Cardiology Flashcards
Describe the investigations for acute coronary syndromes
Troponin – begin to rise 3 to 4 hours after myocardial damage
CK – measured in STEMI patients
Recommended hs-TnI taken on admission & again at 1 hour (only one hs-TnI level is required if the onset of symptoms was 3 or more hours previously)
ECG
Describe the management of a STEMI
Pain relief – morphine & anti-emetic
Oxygenation
Aspirin (300mg loading followed by 75mg od for life)
Prasugrel/clopidogrel/ticagrelor
PPCI
Biochemical screen
Medications post MI: bisoprolol, ACEi, statin
Control of diabetes & hypertension
Describe the management of NSTEMI/unstable angina
Morphine & anti-emetic
Aspirin 300mg loading and 75mg od
LMWH (enoxaparin) for 48 hours
Repeat ECG
Risk assessment of patient with elevated hs-TnI (grace score)
Consider anti-anginals
Describe the investigations for stable angina
FBC & biochemical screen including glucose/HbA1c
Full lipid profile
Resting 12-lead ECG
Describe the management of stable angina
Treated with aspirin 75mg OD, for those allergic, clopidogrel 75mg OD should be used
Sublingual GTN & instructed on its use
Symptom control – B-blockers
Rate control – B-blockers & CCBs (diltiazem or verapamil)
Statin
Describe investigations for hypertension
Urine sample – test for presence of protein in the urine & for estimation of the albumin:creatinine ratio & haematuria
Bloods – glucose, electrolytes, creatinine, eGFR, total cholesterol & HDL cholesterol
Examine the fundi – hypertensive retinopathy
ECG
Echo – if suggestive of LVH, valve disease or LVSD or diastolic dysfunction
List non-pharmacological management of hypertension
Weight reduction if BMI > 25
Moderate salt intake
Minimise alcohol intake
Aerobic exercise
Smoking cessation
List the management of a hypertensive emergency
Aim is to reduce the diastolic BP to 110mmHg in 3-12 hours (emergency) or 24 hours (urgency)
1) Sodium nitroprusside
2) Labetalol
3) GTN
4) Esmolol (acts within 60 seconds, with a duration of action of 10-20 mins)
Describe the investigations done for suspected heart failure
Bloods – U&Es, FBC, LFTs, TFTs, ferritin & transferrin, NT-proBNP
CXR
Echo (confirms diagnosis)
Cardiac MRI – may elaborate cause for HF as echo may miss right ventricle
List potential findings in a CXR & echo for heart failure
CXR – cardiomegaly, pleural effusions, perihilar shadowing/consolidations, alveolar oedema, air bronchograms, increased width of vascular pedicle
Echo – dilated poorly contracting left ventricle (systolic dysfunction), stiff, poorly relaxing, small diameter left ventricle (diastolic dysfunction), valvular heart disease, atrial myxoma, pericardial disease
Describe the management of heart failure
Lifestyle – smoking cessation, restriction of alcohol consumption, salt restriction, fluid restriction (especially in hyponatraemia)
Medications – diuretics, ACEi, ARB, ARNI, B-blocker, hydralazine, isosorbide mononitrate, ivabradine, nitrates
Complex device therapy – when medical therapy fails, then pacemakers can be used when there is LBBB
Describe the difference between CRT & ICD
CRT (cardiac resynchronisation pacemaker) – paces from the septum to the lateral wall -> alters the QRS duration to becoming narrow again -> heart muscle can pump properly
ICD – deliver an electric shock: don’t improve symptoms, their purpose is to prevent sudden cardiac death associated with HF by detecting & cardioverting VT/VF
Describe the symptoms of aortic stenosis
Three classical symptoms: angina, heart failure & syncope
Most common initial symptom = dyspnoea on exertion
Ejection systolic murmur best heard at the aortic area, radiating to the carotid/neck
Describe the investigations and management for aortic stenosis
Echo – allows quantification of the severity of the stenosis and assessment of the rest of the heart
Indications for surgery – symptomatic, asymptomatic severe AS with LVSD/abnormal exercise test/at time of other cardiac surgery
In older patients, TAVI is considered (implanted via the femoral artery)
Describe the symptoms of aortic regurgitation
May remain asymptomatic for many years -> increased volume load on the left ventricle eventually leads to heart failure
Exertional dyspnoea/reduction in exercise tolerance
Murmur best heard at the left sternal edge & is an early diastolic murmur
Associated with a collapsing pulse & De Musset’s sign (head bobbing)
Describe the investigations and management for aortic regurgitation
Echo – quantification of the severity of the regurgitation and assessment of the rest of the heart
Indications for surgery: symptomatic severe AR, asymptomatic with evidence of early LVSD, asymptomatic with aortic root dilatation > 5.5 cm
Describe the symptoms of mitral regurgitation
May remain asymptomatic for many years
Classified by a pan-systolic blowing murmur best hear over the mitral area and radiates to the axilla
Describe the investigations and management of mitral regurgitation
Echo – important to assess LV function and size together with the severity of the jet of blood coming through the valve
Surgical options include mitral valve replacement or mitral valve repair
Surgical intervention is indicated in severe MR: symptomatic patients & asymptomatic patients with mild-moderate LV dysfunction
Medical therapy – diuretics, ACEi, beta blockers
List common organisms in infective endocarditis
Strep viridans
Staph aureus
Pseudomonas aeruginosa
List investigations to do for suspected infective endocarditis
FBC, ESR, CRP, U&Es, LFTs
Urine dipstick & MSU
CXR
ECG
Key diagnostic investigations: blood cultures & echo (TOE will detect 95% of vegetations)
Describe how blood cultures are taken from a patient who has suspected infective endocarditis
At least three (preferably 6) sets of blood cultures should be taken from different sites over several hours
Reasonable to delay abx treatment to allow for comprehensive sampling
Describe the diagnostic criteria for infective endocarditis
Modified Duke’s criteria – diagnosis on basis of two major criteria/one major and three minor/five minor criteria
Major criteria:
1) Positive blood cultures
2) Endocardial involvement
3) Positive echo findings
4) New valvular regurgitation
5) Dehiscence of prosthesis
Minor criteria:
1) Predisposing valvular/cardiac abnormality
2) IV drug abuser
3) Pyrexia > 38
4) Embolic phenomenon
5) Vasculitic phenomenon
6) Blood cultures suggestive
7) Suggestive echo findings
Describe the management of infective endocarditis
Antibiotic therapy
1) Caused by strep: benzylpenicillin IV & low dose gentamicin
2) Caused by enterococci: amoxicillin IV & low dose gentamicin
3) Caused by staph: flucloxacillin & gentamicin
How should you monitor treatment response in IE?
Once weekly echo – assess vegetation size & look for complications
Twice weekly ECG – detect conduction disturbances
Twice weekly bloods
List indications for surgery in IE
Moderate to sever cardiac failure due to valve compromise
Valve dehiscence
Threatened or actual systemic embolism
Uncontrolled infection despite appropriate antimicrobial therapy
List the clinical features of mitral stenosis
Mid-diastolic, low pitched ‘rumbling’ murmur
Malar flush
Atrial fibrillation
Describe the management of mitral stenosis
If in AF, rate control is crucial
Anti-coagulate with warfarin
Diuretics
If this fails -> balloon valvuloplasty, open mitral valvotomy or valve replacement
Describe the management of cardiac tamponade
Oxygen
Diamorphine IV for pain and anxiety
Drainage: needle pericardiocentesis & surgical drainage
Describe the management of hyperlipidaemia
Lifestyle advice – exercise, Mediterranean diet
1st line therapy – atorvastatin 20mg PO at night for primary prevention, atorvastatin 80mg PO for secondary prevention (simvastatin 40mg)
2nd line therapy – ezetimibe
3rd line therapy – alirocumab: monoclonal antibody
List investigations for peripheral arterial disease
Bloods – ESR, CRP, FBC, U&E, lipids, ECG
Ankle brachial pressure
Colour duplex US 1st line
Describe the management of peripheral arterial disease
Risk factor modification – quit smoking, treat hypertension & high cholesterol, clopidogrel
Management of claudication – supervised exercise programme & vasoactive drugs
If conservative measures, intervention is required:
1) Percutaneous transluminal angioplasty
2) Surgical reconstruction
3) Amputation
Describe the pathophysiology of varicose veins
Long, tortuous & dilated veins of the superficial venous system
Blood from superficial veins of the leg passes into deep veins via perforator veins & at the saphenofemoral and saphenopopliteal junctions
Valves prevent blood from passing from deep to superficial veins -> if they become incompetent there is venous hypertension & dilation of the superficial vein occurs
Describe the management of varicose veins
Treat underlying cause
Education – avoid prolonged standing and elevate legs whenever possible
Endovascular treatment:
1) Radiofrequency ablation
2) Endovenous laser ablation
3) Injection sclerotherapy
4) Surgery
