Cardiology Flashcards
What is the pathophysiology of Acute Coronary Syndrome? (4)
It is the accumulation of Low Density Lipoproteins
Leukocytes attach onto the vascular endothelium and gain entry into the intima where they form Foam Cells
The remodelling of arteries and calcification, with Foam Cells causes Atherosclerotic Plaques
Plaque Rupture causes Platelet Activation and Occlusion
What are the 2 types of Myocardial Infarction and what causes them?
Type 1 Myocardial Infarction- due to an Atheromatous Plaque Rupture
Type 2 Myocardial Infarction- which occurs secondary to Ischaemia due to an Increase in Oxygen Demand or Decrease in Oxygen Supply due to (3)-
- Anaemia
- Sepsis
- Vasospasm
(In Type 2, you would treat the underlying cause as well)
What kind of Murmur is typically heard in Myocardial Infarction?
A Systolic Murmur- Mitral Regurgitation or Ventricular-Septal Defect
What are the symptoms of Acute Coronary Syndrome? (4)
Sweating
Anxiety
Nausea/ Vomiting
Central Chest pain which may radiate to the Left Arm and Neck
What 5 investigations should be ordered if Acute Coronary Syndrome is suspected?
Coronary Angiogram- Diagnostic
Perform ECG within 10 minutes
Measure Troponin levels- elevated in STEMI and NSTEMI but not in Unstable Angina
Perform a CXR if needed, to eliminate other potential causes
Work out their GRACE Score
What is the management for Unstable Angina/ NSTEMI? (5)
MONA B
- Morphine
- Oxygen (if<94%)
- Nitrates
- Aspirin
- Beta Blockers
DAPT (2)-
- Aspirin and Clopidogrel
- Aspirin and Prasugrel if Patient is gonna have PCI
Anticoagulation (2)-
- Unfractionated Heparin- if Coronary Angiography is planned or if Creatinine>265
- Fondaparinux- otherwise
If their GRACE Score is 89 or above AND they have an Unstable Angina or NSTEMI, then offer Immediate Angiogram and PCI
PCI should be performed within 120 minutes of Symptom Onset, otherwise offer Thrombolysis with (3) Alteplase, Tenecteplase and Streptokinase and offer Low-Molecular Weight Heparin unless (5)
- Haemorrhage
- Stroke, Head Trauma, Neurosurgery within the last 3 months
- Internal Bleeding
- Endocarditis
- Aortic Dissection
What is the management for STEMI? (5)
(Same as Unstable Angina/ NSTEMI but give Bivalirudin with Aspirin and not Prasugrel with Aspirin if a PCI is being performed)
MONA B
- Morphine
- Oxygen (if<94%)
- Nitrates
- Aspirin
- Beta Blockers
DAPT (2)-
- Aspirin and Clopidogrel
- Aspirin and Bivalirudin if Patient is gonna have PCI
Anticoagulation (2)-
- Unfractionated Heparin- if Coronary Angiography is planned or if Creatinine>265
- Fondaparinux- otherwise
If their GRACE Score is 89 or above AND they have an Unstable Angina or NSTEMI, then offer Immediate Angiogram and PCI
PCI should be performed within 120 minutes of Symptom Onset, otherwise offer Thrombolysis with (3) Alteplase, Tenecteplase and Streptokinase and offer Low-Molecular Weight Heparin unless (5)
- Haemorrhage
- Stroke, Head Trauma, Neurosurgery within the last 3 months
- Internal Bleeding
- Endocarditis
- Aortic Dissection
What are the 6 early complications and 2 late complications (after 2 weeks) of Acute Coronary Syndrome?
Early-
- Post MI Pericarditis
- Cardiac Arrest, most likely due to Ventricular Fibrillation
- Bradyarrhythmias- Heart Block is common after Inferior MI
- Cardiogenic Shock
- Ventricular Septal Defect/ Mitral Regurgitation
- Left Ventricular Wall Rupture- Ischaemia leads to a weakened ventricular wall and rupture which presents as a Cardiac Tamponade and Acute Heart Failure
Late Complications-
- Dressler’s Syndrome (An Autoimmune version of Pericarditis)
- Left Ventricular Aneurysm
What are the 2 common causes of Acute Decompensated Heart Failure?
Coronary Artery Disease
Hypertension
What is the pathophysiology of Acute Decompensated Heart Failure? (5)
The reduced cardiac output activates the Sympathetic Nervous System
This results in Tachycardia and an increased Myocardial Contractility, Peripheral Vasoconstriction and RAAS Activation- Salt and Water retention
Heart Failure patients are Hypovolaemic do BNP is released by Ventricular Myocytes due to stretch
This leads to Pulmonary and Venous Congestion
This leads to a Pulmonary Oedema (look out for shortness of breath)
This can also lead to a Peripheral Oedema due to Venous Congestion
What are the 6 signs of Acute Decompensated Heart Failure? What are the 3 signs of Congestive Heart Failure?
Coarse Bibasal Crackles
S3 heard
Stony Dull Percussion if Effusion is present
Dyspnoea due to Pulmonary Oedema (patient often has a history of Orthopnoea and Paroxysmal Nocturnal Dyspnoea)
Cardiogenic Wheeze
A reduced Left Ventricular Ejection Fraction (<40%)
Congestive Heart Failure (3)
- Pitting Oedema
- Peripheral Oedema
- Raised JVP
What is the 5 step management for Heart Failure? (3 for immediate and 2 for long-term)
- Oxygen if <94%
- Fluid Restriction
- An IV Diuretic- Loop Diuretic usually- like Furosemide
Long Term Treatment-
- ACE Inhibitor and Beta Blocker (Ramipril and Bisoprolol)- if Left Ventricular Ejection Fraction< 40%
- Loop Diuretic for Symptomatic Treatment of Oedema)
What is the pathophysiology of Pericarditis?
The pericardium is innervated by the Phrenic Nerve
It is the Inflammation of the Pericardium commonly caused by the COXSACKIE VIRUS
It may produce a Pericardial Effusion which develops into Cardiac Tamponade
What are the 5 other causes of Pericarditis? Aside from Coxsackievirus
TB
Systemic Autoimmune Diseases
Uraemia- secondary to Kidney Disease
Post-MI
Hypothyroidism
Where is the Pericardial Rub (sign of Pericarditis) heard?
It is heard at the Left Sternal Edge when the patient leans forward. It is High-pitched and Squeaky
What are the 4 symptoms of Pericarditis?
A sharp central chest pain which gets worse when the patient breathes in or lies down
Fever may also be present
Tachypnoea and Tachycardia
A Peripheral Oedema suggests a Right Sided Heart Failure secondary to Pericarditis
What 3 investigations should be ordered if Pericarditis is suspected?
Urea- High Urea suggests a Uraemic Cause
Transthoracic Echocardiogram and CXR to exclude Pericardial Effusion/ Cardiac Tamponade
ECG- PR Depression and ST Elevation
What is the management of Idiopathic/ Viral (2) Pericarditis and Bacterial (1) Pericarditis?
Idiopathic/ Viral Pericarditis
- NSAIDs and Colchicine
- NSAIDs, Colchicine and a low dose Prednisolone
Bacterial Pericarditis
- IV Antibiotics and Pericardiocentesis
Look out for evidence of Cardiac Tamponade (a Raised JVP/ Hypotension)- Perform Pericardiocentesis if suspected
What infection would make Constrictive Pericarditis likely?
TB
What is the pathophysiology of Angina Pectoris?
It is an imbalance in the Oxygen Supply and Demand which leads to Ischaemia
The Monocytes scavenge lipid deposits and transform into Foam Cells
Cytokines are released by Foam Cells which promotes SMC migration into the Intima from the Arteria Media
Could also be Non-Atheromatous due to Coronary Artery Vasospasm (Prinzmetal’s Angina)
What are the 7 signs of Angina Pectoris?
Central chest pain caused on exertion
Dyspnoea
Nausea
Sweating
S3 Heart Sound
Carotid Bruit/ Expansile Abdominal Aorta- suggests Peripheral Vascular Disease which increases the likelihood of Coronary Atherosclerosis
Hypertension
Xanthomata/ Xanthelasma- Hypercholesterolaemia
What investigations should be ordered in Angina Pectoris is suspected?
ECG
What is the management for Angina Pectoris?
GTN Spray for Symptomatic Relief
Antianginal Medication-
- Betablocker or non-dihydro Calcium channel blocker
- Betablocker and dihydro Calcium channel blocker
- Nitrates- patient can grow tolerant
Revascularisation-
- Percutaneous Intervention
- Coronary Artery Bypass Graft
What type of Tachycardia is Atrial Fibrillation?
Supraventricular Tachycardia