Cardio Flashcards
What is the QRISK score used for?
The QRISK score estimates the percentage risk that a patient will have a stroke or myocardial infarction in the next 10 years.
QRISK > 10% what should patients be offered and what does?
Atorvastatin 20mg at night
Atorvastatin 20mg is offered as primary prevention to all patients with:
Chronic kidney disease (eGFR less than 60 ml/min/1.73 m2)
Type 1 diabetes for more than 10 years or are over 40 years
How do statins lower cholesterol?
reduce cholesterol production in the liver by inhibiting HMG space CoA reductase
Which blood test do you need to check after starting statins?
LFTs because they can cause a transient and mild rise in ALT and AST in the first week weeks of use
They usually do not need to be stopped if the rise is less than 3 times the upper limit of normal.
What are some side effects of statin use?
Myopathy
Rhabdomyolysis
Type two diabetes
Haemorrhagic strokes
At how many months do you need to check LFT levels after starting statins?
3 months and 12 months
What are some alternatives to statins to lower cholesterol?
Ezetimibe
PCSK9 inhibitors – evolocumab - this is a monoclonal antibody and given as a subcutaneous injection every 2 to 4 weeks
what are the four A’s of secondary prevention in cardiovascular disease?
Antiplatelet medication – aspirin, clopidogrel, and ticagrelor
Atorvastatin – 80mg
Atenolol – or bisoprolol
ACE inhibitor – ramipril
what is the preferred antiplatelet for patients with peripheral arterial disease and ischaemic stroke?
Clopidogrel
what is the inheritance pattern for familial hypercholesterolaemia?
Autosomal dominant
Which criteria can be used to make a clinical diagnosis for familial hypercholesterolaemia?
Simon Broom criteria
Dutch Lipid clinic network criteria
what are the three features of familial hypercholesterolaemia?
Family history of premature cardiovascular disease
Very high cholesterol – greater than 7.5 mmol/L
Tendon xanthomata
where are patients referred if they have stable angina?
Rapid access chest pain clinic
What medication can be used in cardiac stress testing?
Dobutamine
How long does GTN spray last?
5 mins
How many times can a patient administer GTN spray before they should call the ambulance?
Three times, with five minute breaks in between each dose
what are the key side effects of GTN spray?
Headaches and dizziness caused by vasodilation
If symptoms are not relieved by GTN spray, what are the first line long-term medical options?
Beta blocker – bisoprolol
Calcium channel blocker – diltiazem or verapamil
Which patients are you not allowed to give calcium Channel blockers to??
Patient with heart failure with reduced ejection fraction
what other options may be considered for long-term symptomatic relief of stable angina?
Long-acting nitrates - isosorbide mononitrate
Nicorandil
Ivabradine
Ranolazine
which three vessels can be used in a coronary artery bypass graph as the graft vessels?
Saphenous vein
Internal thoracic artery
Radial artery
what is cardiac syndrome X?
It occurs in perimenopausal or postmenopausal. In women and may involve microvascular dysfunction, causing increased sensitivity of the myocardium, thereby lowering the pain threshold. This is a diagnosis of exclusion and treatment options are similar to medical management of angina.
What does the right coronary artery supply?
Right atrium
Right ventricle
Inferior aspect of the left ventricle
Posterior septal area
what does the left circumflex artery supply?
Left atrium
Posterior aspect of the left ventricle
what does the left anterior descending artery supply?
Anterior aspect of the left ventricle
Anterior aspect of the septum
What new finding is always pathological in an ECG
New left bundle branch block
what do pathological key waves suggest?
Deep infection involving the full thickness of the heart muscle
How long after an MI, will Q-waves appear on an ECG
After six or more hours, following onset of symptoms
when should troponins be measured?
At baseline and three hours after the onset of symptoms
what are some alternative causes of raised troponins?
Chronic kidney disease
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism
what ECG changes might you find in unstable angina or NSTEMI?
ST depression
Tea wave inversion
what should be prescribed with morphine during the initial management of a myocardial infarction?
An anti-emetic such as metoclopramide
What are the typical antiplatelet medications given prior to PCI?
Aspirin and Prasugrel
what are the typical fibrinolytic agents given in thrombolysis for myocardial infarction?
Streptokinase
Alteplase
Tenecteplase
what dose of ticagrelor and aspirin should be given in the management of an NSTEMI or STEMI?
Ticagrelor 180mg
Aspirin 300mg
when should an alternative to ticagrelor be considered in the management of myocardial infarction?
Clopidogrel if high bleeding risk
Prasugrel if having angiography
when should fondaparinux not be prescribed?
If high, bleeding risk or immediate angiography
What does the GRACE score predict?
It gives a six month probability of death after having an NSTEMI
3% or less is considered low risk
Above 3% is considered medium to high risk —> angiography within 72 hrs
What medications are used for secondary prevention after a myocardial infarction?
Aspirin 75mg once daily indefinitely
Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril)
Atenolol (or usually bisoprolol)
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
Which two medications carry a high risk of hyperkalaemia when used together?
ACE, inhibitors or angiotensin receptor blocker
And
Aldosterone antagonists
E.g. spironolactone or eplerenone plus ACE/ARB
What are the possible complications of myocardial infarction – using the pneumonic Darth Vader?
Death
Arrhythmia
Rupture (free ventricular wall/ ventricular septum/ papillary muscles)
Tamponade
Heart failure (acute or chronic)
Valve disease
Aneurysm of ventricle
Dressler’s syndrome
thromboEmbolism (mural thrombus)
Recurrence/ mitral Regurgitation
What are some signs of Dressler’s syndrome?
Pericardial rub
Low-grade fever
Pleuritic chest pain
Pericardial effusion
Pericardial tamponade
Widespread ST elevation
T wave inversion
Raised CRP and ESR
