cardio conditions Flashcards
whats the first line treatment for a 45 year old afroCaribbean with hypertension?
CCB (amlodipine)
how do you treat resistant hypertension?
low dose spironolactone - monitor U&Es
what are investigations for angina?
CT coronary angiography (CTCA) - young atypical symptoms
exercise tolerance test (ETT) - old classic symptoms but normal ECG
old + classic symptoms = clinical diagnoses
whats the first line treatment for angina?
symptomatic relief = GTN spray (vasodilator)
beta blocker - bisoprolol
CCB - amlodipine
how do you diagnose acute coronary syndrome?
unresponsive to GTN
ST elevation or new LBBB = STEMI
raised troponin or other ECG change = NSTEMI
none of above = unstable angina or MSK chest pain
what is meant by serial troponins and when are they commonly done?
used in ACS diagnosis
should be done on arrival to hospital then 6-12hrs later
- a rise is consistent with myocardial ischemia (released from ischaemic muscle)
what is the treatment of an acute STEMI?
within 2hrs of presentation = PCI
after 2 hrs = thrombolysis (injecting fibrinolytic medication which break down fibrin + rapidly dissolves clot)
( + MONAA)
what is the treatment for an acute NSTEMI?
MONAA
M - morphine O - oxygen (<95%) N - nitrates - sublingual GTN A - aspirin (antiplatelet) A - antiplatelet = ticagrelor
what is the GRACE score used for?
gives 6 month risk of death or repeat MI after NSTEMI
<5% = low risk
5-10% = medium risk
> 10% = high risk
medium or high risk - early PCI to treat underlying CAD
what are the 6 As of secondary prevention management of ACS?
Aspirin
Another antiplatelet - clopidogrel, ticagrelor
Atorvastatin
ACEi - ramipril
Atenolol - or other betablocker
Aldosterone antagonist for those with clinical HF (spironolactone)
what are symptoms of limb ischaemia?
limb ischaemia = arteries = ARTS
A - absent pulse + hair
R - red sores (ulcers)
T - toes + feet pale or black
S - sharp calf pain
what are the 6 Ps of acute limb ischaemia?
pain - unrelieved paraesthesia - tingling + numbness pulseless pallor - pale polar - cold paralysis
what are investigations for limb ischaemia?
artery brachial index (ABI)
- normal = 0.9 - 1.3
- claudication = 0.4 - 0.85
- severe = 0 - 0.4
doppler ultrasound
how do you manage limb ischaemia?
LWMH
anti-platelet - aspirin
cholesterol lowering - statins
what are aneurysms? what are pseudoaneurysms?
permanent dilatation of the artery to twice the normal diameter
false aneurysm = pseudoaneurysm = surrounding tissue form wall of aneurysm
when should you repair an abdominal aortic aneurysm?
> = 5.5cm in diameter
expanding at a rate of >1cm/year
symptomatic
what are symptoms of abdominal aortic aneurysms?
mostly asymptomatic but if rapid expansion / rupture:
severe pain - epigastric, radiating to the back
hypotension, tachycardia, profound anaemia, sudden death
trashing - discolouration due to emboli from aortic thrombus
what is the management of a DVT?
6 weeks anti-coagulation = LWMH
thrombolytic therapy for large iliofemoral thrombosis
compression stockings
what is the acute management of supraventricular tachycardia?
step wise with continuous monitoring:
valsalva manoeuvre - NOT in patients with clot risk
carotid sinus massage - “
adenosine - rapid bolus, feel like dying - contraindicated in asthmatics
verapamil (CCB)
DC cardioversion - if haemodynamically unstable do first
long term management of SVTs?
CCBs - verapamil, diltiazem
beta blockers
flecainide / amiodarone
radiofrequency ablation
when would you not give rate control in AF?
reversible
new onset - within 48hrs
causing HF
remain symptomatic despite rate control
the moment AF switches to sinus rhythm is when there’s the highest risk for embolism leading to stroke
how can this risk be reduced?
CHAD2Ds2-VASc - assess risk of emboli stroke (>2 anticoagulate)
HASBLED - risk of bleeding
anticoagulation:
- warfarin= vitamin K antagonist (give K to counteract)
- maintain INR between 2-3
- needs monitored, interaction problems, long half life - DOACs
- shorter half life
- apixaban, edoxaban, rivaroxaban = factor Xa inhibitors
- dabigatran = thrombin inhibitor
what is the most common method of rhythm control?
cardioversion
DC cardioversion = timed electric shock
- must have had symptoms <48hrs or be anticoagulated prior
- echo first to look for emboli
pharmacological cardioversion
- flecainide = Na channel blocker
- amiodarone = K channel blocker
if neither work - catheter ablation
what does an ECG of atrial flutter look like?
regularly irregular
no p waves - “saw tooth T waves”
normal QRS duration
what does an ECG of Wolff-Parkinson White look like? how is this treated?
short PR interval <0.12s
wide QRS complex >0.12s
delta wave - slurred upstroke of QRS
definitive treatment = radiofrequency ablation of the accessory pathway.
how can supraventricular tachycardia and ventricular tachycardia be differentiated?
adenosine
no effect in VT but will help SVT
what is torsades de pointes?
ventricular contraction prior to proper repolarisation
polymorphic VT - QRS progressively smaller then larger over and over
occurs in patients with prolonged QT interval
terminate spontaneously or progress into VT
what does an ECG of Brugada syndrome look like?
ST elevation with RBBB in leads V1-3
changes may be seen after administering flecainide - Na channel blocker
what is the treatment for 2nd (mobitz II) and 3rd degree heart block?
first line = atropine IV
no improvement - other inotropes (noradrenalin) defibrillate
long term = pacemaker
how is heart failure classified?
New York Heart Association (NYHA) classification -
- class I = no exercise limitation, no fatigue, dyspnoea or palpitations
- class II = mild limitation, comfortable at rest but normal physical activity produces fatigue, SOB or palpitations
- class III = marked limitation, comfortable at rest but gentle activity produces symptoms
- class IV = symptoms of heart failure occur at rest and are exacerbated by any physical activity
what are the symptoms of heart failure?
exertional dyspnoea
orthopnoea - SOB when lying down, relieved by standing (how many pillows?
paroxysmal nocturnal dyspnoea - sudden awake with SOB + cough
cough - white/pink frothy sputum
peripheral oedema - pitting
signs of HF?
bi-basal crackles
elevated JVP
3rd and 4 th heart sounds
cardiomegaly
what is an elevated BNP a sign of?
heart failure
what is the drug therapy for heart failure?
ACEi - ramipril (avoid with valvular heart disease)
beta-blockers - bisoprolol (not for asthmatics)
spironolactone in HFrEF + symptoms not controlled with ACE + Beta
- (thin, weak, unable to eject fully, EF <=40%)
treatment for LVF + pulmonary oedema?
Pour SOD
pour - pour away (stop) IV fluids
S - sit up - takes fluid to bases
O - oxygen if <95%
D - diuretic(loop) = furosemide (reduces circulating volume)
causes of infective endocarditis?
bacteraemia - poor dental hygiene, IV drugs, prosthetic heart valves
rheumatic disease
congenital abnormalities + degeneration
- valve disease promotes platelet/fibrin deposition
signs of infective endocarditis?
new/changing heart murmur
sepsis/embolic event of unknown origin
splinting haemorrhages - bloody lines in nail beds
roth spots - red spots in back of the eye with pale centres
janeway lesions - nonpainful, red spots on hand palms or feet soles
osler nodes - painful, bloody nodules on finger tips/toes
what are the causative organisms of infective endocarditis?
staph aureus
- IV drug users
- usually tricuspid valves
staph epidermis - prosthetic valves
strep viridans - after dental surgery
HACEK group (gram -ves) Haemophilus Actinobacillus Cardiabacteria Eikenella Kingella
investigations for infective endocarditis?
take 3 sets of blood cultures from different sites - before treatment
–> if negative think atypical
echo for endocardial involvement - vegetation, abscess, dodgy prosthetic
CRP, inflammatory markers, FBC
patient gets pericarditis 4-6weeks post MI
Dressler’s syndrome
what is the wells score used for?
DVT risk calculation
A 60-year-old man with a history of late-stage cirrhosis and alcohol abuse is being managed on the gastroenterology ward. An abnormality is found on his most recent echocardiogram.
What is the MOST LIKELY diagnosis?
dilated cardiomyopathy
treatment for native valve infective endocarditis
amoxicillin, gentamicin IV for 4-6weeks
–> step viridans (after dental)
(Already Got native valve)
treatment for prosthetic valve infective endocarditis
Vancomycin, Gentamicin IV + Rifampicin PO for 4-6 weeks
–> staph epidermidis
(prosthetic valve has Very Good Rhythm)
treatment for staph aureus infective endocarditis
flucloxacillin IV 4-6weeks
treatment for suspected MRSA infective endocarditis
vancomycin, rifampicin, gentamicin IV 4-6weeks
treatment of first degree heart block
no intervention (if stable)
PR >0.2s
tachycardia treatment of an unstable patient
up to 3 synchronised shocks
amiodarone IV
treatment of stable ventricular tachycardia
amiodarone infusion
