Cardiology Flashcards
3 types of ACS
ST-elevation myocardial infarction (STEMI): ST-segment elevation + elevated Trop t
non ST-elevation myocardial infarction (NSTEMI): ECG changes but no ST-segment elevation + elevated trop t
unstable angina
Supportive management of ACS
MONA
Morphine=only to be given with severe pain
oxygen=only if the oxygen sats are less than 94%
nitrates=should be used with caution in pts with hypotension
Apirin=300mg
Criteria of diagnosing STEMI
Chest pain for more than 20mins
≥ 2 contiguous leads of:
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years
≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
new LBBB (LBBB should be considered new unless there is evidence otherwise)
Definite management of ACS
primary coronary intervention=
should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given
if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered
drug-eluting stents are now used.
radial access is preferred to femoral access
fibrinolysis=
should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given
Practical example
patient who presents with a STEMI to a small district general hospital (DGH) that does not have facilities for PCI. If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient’s ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI
Prior and during the PCI
Antiplatelet prior to PCI
this is termed ‘dual antiplatelet therapy’, i.e. aspirin + another drug
if the patient is not taking an oral anticoagulant: prasugrel/ticagrelor
if taking an oral anticoagulant: clopidogrel
Drug therapy during PCI
patients undergoing PCI with radial access:
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
patients undergoing PCI with femoral access:
bivalirudin with bailout GPI
Fibrinolysis
An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered.
treatment of UA/NSTEMI
Aspirin+clopi if already taking otherwise tica or prasu
fondaparinux = not at a high risk of bleeding and who are not having angiography immediately
if immediate angiography is planned or a patients creatinine is > 265 µmol/L = unfractionated heparin
Pts with UA/NSTEMI ;
should have PCI or not?
immediate: patient who are clinically unstable (e.g. hypotensive)
within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk
With regards to thrombolysis:
tissue plasminogen activator (tPA) has been shown to offer clear mortality benefits over streptokinase
tenecteplase is easier to administer and has been shown to have non-inferior efficacy to alteplase
BP Targets
Clinic BP ABPM / HBPM
Age < 80 years 140/90 mmHg 135/85 mmHg
Age > 80 years 150/90 mmHg 145/85 mmHg
ARBs mechanism
block effects of angiotensin II at the AT1 receptor
54-year-old female
acutely painful hand.
history of hypertension, Raynaud’s phenomenon
smoked twenty cigarettes a day since she was twenty-two years old.
no relief of symptoms despite wearing gloves and making sure her hands are warm.
her right hand is blanched white and feels cold.
radial pulse is not palpable at the wrist.
Dx; Beurger dis
Buerger’s disease/thromboangiitis obliterans
characterised by inflammation and thrombosis of the small and medium arteries in the hands and feet.
it can present as acute ischaemia or chronic progressive ischaemic changes to the skin/tissues. Ultimately it may result in gangrene of the affected area, often needing amputation. It is strongly associated with an extensive smoking history.
treatment is usually conservative, i.e. wear gloves/keep hands warm where possible. Sometimes calcium channel blockers are used in severe cases. The affected fingers classically change from white (hypoperfusion) to blue to red (reperfusion)
Features
extremity ischaemia; intermittent claudication and ischaemic ulcers
superficial thrombophlebitis
Raynaud’s phenomenon
grapefruit juice inhibits the cytochrome p450 enzyme; CYP3A4.
So it should not be taken with?
Statins
warfarin interacts with which flavour juice?
Cranberry
it increases the INR
MOA of statins
Statins inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.
SE of Statins
Myopathy; more commonly occurs with atorvastatin snd simvastatin
Liver impairment;check LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
Increases the risk of Intracerebral haemorrhage in people who already have had a stroke
CI of Statins
Macrolides(Erythro and Clarithro)
Pregnancy
grape fruit juice.
Why should statins be taken at night?
because most of the cholesterol synthesis occurs at night
Drugs causing HTN
steroids
monoamine oxidase inhibitors
the combined oral contraceptive pill
NSAIDs
leflunomide
A 25-year-old man with a history of Marfan’s disease presents with sudden onset shortness of breath and pleuritic chest pain.
Cause?
Pneumothorax
Dissecting aortic aneurysm
as a cause of chest pain
imp features
Tearing’ chest(intrascapular) pain radiating through to the back
Unequal upper limb blood pressure
most commonly occurs in the ascending aorta or just distal to the left subclavian artery (less common).
It is most common in Afro-carribean males aged 50-70 years.
Stanford classification
lesions with a proximal origin (Type A)=surgically treated
Those that commence distal to the left subclavian (Type B)=managed non operatively
Diagnosis of Aortic dissection/aortic aneurysm?
Diagnosis may be suggested by a chest x-ray showing a widened mediastinum.
Confirmation by = CT angiography
chest pain due to perforated peptic ulcer
Imp Feature
worsens immediately after eating.
diagnosis of perforated peptic ulcer
Diagnosis may be made by erect chest x-ray which may show a small amount of free intra-abdominal air (very large amounts of air are more typically associated with colonic perforation).
Tx of perforated peptic ulcer
laparotomy, small defects may be excised and overlaid with an omental patch, larger defects are best managed with a partial gastrectomy.
what is Boerhaaves syndrome
Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting.
common site of Boerhaaves syndrome
rupture is usually distally sited and on the left side.
Dx of Boerhaaves syndrome
CT contrast swallow.
Tx of Boerhaaves syndrome
Treatment is with thoracotomy and lavage, if less than 12 hours after onset then primary repair is usually feasible, surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin.
causes of increased BNP levels
Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (including pulmonary embolism)
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis
GC-SAL2TID
causes of dec BNP levels
BODA3
Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists
If BNP levels are high appointment in
if levels are ‘high’ arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
If BNP levels are raised appointment in
if levels are ‘raised’ arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks
Posterior MI
OPPOSITE TO TYPICAL FINDINGS OF other MI’S
LIKE;
st depression
t wave upright
and this is seen in v1 to v3 leads
LBBB=WILLIAM
RBBB=MARROW
V1/V2; W=downward deflections. V5/V6;M=Upright deflections
v1/v2; M=upright deflections. v5/v6;W=downward deflections
New LBBB is always pathological and may be a sign of a myocardial infarction.
NITRATE TOLERANCE
MORE FROM STANDARD OR MODIFIED RELEASE?
NICE advises that patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance
this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate
Who should receive statins?
all people with established cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
10-year cardiovascular risk >= 10%
patients with type 2 diabetes mellitus should now be assessed using QRISK2 like other patients are, to determine whether they should be started on statins
patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy
in pulseless vt/vfib
when will we give adrenaline and amiodarone?
After the third shock where 1mg IV of adrenaline and 300mg IV of amiodarone should be given while still performing CPR.
Afterwards, 1mg of adrenaline should be continued to be given after every other shock.
The 2nd dose of amiodarone should be considered after a total of 5 defibrillation attempts.
In circumstances where amiodarone is unavailable lidocaine can be used.
76-year-old lady is admitted to the stroke ward after being diagnosed with a right-sided infarct. She was thrombolysed in resus.
ECG shows an absent p wave and an irregular pulse(Afib) She was not on any prior anticoagulation.
When should this patient be commenced on anticoagulation?
following a stroke or TIA, warfarin or a direct thrombin or factor Xa inhibitor should be given as the anticoagulant of choice.
Antiplatelets should only be given if needed for the treatment of other comorbidities
in acute stroke patients,
in the absence of haemorrhage, anticoagulation therapy should be commenced after “"”2 weeks. “””
If very large cerebral infarction= initiation of anticoagulation be delayed
