Cardiology Flashcards
Diagnosing Stable Angina
FIRST LINE:
Resting ECG
FBC, HbA1c, Lipids
CONSIDER:
Exercise ECG only if known CAD
Cardiac CT Angiography
Treating Stable Angina
Sublingual Glycerol Nitrate -ALL
Anti-anginal Therapy -ALL
Beta blocker AND/OR CCB 1st line
Long acting nitrate or ranolazine if above contraindicated
Consider Antiplatelet Therapy for ALL
Aspirin OR Clopidogrel if cannot take aspirin
Can be combined
DO NOT USE VERAPAMIL WITH BETA BLOCKERS AS CAUSES HEART BLOCK
Add ACE Inhibitor if HTN, diabetes, left ventricular dysfunction, heart failure, CKD, previous MI
Statins if dyslipidaemia
Blood sugar control if hyperglycaemia
Diagnosing Unstable Angina
FIRST LINE: Resting ECG Troponin to rule out NSTEMI/STEMI FBC for anaemia and thrombocytopenia U&E's + Creatinine for baseline, treatment choice and GRACE score calculations LFTs to ascertain liver function before anticoagulation Amylase/Lipase TFT's CXR for signs of heart failure
CONSIDER:
Echo
Angiogram
Treating Unstable Angina
Antiplatelet Therapy - ALL
Aspirin OR Clopidogrel if cannot take aspirin
Can be combined
Anti Anginal Therapy - ALL
Beta Blocker OR non-dihydropyridine CCB (e.g. Verapamil)
DO NOT USE VERAPAMIL WITH BETA BLOCKERS AS CAUSES HEART BLOCK
Glycerol Trinitrate and/or Morphine for pain
Antihypertensives if HTN:
Beta Blocker
+/- ACE-I or A2RA
Statins if dyslipidaemia
Blood sugar control if hyperglycaemia
Revascularisation
Diagnosing NSTEMI
FIRST LINE
Resting ECG
Troponin
FBC for anaemia and thrombocytopenia
U&E’s + Creatinine for baseline, treatment choice and GRACE score calculations
LFTs to ascertain liver function before anticoagulation
CONSIDER
Echo
Angiogram
Treating NSTEMI
UNSTABLE Immediate angiography + revascularisation \+ Aspirin \+ P2Y12 Inhibitor \+ Anticoagulation for PCI
Consider GTN, Morphine, Anti-emetic
STABLE
Aspirin
+ P2Y12-I
+ ACE-I or A2RA
Consider B-Blockers, GTN, Morphine, Anti-emetic, revascularisation
Diagnosing STEMI
FIRST LINE Resting ECG Immediate angiography suitability assessment Troponin FBC U&E's + Creatinine
Consider
ABG
Chest XR but must not delay reperfusion
Echo but must not delay reperfusion
Treating STEMI
Immediate reperfusion via PCI or Fibrinolysis \+ Aspirin \+ Morphine \+ P2Y12-I \+ Anti-emetic \+ Parental anticoagulation
POST STABILISATION Dual anticoagulation Beta Blocker ACE-I Statin
Diagnosing Valvular Disease
FIRST LINE
Echo can rule in or out valve incompetencies
ECG can show signs such as
CXR for heart changes
Diagnosing CCF
FIRST LINE
Echo for systolic and diastolic function
ECG for QRS widening
CXR for cardiomegaly, vascular congestion or pulmonary oedema
BNP - below 100 suggests pulmonary cause, above 400 suggests heart failure
Baseline electrolytes
ADDITIONAL
Screening for causes e.g. TFT’s, LFT’s, Ferritin, Lipids, Glucose, HbA1C, Myocardial Bx,
Treating CCF
FIRST LINE
ACE-I or Angiotensinogen Receptor Blocker
A2RA + B Blocker if ACE-I intolerant
CAUSE DEPENDENT
Loop diuretic such as Furosemide if overloaded
Aldosterone antagonist such as Spiro if LVEF < 35%
Anti-arrhythmics such as Digoxin if AF or arrhythmia
Diagnosing Infective Endocarditis
FIRST LINE
Echo ASAP to confirm or rule out diagnosis
Blood Cultures - ideally 3 sets 1 hour apart
FBC - may show normocytic normochromic anaemia, raised neutrophils and raised leucocytes
ECG to check conduction
Urinalysis may show signs of septic emboli such as RBC/WBC casts, protein, pyuria
CONSIDER
CT - infectious embolic events
Rheumatoid facto - Dukes criteria
Treating Infective Endocarditis
FIRST LINE
Supportive care to maintain airway, breathing and circulation
Abx - broad spectrum initially then based on culture sensitivities
CONSIDER
Some patients may require surgery to remove infected tissue then repair or replace valves
Diagnosing hypertension
Blood pressure readings exceeding 140/90
ECG to check for CAD
HbA1C/fasting glucose
Lipids
FBC and U&E’s for baseline and to check for metabolic disease, kidney damage etc.
Electrolytes inc. calcium
Urinalysis to check for protein which would suggest renal compromise
CONSIDER
Plasma renin if hypokalaemia
Plasma aldosterone if HTN is persistently over 150/90 or resistant top treatment
Fundoscopy to check for retinopathy
Renal CT/US if young or renal bruit present
Investigating Malignant Hypertension
BP normally 180/120 but use clinical judgement
Creatinine as AKI with raised creat may be the only sign of a hypertensive emergency
FBC with smear for haemolytic anaemia
Urinalysis for blood and protein
Treating malignancy hypertension
Patients need to be beta-blocked slowly to prevent them having a stroke
Labetalol is first line
Nicardine (CCB) is second line
Fenoldopam (Dop-1-agonist) is third line
Stable Angina Symptoms
Typical Angina:
1) Squeezing chest pain or pressure
2) Induced by exercise
3) Relieved by rest or GTN
Atypical angina will only include 2 symptoms
Less commonly pain can radiate into arm, jaw, epigastric area
Unstable angina symptoms
Anginal chest pain which occurs at rest and may radiate to arms, jaw or neck
May also cause sweating, SOB, back pain, epigastric pain or syncope
NSTEMI Symptoms
Chest pain which can radiate to arms, back, jaw or neck
Marked sweating
Nausea and vomiting
Arrhythmia
Some patients may have SOB, epigastric pain, syncope or back pain
STEMI Symptoms
Severe crushing chest pain which can radiate to arms, back, jaw or neck Dyspnoea Pallor Peripheral vasoconstriction Marked sweating Nausea and vomiting Arrhythmia Palpitations Anxiety Dizziness
Compromised Aortic Valve Symptoms
AORTIC REGURGITATION Diastolic murmur Below symptoms arise from progressive LV dysfunction: Dyspnoea and nocturnal dyspnoea Fatigue Weakness Orthopnoea Collapsing pulse
AORTIC STENOSIS Crescendoing systolic murmur between S1 and S2 Dyspnoea most common complaint Angina like chest pain Syncope
Compromised Mitral Valve Symptoms
MITRAL REGURGITATION
Pan-systolic murmur at apex which radiates
Exercise induced dyspnoea, reduced exercise tolerance, fatigue and lower limb oedema are common presenting complaints
Palpitations, orthopnoea and nocturnal dyspnoea may occur
MITRAL STENOSIS
Diastolic murmur heard between S2 and S1
Increased left atrial pressure can lead to dyspnoea, orthopnoea and nocturnal dyspnoea
CCF Symptoms
FRAMINGHAM MAJOR Pulmonary oedema Neck vein distension S3 heart sound Cardiomegaly Fine crackles Nocturnal dyspnoea or orthopnoea Hepatojugular Reflex Weight loss > 4.5kg with diuretics
FRAMINGHAM MINOR Anke Oedema Exertion Dyspnoea Hepatomegaly Nocturnal cough Pleural effusion Tachycardia
Infective Endocarditis Symptoms
Murmur Anaemia Janeway Lesions Osler Nodes Roth Spots Pyrexia Emboli Nail Haemorrhage
Other symptoms from septic emboli or immune deposits: Back pain from discitis Chest pain Meningeal signs Arthralgia Weakness Glomerulonephritis
Common organisms in infective endocarditis
Native Valves - Staph Aureus or Strep in 80% of cases
Prosthetic Valves - Tends to be Staph Epidermis
IVDU - Skin flora such as Staph Aureus
Enterococcus
Brucella
Culture negative endocarditis
Complications of Endocarditis
Heart failure due to rapid onset valve disease
Peri-valvular abscess
Septic emboli leading to stroke, discitis, splenic infarction, renal infarction
Metastatic abscesses
Mycotic aneurism
ECG changes in angina
May be normal or have any of the following:
ST depression
T way inversion
Ischaemia seen in V4-V6
Reasons for CABG to be used over PCI
PCI has failed
Diabetic patients
Unsuitable anatomy for PCI
Complications of Acute Coronary Syndrome
Cardiac Arrhythmias such as AF Fatal Arrhythmia such as ventricular fibrilation Cardiac failure Ventricular Septal Defect Ruptured Chordae Tendinae Cardiac Tamponade Dressler's Syndrome AKA post-infarction pericarditis Cardiogenic Shock Heart Block
Causes of CCF
Coronary Artery Disease Hypertension Valvular Disease Myocarditis Cardiomyopathy Endocrine Problems Systemic Vascular Disease (e.g. lupus) Toxins
