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Management Year 3 > Cardio > Flashcards

Cardio Flashcards

1
Q

What is the management plan for Acute Atrial Fibrillation?

A
  • If haemodynamically unstable e.g. angina, hypotension, rhythm control is needed
    • O2> U+Es> DC cardioversion (if <48hrs)
    • If unavailable, chemical cardioversion (IV amiodarone/ flecainide) - not flecainide in IHD
    • If >48hrs = 4 week anticoagulate then DC cardioversion
  • Then rate control
    • ​1st line - Bisoprolol or Verapamil
    • 2nd line - Digoxin or Amiodarone
  • Then anticoagulate, unless in sinus rhythm - DOAC preferred
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2
Q

What is the management plan for Chronic Atrial Fibrillation?

A
  • Initially, rate control (aim for <90bpm)
    • 1st line - bisoprolol or verapamil
    • 2nd line - consider digoxin followed by amiodarone
    • If HF consider starting with digoxin to avoid bradycardia
  • Anticoagulate with DOAC for 4 weeks before cardioversion
    • used to be warfarin
  • Rhythm Control - elective cardioversion
    • perform echo first, if risk of failure also pre-treat with bisoprolol or amiodarone
  • Paroxysmal AF - consider pill in pocket (flecainide)
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3
Q

What is the management plan for Cardiac Arrest?

A
  • If not in hospital setting start BLS immediately and consider precordial thump
  • Start ALS as soon as possible, assess rhythm
  • If VT or VF (Shockable rhythm)
    • Defibrillate once and continue CPR for 2 mins and reassess rhythm and shock again if no change
    • If no change after second shock administer 1mg IV adrenaline and repeat every 3-5 minutes
    • If shockable rhythm persists after 3rd shock, consider 300mg IV bolus amiodarone (once only)
  • If PEA or asystole (<60bpm) (non-shockable)
    • CPR for 2 mins and reassess rhythm
    • If no change administer 1mg IV adrenaline every 3-5 min
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4
Q

What is the management for Acute LV Failure?

A
  • IPOD MAN for acute HF (look up)
    • If patient is in cardiogenic shock (SBP <90) administer inotropes e.g. dobutamine
    • Treat pulmonary oedema
    • Sit the patient up with 60-100% oxygen therapy
      • consider CPAP if unresponding
    • Diamorphine - venodilate + anxiolytic
    • GTN infusion
    • IV furosemide
    • Monitor essential sats
  • Treat cause of LV failure e.g. MI, arrhythmias
  • Consider discontinuation of BB short term
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5
Q

What is the management for Chronic LV Failure?

A
  • Treat the cause e.g. HTN or Valvular disease
  • Treat excacerbating factors e.g. anaemia
  • 1st line - ACEi (ARB if contraindicated) +BB, lifestyle changes
    • Consider: diuretic, aldosterone antagonists, hydrazaline and isosorbide dinatrate, digoxin
  • 2nd line - hydrazaline and isosorbide dinatrate + BB mandatory next step if ACEi contraindicated
  • If ejection fraction <35% or severe symptoms consider Cardiac Resynchronisation Therapy
  • NOTE: Avoid NSAIDs and non-dihydropiridine CCB if HF
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6
Q

What is the management plan for DVT?

A
  • Anti-coagulate - warfarin or NOAC
    • LMWH used for 48hrs whilst warfarin reaches INR target range
    • Below knee DVT require 3 months of anti-coag + obs
    • Above knee DVT require 6 months of anti-coag + obs
  • IVC filter considered if Anti-coag is contraindicated or high risk of PE
  • Prevention - Graduated compression sockings
    • Mobilisation
    • Prophylactic heparin in high risk patients
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7
Q

What is the management plan for Chronic Heart Block?

A
  • First Degree or asymptomatic Mobitz I
    • Monitor degree of HB regularly
  • Symptomatic Mobitz I, normal Mobitz II and complete HB
    • 1st Line - Condition specific management + AV-node blocking drugs review
    • 2nd Line - PPM or cardiac resynchronisation therapy
  • If severely symptomatic
    • 1st Line - Condition specific management + AV-node blocking drugs review and Temporary Pacing
  • Acute 3rd degree
    • Haemodynamically stable = Transcutaneous pacing
    • Haemodynamically unstable = IV atropine
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8
Q

What is the management plan for Acute Heart Block?

A
  • 1st degree or Mobitz 1
    • Asymptomatic - regular monitoring
    • Symptomatic - discontinuation of AV-nodal blocking medication
      • 2nd Line - consider PPM or cardiac resynchronisation therapy
  • Mobitz 2 or complete HB
    • Mildly symptomatic - discontinuation of AV-nodal blocking medication + specific management if drug toxicity
      • 2nd Line - PPM or cardiac resynchronisation therapy
    • Severely symptomatic - 1st Line - same as above + temporary pacing
      • 2nd Line - PPM or cardiac resynchronisation therapy
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9
Q

What is the management plan for Hypertension?

A
  • Conservative management - smoking/alcohol cessation, diet, weight loss
  • Identify secondary cause specifically in young people
  • Target <80 = 135/80, >80 = 145/85
  • If severe (diastolic >140)
    • Atenolol and Nifedipine
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10
Q

What is the management plan for Acute Malignant Hypertension?

A
  • 1st Line - IV BBs i.e. Labetalol
  • 2nd Line - dihydropyridine CCB i.e. Nicardipine
  • 3rd Line - Fenoldopam
    • nitroprusside is restricted due to risk of thiocynate poisoning
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11
Q

What is the management plan for Infective Endocarditis?

A
  • 4 - 6 weeks of Abx always
  • Suspected Abx - O2 + Resus and empirical broad spectrum Abx
    • Blind native valve - Benzylpenicllin + low-dose gentamicin
    • Blind prosthetic valve - vancomycin + rifampicin + LD gentamicin
  • Staphylococci causing endocarditis
    • Native valve - Flucloxacillin/ vancomycin (penicillin allergy)
    • Prosthetic valve - Flucloxacillin + rifampicin + LD gentamicin
  • Streptococci - Benzylpenicillin sodium
  • Enterococci = Ampicillin + Gentamicin
  • HACEK = Ampicillin/ ceftriaxone + Gentamicin

Surgery - urgent valve replacement if unresponsive to Abx

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12
Q

What is the management plan for Stable Angina?

A
  • Primarily manage modifiable risk factors
  • Acute attacks - manage with sublingual GTN spray
  • Long term prevention
    • 1st Line - BBs e.g. atenolol + statin + aspirin
      • If contraindicated e.g Prinzmetal’s use verapamil
    • 2nd Line - combination of BB and CCB
      • If contraindicated consider addition of long-acting nitrates
    • 3rd Line = Percutaneous Angiography or CABG
  • Syndrome X - CCBs
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13
Q

What is the management plan for unstable Angina + NSTEMI?

A

MONA BASH

  • Immediate - Aspirin + clopidogrel
    • ​Oxygen if hypoxia or pulonary oedema
    • If low bleed risk = Fondaparinux
    • BB should be given if no LV dysfunction
    • If coronary angiography planned <24hrs = unfractionated heparin
  • Risk stratisfy with GRACE score
    • High = GpIIb/IIIa inhibitor e.g. tirofiban
      • coronary angiography <72hrs
    • Low = Conservative management plus symptom relief

Long term management is similar to that of stable angina

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14
Q

What is the management plan for STEMI?

A
  • Same management as NSTEMI/UA except:
    • Clopidogrel 600mg if undergoing PCI
      • plus abciximab and IV heparin
    • Clopidogrel 75 mg if >75 years undergoing thrombolysis
      • Plus Heparin/ LMWH
  • If availale in <90 mins Primary PCI
  • Otherwise perform thrombolysis with alteplase
    • Only considered if <12 hours post event
    • If pain persists rescue PCI can be performed after
    • >12 hrs coronary angiography
  • Long-term management
    • Anti-platelet
      • ​Aspirin for 2 weeks, followed by lifetime clopidogrel (75mg/day)
    • BBs unless contraindicated
    • ACEi for all patients unless contraindicated
    • Statins
    • Advice and Lifestyle management
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15
Q

What is the management plan for Pericarditis?

A

Initially the aim is to treat the cause, and restrict exercise

  • Acute - pericardiocentesis performed
    • If purulent consider Abx
  • 1st Line - NSAIDs + PPI
    • Consider Colchicine if idiopathic/viral
  • 2nd Line - Corticosteroids
  • 3rd Line - Immunosuppression e.g. Azathioprine
  • 4th Line - Surgical pericardiectomy for constrictive pericarditis
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16
Q

What is the management plan for Pulmonary Emboli?

A
  • Primary Prevention - compression stockings, heparin prophylaxis for high risk, good mobilisation + hydration
  • High/intermediate risk PE
    • If massive RESUS - ABCDE
    • 1st Line - IV fluids, vasoactive agents + LMWH + Warfarin
    • For massive PE > Thrombolysis with alteplase
    • For Intermediate consider embolectomy or IVC filter (when recurrent or anti-coagulant is contraindicated)
  • Low risk PE
    • 1st Line - Oxygen + Analgesia + LMWH/ NOAC
    • Consider IVC if recurrent or anti-coagulant is contraindicated
  • Long-term Management
    • NOAC or warfarin for 3 months post event
      • ​6 months if unprovoked or malignancy
    • If malignancy present use LMWH
17
Q

What is the management plan for a SVT?

A

If Haemodynamically unstable:

  • 1st Line - DC Cardioversion

If Haemodynamically stable

  • 1st Line - Vagal maneouvres e.g carotid massage or valsava
  • 2nd Line - Chemical Cardioversion - 6mg Adenosine
    • followed by 12 mg every 2 minutes twice
    • If no change switch to IV metoprolol/amiodorone
    • If asthmatic use verapamil
  • 3rd Line - DC Cardioversion

Ongoing management

  • AVNRT = Catheter Ablation + BB (CCB if asthma)
  • AVRT = Catheter Ablation
  • Sinus Tachycardia = BB or CCB (treat secondary cause)
18
Q

What is the management plan for Varicose veins?

A
  • For symptomatic superficial vein insuffiency
    • 1st Line - Graduated compression stockings
    • 2nd Line - phlebectomy or sclerotherapy
    • 3rd Line - Ablative therapy +/- phlebectomy/sclerotherapy
  • For Deep vein insuffiency
    • 1st Line - phlebectomy + graduated compression stockings
19
Q

What is the management plan for Venous Ulcers?

A

For all symptomatic patients:

  • Graduated compression (reduced venous stasis)
    • NOTE: must exclude diabetes, neuropathy and PVD before this is attempted
  • Debridement and cleaning
  • Antibiotics - if infected
  • Topical steroids - may help with surrounding dermatitis
20
Q

What is the management plan for Ventricular Fibrilliation?

A

If VF (Shockable rhythm) - requires urgent defib + cardioversion

  • Defibrillate once and continue CPR for 2 mins and reassess rhythm and shock again if no change
  • If no change after second shock administer 1mg IV adrenaline and repeat every 3-5 minutes
  • If shockable rhythm persists after 3rd shock, consider 300mg IV bolus amiodarone (once only)

Ongoing management

  • If patient survives - full assessment of LV function + MI perfusion
  • 1st Line - ICD +Empirical BB
  • 2nd Line - some patients require Catheter Ablation
21
Q

What is the management plan for Ventricular Tachycardia?

A

Identify if VT is pulseless, unstable of stable

  • Pulseless - requires defibrillation (see VF)
  • Unstable - requires ALS + treatment of cause
    • 1st Line - DC cardioversion
    • Plus Amiodorone + electrolyte corrections
  • Stable VT - can be medically managed
    • 1st Line - Amiodorone + electrolyte corrections
    • 2nd Line - DC cardioversion

Ongoing management:

  • ICD considered if: sustained VT with syncope/ ejection fraction <35%/ previos arrest due to VT or MI complication
  • Consider anti-arrthymic monotherapy too

Management Year 3 (13 decks)

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