Cardio 3 Flashcards
anti-coags and their antidote
Dabigatran-
Dabigatran- Idarucizumab
post-MI what suggests a left ventricular aneurysm?
pulmonary oedema- bibasal crackles.
S3 heart sound suggests the left ventricle is larger than normal (as S3 represents the sloshing of blood into a large ventricle during diastole)
S4 heart sound suggest that the left ventricle is stiffer than normal (as S4 represents the forceful atrial push of blood against a hard ventricular wall)
left ventricular aneurysm will cause persistent ST elevation in V1-6 on an ECG. This is because the fibrosis and dead tissue is not able to properly move as expected.
Wellen’s syndrome ECG
shows deeply inverted T-waves in leads V2-V3 (which may extend to V1-V6) with no or minimal ST-elevation and preserved R wave progression.
biphasic or deep T wave inversion in V2-3
minimal ST elevation
no Q waves
high-grade stenosis in the left anterior descending coronary artery.
Kussmaul’s sign constrictive pericarditis
JVP will rise on inspiration;
NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
What does a pacemaker look like on ECG?
- A long straight line vertical going over all the leads, it precedes the QRS complex
peri-arrest management bradycardia + haem unstable
1
2 can repeat step 1. up until…
3
4
- Atropine Atropine (500mcg IV)
- Can repeat up to a max of 3mg
- Trans-cutaneous pacing
- Isoprenalne/ adrenaline infusion titrated to response
Clinically how can you differentiate Rheumatic fever from IE?
Rhemuatic (4)
Rheumatic fever:
- Recent sore throat
- rash (annular macules)
- Arthritis
- Murmur
(usually strep! think sore throat!)
IE
- Obvs fever and new murmur but more likley to be IV drug user/ staph infection from skin
- Rashes are less common, Skin changes are more nail changes splinter haemorrhages, roth spots, osler nodes and janeway lesions
What do these meand and condition
Soft S1 (2 condition)
Absent S2 (1 condition)
Loud P2
S3 ( 1 condition but normal if…)
S4 (3 condition)
Soft S1- prolonged PR, severe mitral stenosis or mitral regurgitation
Absent S2- severe aortic stenosis
Loud P2- early sign of pulmonary hypertension (right sided HF)
S3 - Rapid ventricular filling- LV failure. Normal if < 30yo
S4- atrial contraction against a stiff ventricle- hypertrophic obstructive cardiomyopathy and hypertension, aortic stenosis
What should you do If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI (hours after)
urgent coronary artery bypass graft (CABG) is recommended
because PCI has failed
Post MI complications what is the STEM that gives it away
Pericarditis (3)
Dresslers (when, 4 key signs, treatment)
Left ventricle Aneurysm (ECG, risk of…, treatment)
Left ventricular free wall rupture (when, TRIAD! treatment)
VSD (when, 2 features, echo to differentiate between it and…, management)
Acute mitral regurg (what territory MI increased likelihood and why, 2 presentations, murmur, treatment 2)
Pericarditis-
- in first 48 hours is common
- pain worse on lying flat, better leaning forward
-may auscultate muffled heart sounds if effusion, echo to confirm
Dresslers (autoimmune ttack myocardium)
- 2-6 weeks after MI
- fever, pleuritic pain, pericardial effusion and increase ESR
- treat with NSAIDs
Left ventricle Aneurysm
- persistent ST elevation and left ventricular failure.
- Thrombus may form within the aneurysm increasing the risk of stroke
- Patients are therefore anticoagulated.
Left ventricular free wall rupture
- 1-2 weeks post-mi
- acute HF secondary to cardiac tamponde (muffled heart sounds, raised JVP, pulses paradoxicus- BP drop when breathing in)
- Urgent pericardiocentesis and thoracotomy
VSD
- first week
- heart failure associated with a pan-systolic murmur.
Acute mitral regurg
- Echo to rule out acute mitral regurg which presents similarly
- Urgent surgical correction is needed.
Acute mitral regurgitation
- More common with infero-posterior infarction and may be due to ischaemia or rupture of the papillary muscle
- Acute hypotension and pulmonary oedema
- early-to-mid systolic murmur
- treated with vasodilator therapy but often require emergency surgical repair.
What drug can cause cool peripheries?
Propranolol
Which betablocker can cause long QT syndrome?
Sotalol
Aortic stenosis common causes
< 65yo think-
> 65yo think -
younger patients < 65 years: bicuspid aortic valve
older patients > 65 years: calcification
What are the indications for treating stage 1 essential HTN?
(6)
- < 80yo (if 80+ dont bother!)
- Q-RISK > 10%
- Diabetes
- established coronary vascular disease
- Renal disease
- End organ failure damage
What do you look out for wolf-park white ECG?
(3)
- sloped QRS (delta wave)
- Short PR interval
- non-specific ST-T changes
non-shockable rhythm management
1.
2.
3.
4.
dont give…
- Commence CPR 30;2
- IV access if no interosseous give adrenaline 1mg - repeat every 3-5 mins
- 2 mins chest compress
- Repeat adrenaline at 3-5 mins
don’t give amiodarone in non-shockable!
name drugs which can lower INR in someone on warfarin
7!!
cytochrome p450 inducers!
drug metabolised quicker so has less effect
- carbemazapine, pheytoin
- barbiturates: phenobarbitone
- rifampicin
- St John’s Wort (depression mild herbal)
- chronic alcohol intake
- griseofulvin
- smoking (affects CYP1A2, reason why smokers require more aminophylline)
when starting ACEi it can cause a lucid drop in renal function but if too low can highlight what pathology?
significant renal impairment may occur if the patient has undiagnosed bilateral renal artery stenosis
management of cardiac tamponade
non-metastatic cause
metastatic cause (which is what cancer)
Non met = urgent pericardiocentesis
Met
= Percutaneous balloon pericardiotomy
Melanoma most common
others- lung, breast, haematological cancers
Acute HF management
1. first things first
3.
3.5- may have a role in…
main CI…
If severe hypotension this is trickyyyy….
- med
- med if 1. doesn’t work
- mechanical
- sit patient up!
- IV high dose furosamide or bumetanide (repeat CXR to see if improve)
- O2! target 94-98%
- 3.5- vaodilators not routinely used but nitrates may have a role if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease
the major side-effect/contraindication is hypotension
- resp failure/ not improvement then CPAP
hypo
- inotropic agents
e.g. dobutamine
if - severe left ventricular dysfunction who have potentially reversible cardiogenic shock - vasopressor agents
e.g. norepinephrine
- used if insufficient response to inotropes and evidence of end-organ hypoperfusion - mechanical
- intra-aortic balloon counterpulsation or ventricular assist devices
ALS guidlines
Shockable rhythm =
1
2
3
4
5
6
7. If PE suspected
Non-Shock-able rhythm =
1
2
3
Shockable rhythm =
1. Start compressions 30;2 whilst waiting for defib
2. Shock once (stacked if witnessed in cardiac centre)
3. adrenaline 1mg after 3rd shock - repeat 1mg every 3-5mins
5. amioderone 300mg after 3rd shock (lidocaine as sub-situate)
6. repeat amioderone 150mg after 5th
7. PE suspected- give thrombolysis ad continue CPR for 60-90mins
Non-Shock-able rhythm =
1.Compressions 30:2
2. Give adrenaline 1mg asap
3. Re-check after 2 mins
4. Repeat adrenaline every 3-5 mins?
Reversible causes for cardiac arrest 4H’s 4Ts
H- hypoxia
H- Hypothermia
H- Hyper K+, Hypo K+, Hypoglycaemia, acidaemia
H- Hypovolaemia
T- tension PTX
T- Thrombosis
T- Tamponade
T- Toxins
Loop Diuretics Adverse Affects
- Hypo K+, Na+, Mg2+
- Ototoxicty
- HYPOCALCAEMIA
- Renal Immpair (stop in AKI)
- Gout
- Hypergycaemia
Drug induced Ototoxicity
FAV Q&A
( + 2 more)
FAV. Q&A
F-furosamide
A- Aminoglycosides (gentamicin)
V- Vancomycin
Q- Quinolines
A- Aspirin
Also NSAIDs and cisplatin (chemo drugs)
CI (2) for statins
1
2- other meds
Dosages
- Primary prevention =
increase the dose if…
- Secondary prevention =
- Preg
- macrolides (e.g. erythromycin, clarithromycin) are an important interaction. Statins should be stopped until patients complete the course
Dosages
- Primary prevention = 20mg
increase the dose if… non-HDL >= 40%
- Secondary prevention = 80mg
What is
Pulses alternans
whats it seen in?
Kaussmauls sign
whats it seen in? (2*/6)
Pulses alternans- drop in BP on inspiration
- Cardiac tamponade
Kaussmauls sign- Rasied JVP on inpiration
- *Constrictive pericarditis
- *right-sided heart failure
- right-sided heart infarction
- tricuspid stenosis and massive pulmonary embolism.
What do you see on ECG in hypothermia?
*1.
2
3
4
*1. J waves (Osborne waves) - small hump at the end of the QRS complex
2. first degree heart block
3. long QT interval
4. atrial and ventricular arrhythmias
Hypothermia
- Vasoconstriction occurs and 2 hormones are released
Mild =
mod or severe =
Risk Factors (4/6)
- TSH
- ACTH
Mild = 32-35
mod or severe = < 32
- Homeless
- Elderly/ extremes of age
- Hypothyroidism
- impaired mental status
- substance misuse
- GA
Hypothermia
Investigations
Bedside
- Obs- Temp (probe where?)
-
-
Bloods
- FBC (2)
- Electrolyte
- ABG
-
- rectal or thermistor probs
- ECG: J waves, or acute ST elevation
- BM- stress hormones are increased and the body czn have more peripheral resisitcne to insulin
Bloods
- FBC- Hb and haematocrit can increase
- WCC and Plt low as sequested in spleen
- K+ HYPO
- Coagulation
- ABG
CXR
Hypothermia Management
Conservative/ Initial:
1
2
3
4. If don’t respond…
- should be ready for… in severe cases
- don’t use….
Initial
1. remove from cold + wet/cold clothing
2. warm by blankets
3. secure airway
4. If don’t respond to passive warming give warmed IV fluids or apply forced warm air
- be ready for CPR
IV drugs should be avoided as patient more likely to have drastic response to drugs
What Anti-hypertensive is CI in patients with renovascular disease? (bilateral renal artery stenosis)
ACE inhibitors
causes the creatinine to increase dramatically as a result of angiotensin II constricting the efferent arteriole, subsequently leading to dilatation of the efferent arteriole and reduced filtration.
Patients on warfarin undergoing surgery:
- Emergency =
- can wait 6 -8 hours =
emergency = four-factor prothrombin complex concentrate
6-8 hours= give 5 mg vitamin K IV
both occasions stop warfarin
ECG seen in severe cardiac tamponade
Electrical alternans- alternation of QRS complex amplitude between beats.
Differenciate these classic post MI complications
Left ventricular free wall rupture
- when?
- presents with
Ventricular septal defect
- when?
- presents with (2)
- do….
Acute mitral regurg
- when?
- MI where?
Presents (3)
need…
Left ventricular free wall rupture
- 1-2 weeks after
- presents with Cardiac tamponade: Muffled heart sounds, pulsus paradoxicus, raised JVP
Ventricular septal defect
- first week
- presents with pans-systolic mrumur and assoc. heart failure
- DO ECH TO RULE OUT ACUTE MITRAL REGURG!
Acute mitral regurg
- first week
presents with:
- Inferio-posterior infarction- therefore PAPILLARY muscle rupture
1. Acute hypotension
2. Pul oedema
3. early-to-mid systolic murmur
- need emergecny surgery
Amyloidosis seen in patient s wtih mulptiple myeloma have what cardiomyopathy?
restrictive cardiomyopathy- Protein deposition in the myocardium
Management of NSTEMI
- already given Asprinin loading dose, GTN, O2 if needed, +/- morphone etc..
If haem unstable:
If stable:
1.
2.
-
-
3. Further drugs for PCI
- everyone gets…
Antiplatelet:
- not taking anticoag =
- taking anti-coag =
- Conservtive STEMI Further anti-platelet =
anti-platelet =
If haem unstable:
- Immediate coronary angio and PCI
If stable:
- Fondiparinux
- GRACE score:
- > 3% high risk next 6 month mortality = coronary angio < 72hrs
- < 3% consider coronary angio - Further dru gs for PCI
- everyone gets… unfractionated heparin
Antiplatelet:
- not taking anticoag = prasugrel or ticagrelor
- taking anti-coag = clopidogrel - Clopidogrel if high bleed risk
Tecagralor if not high bleed risk
- Clopidogrel if high bleed risk
Common SE of thiazides
1. Electrolytes
2.
3
4
5
6
Rare SE of thiazides
1
2
3
4
Common
- Hyper GLUC, Glucose, Urea, Lactate, Ca2+
- Hypo Na+, K+, Mg2+
- Gout
- Impotence
- Postural hypotension
- Dehydration
Rare
1- pancreatitis
2- agranulocytosis
3- photosensitive rash
4- thrombocytopaenia
In broad complex tachycardias, which classic cardio drug is CI and why?
verapamil
can precipitate marked haemodynamic deterioration, ventricular fibrillation (VF), and cardiac arrest.
