CHADSVasc
If not - Transthorasic echo to exclude valvular disease -> indication for anticoagulation
Orbit score
Anaemia
Age > 74
Bleeding hx
Renal impairment (GFR < 60)
anti platelet tx
cardiac enzymes to look for in MI?
troponin T and I
CK-MB is useful to look for reinfarction as it returns to normal after 2-3 days (troponin T remains elevated for up to 10 days)
(myoglobin is the first to rise)
Hypertrophic obstructive cardiomyopathy echo
Echo findings include MR, systolic anterior motion (SAM) of the anterior mitral valve and asymmetric septal hypertrophy
MR SAM ASH
chronic Heart failure dx
N-terminal pro-B-type natriuretic peptide (NT‑proBNP)
if high (>2000) -> specialist assessment (including transthoracic echocardiography) within 2 weeks
if raised (400-2000) -> “ “ within 6 weeks
chronic Heart failure mx
1st: ACE-inhibitor AND beta-blocker (bisoprolol, carvedilol, and nebivolol)
2nd: ++ aldosterone antagonist (spironolactone and eplerenone), heart failure with a reduced ejection fraction ++ SGLT-2 inhibitors
3rd (specialist) :
- ivabradine - sinus rhythm > 75/min and a left ventricular fraction < 35%
- sacubitril-valsartan - should be initiated following ACEi or ARB wash-out period
- digoxin
- hydralazine in combination with nitrate - esp in Afro-Caribbean patients
- cardiac resynchronisation therapy - widened QRS (e.g. left bundle branch block) complex on ECG
Other treatments
- annual influenza
- one off pneumococcal vaccine
DVLA & ACS
acute coronary syndrome- 4 weeks off driving, 1 week if successful PCI
Bifascicular block & trifasicular block
Bifascicular block
the combination of RBBB with
- … left axis deviation - left anterior hemiblock
- … right axis deviation - left posterior hemiblock
Trifascicular block
- features of bifascicular block as above + 1st-degree heart block
Acute Heart failure mx
Sit pts up
IV loop diuretics- e.g. furosemide or bumetanide
O2 - target sats: 94-98%
Vasodilators- not for everyone, if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease (CI in hypotension)
Patients with respiratory failure- CPAP
Hypotension/ cariogenic shock
- ionotropic agents - severe left ventricular dysfunction who have potentially reversible cardiogenic shock
- vasopressor agents - norepinephrine
- mechanical circulatory assistance - intra-aortic balloon counterpulsation or ventricular assist devices
continue regular CHF meds: beta-blockers should only be stopped if the patient has HR< 50 beats per minute, second or third degree atrioventricular block, or shock
S3 (third heart sound) in
caused by diastolic filling of the ventricle
considered normal if < 30 years old (may persist in women up to 50 years old)
heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
S4 (fourth heart sound)
may be heard in aortic stenosis, HOCM, hypertension
caused by atrial contraction against a stiff ventricle
therefore coincides with the P wave on ECG
in HOCM a double apical impulse may be felt as a result of a palpable S4
loud & quiet S1 sound causes
Causes of a loud S1
mitral stenosis
left-to-right shunts
short PR interval, atrial premature beats
hyperdynamic states
Causes of a quiet S1
mitral regurgitation
causes of loud, soft, split S2 sound
Causes of a loud S2
hypertension: systemic (loud A2) or pulmonary (loud P2)
hyperdynamic states
atrial septal defect without pulmonary hypertension
Causes of a soft S2
aortic stenosis
Causes of fixed split S2
atrial septal defect
Causes of a widely split S2
deep inspiration
RBBB
pulmonary stenosis
severe mitral regurgitation
stages of HTN
1
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
2
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
3
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg
HTN tx criteria
ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)
- treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater
- under 60 and an estimated 10-year risk below 10%
ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)
offer drug treatment regardless of age
HTN lifestyle advice
Lifestyle
- a low salt diet is recommended, aiming for less than 6g/day, ideally 3g/day.
- caffeine intake should be reduced
- stop smoking, drink less alcohol, eat a balanced diet rich in fruit and vegetables, exercise more, lose weight
Modified duke criteria
Infective endocarditis diagnosed if
pathological criteria positive, or
2 major criteria, or
1 major and 3 minor criteria, or
5 minor criteria
pathological
- Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery
Major
- Positive blood cultures (2 +ve typical organisms: viridian/ HACEK // two blood cultures taken > 12 hours or >3 +ve Staph aureus or Staph epidermidis // +ve serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci // molecular assays)
- Endocardial involvement (new valvular regurgitation // positive echocardiogram: oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves)
Minor
- predisposing heart condition or intravenous drug use
- microbiological evidence does not meet major criteria
- fever > 38ºC
- vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
- immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots
Native valve infective endocarditis emperical tx
native valve:
- Amoxicillin (+/- low-dose gentamicin)
(Flucloxacillin when staph identified. Benzylpenicillin when strep identified)
Pen allergic:
- vancomycin + low-dose gent
prosthetic valve
- vancomycin + rifampicin + low-dose gentamicin
Infective endocarditis indications for surgery
valvular incompetence
aortic access (lengthening PR interval)
resistant to antibiotic/ fungal infection
congestive cardiac failure
recurent emboli
JVP wave forms
a’ wave = atrial contraction
large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
absent if in atrial fibrillation
Cannon ‘a’ waves
caused by atrial contractions against a closed tricuspid valve
(complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing)
‘c’ wave
closure of tricuspid valve
not normally visible
‘v’ wave
due to passive filling of blood into the atrium against a closed tricuspid valve
giant v waves in tricuspid regurgitation
‘x’ descent = fall in atrial pressure during ventricular systole
‘y’ descent = opening of tricuspid valve
risk factors for asystole in Bradycardia
complete heart block with broad complex QRS
recent asystole
Mobitz type II AV block
ventricular pause > 3 seconds
Rheumatic fever dx criteria
2 major criteria
1 major with 2 minor criteria
Major
- J - polyarthritis
- O - carditis and valvulitis (eg, pancarditis)
- N - subcutaneous nodules
- E- erythema marginatum
- S- sydenham’s chorea (late)
Minor criteria
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval
Rheumatic fever mx
antibiotics: oral penicillin V
anti-inflammatories: NSAIDs are first-line
treatment of any complications that develop e.g. heart failure
Contraindications for statin
macrolides (e.g. erythromycin, clarithromycin) - stop stain till you finish course
pregnancy
