Cardio Flashcards
Mx of VT/VF
defib!
if awake, anaesthetist GA/midazolam then defib
if cant have GA, amiodarone IV +/- BB
symptoms of VF
syncope/ LOC
symptoms of VT
palpitations
SOB
syncope/pre-syncope
chest pain
causes of VT/VF
MI drugs LV impairment electrolytes channelopathies [long QT/Brugada] HCM
if Pt went into VT/VF due to MI, recurrence not v likely unless another MI.
If cause is still there e.g. HCM, how would you Mx?
amiodarone/ BB
ICD [internal cardiac defib]
[maybe ablation]
VT ECG findings
broad complex
regular
VF ECG findings
broad complex
irregular
Atrial flutter ECG finding
saw tooth
regular
SVT ECG findings
narrow complex
SVT sx
palpitations
Mx of SVT
vagal manoeuvres [syringe + carotid massage]
adenosine 6mg, then try 12mg
verapamil
if compromised, dc cardioversion
long-term - BB, flecainide, CCB, (ablation)
causes of AF
age big LA HF mitral disease hyperthyroid HtN MI > LV damage
tool to decide whether to anticoagulate someone with AF & score to anticoag
CHADS2VASC
>1 male, >2 female
chronic AF Mx
warfarin/NOAC
metoprolol [/diltiazem/verapamil/amiodarone]
digoxin in sedentary
cardioversion +/- amiodarone, or flecainide
should the AVR lead on an ECG have a positive or negative tracing
-ve
how can you identify a patient is in sinus rhythm from an ECG
every QRS must be preceded by a P wave [impulse originates from sinus node]
regular
rate 60-100
how do you work out the axis from an ECG
lead 1 and AVF should both be positive
what is sinus arrhythmia
slight shortening and lengthening with respiration, common in young
what causes a prolonged PR interval
heart block
what causes a short PR interval
accessory pathway e.g. WPW
how long should the PR interval be
3-5 small squares
describe the degrees of heart block
1st = constant prolonged PR 2nd = mobitz 1 lengthening, then drops 1. mobitz 2 constant prolonged then drops 1. 3rd = no relationship between P + QRS
mx of heart block
pacemaker
define heart block
disrupted passage of impulse through AVN
causes of 1st and 2nd degree heartblock
IHD/MI myocarditis athletes sick sinus syndrome drugs - digoxin, B blocker
what is sick sinus syndrome
dysfunctional sinus node (fibrosis)
can cause brady/tachycardia, AF, sinus pause
usually in the elderly
what causes a deep / pathological Q wave on ECG
MI
what causes a tall/big QRS on ECG
LV hypertrophy
what causes a long/ wide QRS
BBB [ventricle conduction problem]
sign of hyperkalaemia on ECG
tall tented T waves
what does T wave inversion on ECG indicate
infarct/ ischaemia [MI/IHD]
leads II, III, and AVF affected. Likely site of infarct + vessel
inferior. RCA
leads I, aVL, V4-6 affected. Likely site of infarct + vessel
lateral, circumflex
leads V1-3 affected. Likely site of infarct + vessel
anterioseptal, LAD
causes of long-QT on ECG
genetic predisposition [long-QT syndrome]
drugs: antipsychotics, macrolides
hypocalc/hypokal
what hormone abnormality might cause someone to go in and out of AF
hyperthyroidism
If the SAN gives HR of 100bpm, what slows the heart rate?
vagal tone (activity of the vagus nerve)
signs of ischaemia/ infarct on ECG
ST elevation/ depression
T wave inversion
Q waves
blood results/ biomarkers that might be seen in alcoholism
^GGT
low urea
^MCV
[^AST + ALT]
brugada on ecg
high J point
coved ST elevation
“saddleback” between ST + T wave
what causes brugada
autosomal dominant
causing Na+ chanelopathy
brugada Sx
syncope
sudden death
brugada Mx
internal defib
what causes a bifid P wave
1 atria hypertrophy e.g. mitral stenosis
in terms of the level of damage to myocardium, what do STEMI and NSTEMI represent
STEMI = transmural infarct NSTEMI = ischaemia/ not fully occluded vessel
likely troponin findings in STEMI, NSTEMI and unstable angina
stemi + nstemi = raised troponin
unstable angina not
immediate Tx of suspected MI
300mg aspirin morphine 5-10mg anti-emetic e.g. metoclopramide 10mg anticoag: bivalirudin/enoxaparin/fondaparinux [O2] [GTN] cath lab for PCI
consequences of MI
cardiac arrest
HF
VF
AF
long term Mx of ACS
aspirin + clopidogrel anticoag [fondaparinux] til discharge atorvastatin BB ACEi STOP SMOKING antiHTN, DM Mx
usual pathology in ACS
+ rarer causes
plaque rupture
thrombosis
inflammation
vasculitis
emboli
coronary spasm
causes of secondary hyperTN
cushings conn's disease phaeochromocytoma renal disease coarctation of the aorta drugs: NSAIDs, COCP, steroids
secondary causes of hyperlipidaemia
renal failure liver disease hypothyroidism diabetes excess alcohol biliary obstruction drugs: steroids, oestrogens
what is the side effect of statins, how would someone present and how would you investigate this?
myositis
muscle tenderness
CK
53 yr old hypertensive male Pt presents w/ sudden onset severe central CP, radiating to scapular.
BP low, sweaty, pale, early diastolic murmur, ECG shows LVH only. CXR widened mediastinum. Main differential?
aortic dissection
how do you confirm a suspected aortic dissection?
CT
how do you manage BP 80/40 in Pt with aortic disection/
conservatively /permissive hypoTN
until aorta repaired
provided Pt awake [cerebral perfusion] + bilateral radial pulses
68 yr old w/ dizzy spells increasing in frequency + w/ exertion.
Hx of angina, neuro exam normal, BP 110/70, sinus rhythm, systolic murmur which radiates across precordium + to carotids. Likely diagnosis?
aortic stenosis
Ix technique for suspected aortic stenosis
transthoracic echo
68 yr old ^SOB, palpitations, CP. HR 160, BP 88/40, sat 92, RR 22, creps. ECG shows AF. Acute Mx of the tachyarrhythmia?
electrical cardioversion [with sedation or GA]
ECG axis deviation - looking at lead I and lead II, what will you notice in left and right axis deviation
Left Leaving [away from each other]
Right axis deviation - pointing towards each other
on ECG, how many little squares should the PR interval and the QRS complex be
PR - 3-5 small squares
QRS - up to 3 small squares
what is the most common heart valve problem after MI?
mitral regurg
signs of bleeding in your patient
visible bleeding low BP tachycardia weak pulses cold/clammy peripheries prolonged cap refill not talking [=not perfusing brain]
what movement improves pericarditic pain
leaning forward
what would you notice in BP in aortic dissection?
unequal between L and R arms
causes of palpitations
arrhythmia: sinus tachy, ectopics, AF, SVT, VT
Thyrotoxicosis
Anxiety
Phaeochromocytoma
when do you see a J wave on ECG
hypothermia
SAH
hypercalcaemia
causes of sinus bradycardia
fitness vasovagal sick sinus syndrome drugs: BB, digox, amiod hypothyroid hypothermia ^ICP cholestasis
common causes of AF
IHD/MI HF HTN thyrotox alcohol obesity
causes of 3rd degree heart block
IHD/MI idiopathic fibrosis congenital aortic valve calcification cardiac trauma/ surg digoxin toxicity infiltration: abscess, granuloma, tumour, parasite
what is prinzmetals angina?
coronary spasm
causes of T wave inversion
many including ischemia, BBB, hypertrophy, PE
PE ECG changes
sinus tachy
RBBB
RV strain [R axis dev, dominant R wave, T wave inv/ ST dep in V1/V2]
(SIQIIITIII)
hyperkal on ECG
tall tented T waves
wide QRS
absent P
‘sine wave’ appearance
hypokal on ECG
small flattened T waves
prominent U waves
peaked P waves
hypercalc on ECG
short QT
hypocalc on ecg
long QT
small T waves
what are bifascicular and trifascicular block
bi = RBBB + left bundle hemi block
manifests as axis deviation
tri = bi + 1st degree heart block
define heart failure
cardiac output inadequate to meet body’s requirements
describe the diff between systolic and diastolic HF
inability of ventricle to contract vs inability to relax/fill
causes of systolic HF
MI
cardiomyopathy
IHD
causes of diastolic HF
constrictive pericarditis restrictive cardiomyopathy ventricular hypertrophy tamponade obesity
Sx of LV HF
dyspnoea poor exercise tolerance fatigue orthopnoea paroxysmal nocturnal dyspnoea nocturnal cough pink frothy sputum wheeze [cardiac asthma] nocturia cold peripheries weight loss
casues of RV HF
LVF
pulm stenosis
lung disease [cor pulm]
Sx of RV HF
peripheral oedema ascites nausea anorexia facial engorgment epistaxis
when RV HF and LV HF occur together this is called
CCF
what criteria could you use to diagnose CCF?
framingham
what classificaiton system can you use to assess severity in HF
new york classification of HF
Ix a pt with suspected HF
ECG
BNP
echo
CXR
FBC, U+E
briefly outline the new york classification of HF
I = present, no undue SOB II = comfortable @rest, activity =SOB III = limited by SOB from less than ordinary activity IV = SOB @rest
CXR features of heart failure
alveolar oedema [bat wings] kerley B lines [interstitial oedema] cardiomegaly dilated vessels effusion
Mx of acute HF
sit up high flow O2 IF low sats ECG -> treat any arrhythmia [AF] diamorphine furosemide GTN [only BP>90] nitrate infusion [BP>100] consider CPAP
causes of severe pulm oedema
MI/IHD arrhythmia valve disease malig HTN ARDS fluid overload neurogenic [head injury]
differentials for severe pulm oedema
asthma/COPD
penumonia
Sx of severe pulm oedema
dyspnoea
orthopnoea
pink frothy sputum
signs in severe pulm oed
distressed ^RR ^HR sweaty, pale wheeze pink frothy sputum pulsus alternans ^JVP fine lung crackles triple/gallop rhythm
Ix in acute pulm oed
CXR ECG [MI/arrhyth] U+E trop ABG [echo, BNP]
lifestyle Mx points in chronic HF
stop smoking
stop alcohol
less salt
optimise weight and nutritoion
medical [non-lifestyle] mx of HF
treat cause [e.g. arrhyth]
treat any exac factors [anaemia]
BB ACEi/ARB diuretics [furos>spiro>thiazide] digox vasodilator [hydrazaline + isosorbide dinitrate]
avoid NSAID, verapamil
flu + pneumococcal vacc
pacemaker
LVAD
transplant
how would you manage an admitted pt with bad HF
IV diuretics opiates IV nitrates Na and fluid restict DVT proph
are left/ right heart murmurs best heard on inspiraiton or expiration?
Left heart lesions are louder in expiration,
right-sided lesions are louder on inspiration.
indications for temporary cardiac pacing
symptomatic brady, unresponsive to atropine
post MI in: 2nd/3rd degree HB, bi/trifascicular block
drug resistant SVT/VT
[other: in cardiac surg in GA electrophysiological studies drug overdose -BB/digox/verapamil]
indications for permanent pacemaker
3rd degree HB, mobitz II post MI persistent HB symptomatic brady e.g. sick sinus synd HF drug resistant tachyarrhythmia
long QT syndromes put the patient into what ventricular arrhythmia?
torsades de pointes
pt presents with Hx of passing out. ECG shows coved ST elevation. He says he is concerned as his grandad and uncle had similar episodes and both died very suddenly of cardiac arrest of unknown cause.
Diagnosis?
brugada
why dont you give diltiazem/verapamil with BB?
risk of severe bradycardia [+/- LVF]
- what is malignant HTN?
- give some symptoms and signs
- what are some emergency complications
- rapid rise in BP leading to vascular damage
- headache, [visual disturbance]
retinal haemorrhages and exudates, [papilloedema] - AKI, encephalopathy, HF
give 4 casues of secondary HTN
renal disease [glom neph, PAN, SSc, pyelo, PKD, vasc]
cushings, conns, phaeo, acroM, ^PTism
coarctation
preg
steroids, MAOI, OCP
findings in HTNive retinopathy
tortuous arteries with thick shiny walls [silver/copper wiring] AV nipping flame haemorrhages cotton wool spots papilloedema
Mx of hypertensive encephalopathy
labetalol
Mx of prinzmetals angina
GTN correct low Mg stop smoking avoid triggers such as recreational drugs CCB \+/- long acting nitrate
describe the pathophysiology behind rheumatic fever
group A beta haemolytic strep pharyngeal infection leads to antibody production. Antibodies mistakenly react with valve tissue.
2-4 weeks later
give some clinical features of rheumatic fever
recent strep infection
fever
tachy murmur [mitral + aortic regurg] pericardial rub CCF ccardiomegaly conduction defects
arthritis
nodules
erythema marginatum
[chorea]
Mx of rheumatic fever
ben pen stat then phenoxymethylpenicillin analgesia [aspirin/NSAID] [pred] [haloperidol/diazapam for chorea]
using 5 words max, explain the pathology behind ACS
plaque rupture, thrombosis, imflammation
other than plaque rupture, thrombosis, imflammation… what other pathologies can cause ACS?
emboli, coronary spasm, vasculitis
unstable angina vs MI - what will troponin show?
MI = trop release
unstable angina does not
ACS non-modifiable risk factors. [3]
age
male
FH [MI in 1st deg relative <55]
ACS modifiable risk factors - list 4
smoking HTN DM ^lipidaemia obesity sedentary cocaine
diagnostic factors for ACS
new ischaemic ECG changes e.g. Q waves
trop ^
echo e.g. reduced wall movement
Sx ACS
acute central crushing CP
ass. w/ nausea, sweating, SOB
2 types of patient that have silent MIs [ACS without chest pain]
diabetics
elderly
how might a silent MI present
post op hypoTN or oliguria vomiting syncope pulm oedema acute confusion
signs in ACS
pallor sweaty distress/anxious tachy or bradycardia BP hyper or hypoTN 4th heart sound
HF: ^JVP, lung crackles, 3rd HS
pansystolic murmur [VSD/ pap muscle dysfn/rupture]
low grade fever
later: pericardial friction rub, peripheral oedema
STEMI ECG changes a) within hrs, and b) over hrs to days
a) hyperacute (tall) T waves, ST elevation, new LBBB
b) T-wave inversion, pathological Q waves
possible NSTEMI ECG findings
ST dep
T wave inv
non-spec changes
normal
bloods to take in MI/ ACS
FBC U+E glucose lipids cardiac enzymes
differentials for ACS/MI - give 4
stable angina pericarditis myocarditis takotsubo cardiomyopathy dissection PE GORD oesphageal spasm pneumothorax MSK pain pancreatitis
troponin levels can be high with what other causes of myocardial damage [other than ACS]
myocarditis
pericarditis
ventricular strain
tacharrhythmia
CPR
DC CV
ablation therapy
non-cardiac causes of raised trop
PE > RV strain
SAH, burns, sepsis, renal failure
STEMI includes ST elevation on ECG [or inf. w/ ST depression] and also what other ECG change?
new LBBB
immediate STEMI Mx
aspirin
PCI
ticagrelor
heparin
[if no PCI within 2 hrs - fibrinolysis]
management of chest pain in MI
GTN PRN
morphine
consider nitrate infusion
when managing chest pain in STEMI, if the patient has recently used sildenafil, which treatment would you omit?
nitrate infusion
if AF started more than 48 hours ago, what should you do before cardioversion, and why?
anticoagulate with DOAC[apixaban]/warf for 3 weeks, because intracardiac clots may have formed.
give 5 causes of AF
HF HTN IHD PE mitral valve disease pneumonia hyperthyroidism caffeine alcohol post-op low K+/Mg2+
rarer: lung CA, cardiomyopathy, sick sinus syndrome, constrictive pericarditis, endocarditis, haemochromatosis, sarcoid
AF may be asymptomatic but what sx can it cause?
faitness
palpitations
CP
dyspnoea
blood tests to order in AF
U+E
TFT
cardiac enzymes
Mx of patient in acute AF with shock/ MI/ syncope/HF
ABCDE + senior input
DCCV
amiodarone if unsusccessful
Mx of acute AF if pt is stable and AF started <48hrs ago
DCCV or flecainide or amiod
heparin
contraindications of using flecainide for new AF
structural heart disease e.g. scar tissue from MI
IHD
Mx of acute AF if Pt is stable and AF started >48 hrs ago or unclear time of onset
rate: bisoprolol or diltiazem
anticoag for at least 3 weeks before rhythm control!
managing chronic AF
rate control: BB or rate limiting CCB [verapamil], 2nd line digoxin, 3rd line amiod, [or sedentary - digoxin alone]
anticoag: CHADSVASC/ HASBLED then DOAC or warfarin
rhythm: DCCV/ amiod/ flecainide/ AVN ablation with pacing
in managing chronic AF, the main goals are rate control and anticoag. When would you also give rhythm control?
symptomatic CCF young 1st presentation with unprovoked AF from a corrected prescipitant eg electrolytes
how is paroxysmal AF managed? [terminates in <7 days but may recur]
sotalol or flecainide PRN
anticoag based on CHADSVASC - DOAC or warf
consider ablation if symptomatic or frequent
management of Atrial flutter
DCCV if haemodyn unstable
if stable: metoprolol/verpamil/diltiazem. [amiod]
heparin and warf
ablation
modifiable risk factors to advise ACS patients on
stop smoking
treat DM, HTN, ^lipidaemia
diet: ^oily fish, fruit n veg, fibre, low in sat fat
exercis/ cardiac rehab
MH
cardioprotective meds to start ACS pt on
aspirin + clopi 12 month [+PPI]
fondaparinux til discharge
BB [if contraindicated, verapamil/diltiazem]
ACEi/ARB if HTN/DM/LV dysfn
atorvastatin
eplerenone if post-MI HF
how soon after ACS can you drive?
what about after successful angioplasty?
what about lorries/buses?
1 week after angioplasty
4 weeks after ACS without successful angioplasty
stop driving + inform DVLA, may be able to restart after 6 weeks, depending on fn.al tests
jobs that cannot restart post-MI + jobs that have to do functional testing e.g. exercise testing
airline pilot + air traffic controller cannot restart
public service driver or HGV - exercise testing
list 5 complicaitons of MI
cardiac arrest cardiogenic shock HF Bradyarrhythmias [sinus brady, HB, BBB] tachyarrhythmias [sinus tachy, SVT, AF, flutter, VT, VF] Pericarditis Embolism tamponade mitral regurg ventricular septal defect Dressler's syndrome LV aneurysm
cardiac arrest advanced life support algorithm:
management if patient is unresponsive and not breathing normally
call resus team head tilt/chin lift/jaw thrust look/listen/feel for breathing if any doubt whether breathing is normal: start CPR 30:2 give adrenaline every 3-5 mins attach defibrillator
if VF or pulseless VT, 1 shock then resume CPR
amiodarone after 3 shocks
return to spontaneous circulation: ABCDE + treat cause
list the treatable reversible causes of cardiac arrest
Hypoxia
Hypovolaemia
Hypo/hyperkalaemia /metabolic
Hypothermia
Thrombosis [coronary/pulm]
Tension pneumothorax
Tamponade
Toxins
in a cardiac arrest situation, what are the non-shockable rhythms?
asystole
pulseless electrical activity
causes of cardiogenic shock?
MI arrhythmias PE tension pneumothorax tamponade myocarditis myocardial depression [drugs, hypoxia, acidosis, sepsis] valve destruction e.g. endocarditis aortic dissection
in a patient with cardiogenic shock, if you suspect an aortic dissection or PE as the cause, what other investigation may be indicated?
CT thorax
causes of cardiac tamponade
lung/breast CA pericarditis MI trauma bacteria e.g. TB coronary dissection in PCI, ruptured ventricle
which drugs should be stopped in 2nd and 3rd degree HB?
BB and CCB
should you insert pacemaker in the varying degrees of heart block, and BBB?
1st - no
2nd wenckeback [mobitz 1] - no, unless poorly tolerated
2nd [mobitz 2] - YES.
3rd - sometimes
trifascicular block should be paced
murmurs: soft first Heart sound means
mitral regurg
murmurs: gallop rhythm + 3rd HS
CCF
murmurs: loud 1st HS + opening snap in diastole
mitral stenosis
post MI pt w/ central CP relieved by sitting forward, ECG shows saddle shaped ST elevation. What is the diagnosis? investigation of choice? and management?
pericarditis
echo [to check for effusion]
NSAIDs
why does systemic embolism occur as a complication of MI? and how would you combat it?
arise from LV mural thrombus
consider warfarin for 3 months
describe kussmaul’s signs in cardiac tamponade
JVP rises during inspiration
give 3 possible indications for CABG
pt not suitable for PCI failed PCI multi-vessel disease left main stem disease multiple severe stenoses refractory angina
post-CABG:
a) medication you give patient to avoid graft embolism
b) driving considerations
c) how long before back to work
a) aspirin
b) 1 month, tell DVLA only if HGV driver
c) e.g. 3 months
cardiac and non-cardiac causes of arrhythmias
cardiac: IHD, cardiomyopathy, mitral stenosis >LA enlargement, pericarditis, myocarditis, abherrant conduction pathways
non cardiac:
alcohol, smoking, caffeine
pneumonia
drugs [BB, digox, L-dopa, tricyclics, doxorubicin]
metabolic [K+/Ca2+/Mg2+, hypoxia/hypercapnia, met acidosis, thyroid]
phaeo
what arrhythmias can be caused by sick sinus syndrome?
sinus brady sinus pause atrial tachy AF tachy brady syndrome
causes of myocarditis [50% are idiopathic]
viral [EBV/CMV/HSV/HIV], bacterial [staph/strep/TB]
drugs (cyclophos/mabs/pen/spiro)
toxins [cocaine/alc/lithium/lead]
immuno(SLE/sarcoid/rejection)
murmur in myocarditis
soft S1, S4 gallop
ECG changes in myocarditis
ST changes T wave inv atrial arrhythmias AV block QT prolongation
what bloods might be raised in myocarditis?
trop
CPR, ESR
viral serology
what may be seen on an echo in myocarditis
diastolic dysfn, regional wall abnormalities
following bloods, ecg, echo in myocarditis, what other 2 investigaions might you consider? 1 of which is the gold standard
cardiac MRI if stable
endomyocardial biopsy
Mx of myocarditis
suppoortive, treat cause, treat arrhythmias + HF
NSAID use is controv
avoid exercise - can precipitate arrhyth
what secondary problem can patients with myocarditis get? sometimes even yrs after apparent recoveyr
dilated cardiomyopathy
[and severe HF]
associations of dilated cardiomyopathy
alcohol, HTN chemo haemochrom viral infection autoimmune peri/postpartum thyrotoxicosis congenitkal x linked
signs in dilated cardiomyopathy
tachycardia low BP raised JVP displaced diffuse apex S3 gallop mitral/tricusp regurg pleural effusion oedema jaundice hepatomeg ascites
echo findings in dilated cardiomyopathy
globally dilated hypokinetic heart, low ej fraction
[look for MR/TR, LV mural thrombus]
management of dilated cardiomyopathy
bed rest, BB, diuretics, ACE-i, anticoag, bivent pacing, ICD, LVAD, transplant
define the pathology of HCM
LV outflow tract obstruction from asymmetric septal hypertrophy
leading cause of sudden cardiac death in the young
HCM
inheritance pattern of HCM
auto dom, or 50% sporadic
how does HCM present
sudden death angina dyspnoea palpitations syncope CCF
signs in HCM
jerky pulse a wave in JVP double apex beat systolic thrill at lower left sternal edge harsh ejection systolic murmur
ECG findings in HCM
LVH
progressive T-wave inv
deep q waves
AF, WPW, ventricular ectopics, VT
echo findings in HCM
assymetrical septal hypertrophy
small LV cavity with hypercontractile post wall
mid-systolic closure of aortic valve
systolic anterior movement of mitral valve
Mx of HCM
BB, verapamil for Sx amiod for arrhythmias anticoag for AF/emboli septal myomectomy in severe ICD
causes of restrictive cardiomyopathy [some is idiopathic]
amyloidosis haemochrom sarcoidosis scleroderma endomyocardial fibrosis
what signs and symptoms may a cardiac myxoma present with?
may mimic IE [fever, WL clubbing, ^ESR, emboli]
or mitral stenosis [left atrial obstruction, AF]
tumour ‘plop’ may be heard
describe pulsus paradoxus and give 3 causes
drop in pulse pressure on inspiration
cardiac tamponade, chronic sleep apnea, croup, and obstructive lung disease
new diagnosis of angina. what drugs will you prescribe
GTN spray and BB or CCB
[alternatives:
isosorbide mononitrate
ivabradine]
aspirin
consider ACEi
statin
(anti-HTN if required)
advice to patient about GTN
if they experience chest pain they should:
Stop what they are doing and rest.
Use their GTN spray or tablets as instructed.
Take a second dose after 5 minutes if the pain has not eased.
Call 999 for an ambulance if the pain has not eased 5 minutes after the second dose, or earlier if the pain is intensifying or the person is unwell.
mechanism of action for BB and CCB in angina
negatively chronotropic and inotropic
undisplaced tapping apex beat indicates
A tapping apex beat reflects the perception of the opening snap in mitral stenosis.
