Cardio Flashcards
ACS Causes
plaque rupture, thrombus, inflammation
emboli, coronary spasm, vasculitis
ACS Risk Factors
age, F, FH of IHD
smoking, DM, obesity, sedentary lifestyle, hypertension, hyperlipidaemia
ACS S+S
acute central chest pain >20min, palpitations, syncope, dyspnoea, nausea, sweatiness
pallor, anxiety, weakness, change in BP and HR
signs of heart failure: inc JVP, basal creps
added heart sounds
pansystolic murmur
low grade fever
peripheral oedema, pericardial friction rub
ACS Ix
Troponin
ECG
CXR
Echo
Causes of Raised Trop
ACS, pericarditis, myocarditis, ventricular strain, tachyarrhythmias
PE, SAH, burns, sepsis, renal failure
ACS Rx
Drugs:
chest pain = GTN, morphine
antiplatelets = apsirin + clopidogrel >12m
anticoag = fondaparinux until discharge
beta-blocker or Ca blocker = bisoprolol, diltiazem, verapamil
ACE-I for LV dysfunction, DM, hypertension
statin
PCI:
- STEMI and high risk NSTEMI = immediate/<24hr
- intermediate NSTEMI = angiography <3d
- if multi vessel disease = CABG
Tests:
echo to assess LV function
Modify RFs
- diet high in oily fish, fruit, veg, high in fibre low in sat. fats
- no smoking, more exercise, less stress
Aortic Disesction S+S
sudden, tearing chest pain, radiation to back radio-radio delay aortic valve incompetence inferior MI cardiac arrest
carotids: hemiplegia
anterior spinal artery: paraplegia
renal artery: anuria
acute limb ischaemia
Aortic Dissection Rx
crossmatch 10U blood ECG CXR CT or TOE ITU
Hypotensives: keep systolic 100mg
short half life beta blockers: labetalol
Ca channel blockers
Arrhythmias Causes
IHD, dilatation from regurg, cardiomyopathy, pericarditis, myocarditis, aberrant conduction
caffeine, smoking, alcohol, pneumonia, phaeo
drugs: beta 2 agonists, digoxin, L-dopa, tricyclics
metabolic imbalance: K, Mg, Ca, hypoxia, hypercapnia, acidosis, thyroid
Arrhythmias S+S
chest pain, palpitations, syncope, hypotension, pulmonary oedema
When to give ICD
ventricular arrhythmias post-MI or congenital arrhythmia
Sudden cardiac death causes
WPW
LQTS = channelopathies, prolonged repolarisation, predisposes torsades pointes
ARVC = epsilon wave, T inversion, broad QRS in ant.
Brugada = Na channelopathy, coved ST elevation in ant/, precipitated by fever, meds, electrolyte imbalances, ischaemia
Sick sinus syndrome
SAN fibrosis in elderly
sinus bradycardia + tachyarrhythmias: AF, supraventricular tachy
Rx:
thromboembolism prophylaxis if AF
pacemaker
rate slowing meds
Causes of AF
heart failure, hypertension, IHD, mitral valve disease
PE, pneumonia, hyperthyroidism
dec K, dec Mg
caffeine, alcohol, post-op
AF S+S
chest pain, dyspnoea, palpitations, faintness
irregularly irregular pulse
signs of LVH
AF signs on echo
L atrial enlargement, mitral valve disease, poor LV function
Acute AF Rx
adverse signs present: ABCDE, DC cardioversion, amiodarone
if AF started <48hr ago: rate and rhythm control
= DC cardiovert, flecainide, amiodarone + heparin
if AF started >48hr: rate control = bisoprolol or diltiazem
- to rhythm control, must be anticoagulated for >3wks first
Chronic AF Rx
Rate Control and Anticoagulate
(rhythm control only if symptomatic, CCF, younger, [resenting for 1st time with lone AF, persisting AF from treated cause)
Rate control
- 1st: Beta-blocker or rate limiting Ca channel blocker
- If fail, add digoxin
- If fail, add amiodarone
- Digoxin as monotherapy only in sedentary patients
- DO Not give beta-blockers with verapamil
- Aim HR<90bpm at rest and 200-age bpm on exertion
Rhythm control
- Elective DC cardioversion
○ Do echo first to check for intracardiac thrombi
○ If inc risk of cardioversion failure (past failure or recurrence) give amiodarone for 4wks before procedure and 12m after
- Elective pharmacological cardioversion
○ Flecainide
- Refractory cases: AVN ablation with pacing, pulmonary vein ablation, maze procedure
Paroxysmal AF (infrequent AF, BP>100mmHg systolic, no past LV dysfunction)
- Pill in pocket: sotalol or flecainide PRN - Anticoagulate - Ablation if symptomatic or frequent episodes
AF Anticoagulation
Heparin
DOAC or warfarin if high risk of emboli/long term
CHA2DS20VASc score = assess embolic stroke risk
CHA2DS20VASc score
Assesses risk of embolic stroke
Congestive cardiac failure (1) Hypertension (1) Age 65-74 (1) Age >74 (2) DM (1) Previous stroke/TIA/thromboembolism (2) Vascular disease (1) Sex (1 if F) - Anticoagulate if score >0 in M, >1 in F
HAS-BLED score
Assesses risk of anticoagulation
1 point for each: Labile INR Age >65 Meds that predispose bleeding (NSAIDs, antiplatelets) Alcohol abuse Uncontrolled hypertension Hs of major bleeding Renal disease Liver disease Stroke history
Risk Factors for IE
○ Past IE or rheumatic fever ○ IVDU ○ Damaged or replaced valve ○ PPM or ICD ○ Structural congenital heart disease (but not simple ASD, fully repaired VSD, patent ductus) ○ Hypertrophic cardiomyopathy
Causes IE
- Acute = normal valves, may present with acute heart failure + emboli
○ Commonest: Staph aureus
○ RFs: skin breaches (dermatitis, IV lines, wounds), renal failure, immunosuppression, DM - Subacute = abnormal valves
○ RFs: aortic and mitral valve disease, tricuspid valves in IV drug users, coarctation, patent ductus arteriosus, VSD, prosthetic valves
○ Prosthetic valves endocarditis may be early (within 60d of surgery, usually Staph epidermis, poor prognosis) or late
Bacteria
- Strep viridans (subacute)
- Staph aureus
- Strep bovis (need colonoscopy, tumour likely portal of entry)
- Enterococci
- Coxiella burnetti
- Rare: HACEK Gram -ve - (Haemophilus, Actinobacillus, Cardiobacerium, Eikenella, Kingella), diphtheroids, chlamydia
Fungi - Candida, aspergillus, histoplasma - Usually IV drug abusers, immunocompromised, prosthetic valves - Need surgical management Other - SLE = Libman-Sacks endocarditis - Malignancy
IE S+S
- Septic signs: fever, rigors, night sweats, malaise, weight loss, anaemia, splenomegaly, clubbing
- Cardiac lesions: new murmur, change in pre-existing murmur
○ vegetations can cause valve destruction, severe regurgitation, valve obstruction
○ Aortic root abscess causes prolonged PR interval, can cause AV block
○ LVF common cause of death - Immune complex deposition: vasculitis, microscopic haematuria, glomerulonephritis, AKI, Roth spots (boat shaped retinal haemorrhage with pale centre), splinter haemorrhages, Osler’s nodes
- Embolic: emboli causing abscesses in any organ, Janeway lesions
IE Duke’s Criteria
2 major OR 1 major and 3 minor OR 5 minor
Major: Positive blood culture - typical organism in 2 cultures - 3 positive cultures >12hr apart - positive for Coxiella Endocardium - positive ECHO: abscess, vegetations, pseudoaneurysm, dehiscence of prosthetic - abnormal activity around prosthetic on PET/CT - paravalvular lesions on CT
Minor
- fever >38
- predisposition
- vascular phenomena
- immunological phenomena
- positive blood culture that does not meet major
IE Rx
Blind native or prosthetic >1y = ampicillin, flucloxacillin, gentamicin
Blind prosthetic = vancomycin, gentamicin, rifampicin
Staph native = flucloxacillin
Staph prosthetic = flucloxacillin, rifampicin, gentamicin
Strep = benzylpenicillin +/- gentamicin
Enterococci = amoxicillin, gentamicin
HACEK = ceftriaxone
Candida = amphotericin Aspergillus = voriconazole
