Cardiology Flashcards
ACS
- Presentation
- ECG changes, including territories + arteries affected
- Differentials for ST elevation and depression on ECG
Presentation
- Central crushing chest pain w/ radiation to both, left or right arm/jaw
- Sweating, n+v, SOB, syncope
- Rise in troponin (STEMI + NSTEMI) or no rise (unstable angina)
ECG changes
- STEMI. ST elevation in 2 contiguous leads:
- >1mm (small square) in most leads
- in V2-3: >1.5 in women; >2.0 in men >40 or >2.5 in men <40
NSTEMI
- >0.5mm in 2 continguous leads
New LBBB (most likley anterior/anteroseptal)
Territories
II, III, aVF = inferior = right coronary artery
V1-2 = septal = LAD
V3-4 = anterior = LAD
I, aVL, V5-6 = lateral = Left circumflex
V4-6, aVL = anterolateral = left circumflex + LAD
Posterior MI = flat ST depression, upright t waves + tall R waves in V1-3 (confirm w/ posterior leads V7-9)
Differentials for ST segment changes
ST Elevation
- STEMI
- Pericarditis/myocarditis
-High take-off (normal variant)
- Left ventricular aneurysm (if persisting after MI)
- Prinzmetal’s angina (coronary artery spasm)
- Takotsubo cardiomyopathy
- Rare: subarachnoid haemorrhage
ST Depression
- Secondary to abnormal QRS (LBBB, RBBB, LVH)
- Ischaemia
- Digoxin
- Hypokalaemia
- Syndrome X (anginal chest pain w/ no angio abnormalities. Type of IHD, more common in post- and perimenopausal women)
Describe the immediate and long-term management of ACS
Immediate in all
- MONA
- Morphine, oxygen (only if needed)
- Nitrates (subling or IV) (caution in hypotension)
- Aspirin 300mg (in all)
- Then depends on ECG changes:
STEMI
- If PCI available within 120mins -> PCI
Give Prasugrel prior to PCI
- If PCI not available within 120mins -> thrombolysis
Give an antithrombin: fondaparinux (if low bleeding risk + angio not happening immediately) or unfrac heparin (if higher bleeding risk or immediate angio)
Give *ticagrelor *post-procedure
If ECG changes persist post-thrombolysis then PCI
N.B. Antiplatelets - switch to clopidogrel in all cases if high bleecing risk or patient already on anticoagulant
NSTEMI/Unstable Angina
If unstable e.g. hypotension -> immediate angio + PCI
Otherwise stratify risk using GRACE
- If high risk (3 or more%) - angio/PCI within 72h
Give unfractionated heparin and dual antiplatelts w/ prasugrel, ticagrelor or clopi (clopi if on anticoag already)
- If low risk (<3%) - conservative management - Dual antiplatelet therapy: Aspirin + ticgrelor (if low bleeding risk) or clopi (if high bleed risk)
Long-term/Secondary Prevention
ABCs
- ACEi
- B- blocker
- C - clopidogrel/Dual antiplatelet therapy
- S - statin
Give possible post-MI complications and how they present
Early Complications
Cardiac Arrest - most secondary to VF
Cardiogenic Shock
Tachycarrhytmia - e.g. VF
Bradyarrhythmia - AV block - esp w/ inferior MI
Pericarditis - common within first 48h -> pain worse lying down, pericardial rub, pericardial effusion on echo
Later Complications
Chronic Heart Failure = ACE + B-blockers improve long-term prog; loop diuretics for symptoms
Dressler’s Syndrome - 2-6/52 post-MI - autoimmune reaction -> fever, pleuritic pain, pericardial effusion + raised ESR.
Treat w/ NSAIDs
Left Ventricular Aneurysm - persistent STE + LV failure. Thrombus can form within the aneurysm, increasing stroke risk.
Left Ventricular Free Wall Rupture - - 1-2/52 post-MI -> acute HF secondary to cardiac tamponade (raised JVP, pulsus paradoxus, dimished heart sounds) - needs urgent pericardiocentesis + thoracotomy
Ventricular Septal Defect -
- Rupture of septum in 1st week -> acute HF, pan-systolic murmur
- Echo to exclude acute mitral regurg (presents v similar)
- Urgent surgical correction needed
Acute Mitral Regurgitation
- More common in infero-posterio MI -> ischaemia/rupture of pappilary muscle
- -> acute hypotension, pulmonary oedema, systolic murmur
- Vasodilators + emergency surgical repair
Stable Angina
- Presentation (+ how this is different to unstable)
- Investigation
- Management
Presentation
- Chest pain on exertion + relieved by rest
- Unstable: on minimal exertion/at rest and not relieved by rest/nitrates
Investigation
- ECG - often normal but can be changes
- Stress test - ECG, cardiact CT, stress echo/angio
Management
- In all:
Aspirin
Statin
GTN (2x 5 mins apart, then 999)
Lifestyle modification
1st line: B-blocker OR rate limiting CCB (eg. verapamil or diltiazem) (NEVER both together –> heart block)
2nd line: B-blocker PLUS non-rate limiting CCB (e.g. amlodipine or nifedipine)
3rd line - if above not tolerated: Long-acting nitrate (isosorbride mononitrate - if standard release need to give asymmetrical dosing to allow drug free period each day to reduce risk of resistance); Ivabradine, Nicorandinal, Ranalozine
(don’t add third drug alongside CCB/B-blocker unless awaiting PCI/CABG)
Aortic Dissection
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- Tear between tunica intima + media
- RFs: connective tissue disease, male, age 50-70, HTN, atherosclerosis
Stanford Classification
- Type A - involves ascending aorta. Can be confined to ascending aorta (DeBakey II) or propogate to aortic arch (DeBakey I)
- Type B - does not involve ascending aorta (DeBakey 3)
Presentation
- Tearing chest pain radiating to back
- Tachycardia, hypotension, new aortic regurg, end-organ hypoperfusion
- Backward tear -> aortic regurg/incompetence, inferior MI due to RCA involvement
- Forward tear -> unequal arm pulse/BP, stroke, renal failure
Investigation
Type A: surgical. Control BP between 100-120 systolic.
Type B - conservative, bed rest, reduce BP w/ IV labetolol to prevent progression
Tachycardia Algorithm
Are adverse features present?
- Yes –> synchronised DC shock (up to 3x, then help)
-Shock, Syncope, Myocardial Ischaemia, HF
If no adverse features:
Narrow QRS
Regular (SVT (AVNRT or AVRT))
- Vagal manoeuvres
- Adenosine IV (6mg, then 12mg, then 18mg)
- Verapamil or B-blocker
Irregular (probs AF)
- B-blocker
- Consider digoxin/amiodarone if evidence of HF
Broad Complex
Irregular - seek help, could be:
- AF w/ bundle branch block (treat as per irregular narrow)
- OR polymorphic VT (torsades) - 2g Mg IV over 10 mins (N.B. torsade is caused by long QT)
Regular
- VT - Amiodarone 300mg IV
- OR if previous certain SVT w/ BBB or aberrant conduction treat as SVT
For the regular rhythms (both broad + narrow) if above ineffecitve -> synchronised DC shock up to 3 attempts
Bradycardia Algorithm
A-E approach + treat reversible causes
Adverse features? (shock, syncope, myocardia ischaemia, HF)
If Yes –>
1. Atropine 500mcg IV (can repeat up to max of 3mcg)
2. Isoprenaline/ Adrenaline infusion OR transcutaneous pacing (+ seek help)
If No –>
Is there a risk of aystole? (recent asystole, mobitz II or complete heart block, ventricular pause >3s) –> treat as per adverse features
If No risk of asystole -> observe
How is HTN diagnosed?
What is the target BP aim?
Diagnosis
Stage 1 HTN
Clinic BP >140/90 AND ABPM/HBPM average >135/85
Stage 2 HTN
Clinic BP >160/100 AND ABPM/HBPM >150/95
Stage 3 HTN (Severe)
Clinical BP >180 OR Diastolic > 110
Basically:
Clinic Reading >180 = treat now
Same day specialist ref if: Malignant/Accelerated HTN (papilloedema or retinal haemorrhages) OR life-threatening Sx (new confusion, chest pain, HF or AKI) OR if suspecting phaeochromocytoma (labile/posutral hypotension, palps, pallor, diaphoresis, abdo pain)
Clinic reading >140 but <180 - ABPM/HBPM
ABPM/HBPM
<135/85 - not hypertensive
>135/85 = stage 1
>150/95 = Stage 2
Who to treat?
All Stage 2 or 3
Some stage 1:
- >80
- <80 PLUS one of: target end organ damage, establised CVS disease, renal disease, DM, QRISK 10% or more.
Blood Pressure Target
- <80yo
Clinic: 140/90
Home: 135/85
- >80yo
Clinic: 150/90
Home: 145/85
N.B. pts <40yo w/ stage 1 HTN should be referred - ? secondary cause
Give possible causes and features of secondary hypertension
Renal
- Nephritic syndrome (haematuria, HTN, drop in renal function)
- Pyelonephritis
- Adult polycystic kidney disease (HTN, abdo pain, haematuria, UTIs, stones)
- Renal artery stenosis (worsening kidney function w/ ACEi)
Endocrine
- Phaeochromocytoma (headache, sweating, flushing, tachy, postural hypotension)
- Hyperaldosteronism (e.g. conn’s) - raised Na, low K+
- Cushing’s (buffallo hump, moon face etc.)
- Liddle’s syndrome (rare genetic disorder caused by abnormal renal function)
- Congenital adrenal hyperplasia
- Acromegaly (too much GH)
Drugs
- Steroids
- MAOI
- COCP
- NSAIDs
- Leflunomide (DMARD)
What is involved in management of HTN?
Lifestyle advice
- Reduce salt, caffeine + alcohol
- Stop smoking
- Exercise/Weight loss
- Balanced diet
Medication
- <55 OR T2DM
1st: ACEi or ARB
2nd: add CCB or Thiazide-like diuretic
3rd: All 3
4th: If K+ <4.5 = spironolactone; if K+ >4.5 B-blocker or A-blocker
5th: specialist review
- > 55 and no T2DM OR Black ethnicity
1st: CCB
2: add ACEi/ARB or Thiazide-like diuretic (if black consider ARB rather than ACEi
3rd: All 3
4th: As above
5th: specialist
ACE Inhibitors
- Examples
- Side effects
- Cautions and contraindications
- Interactions
- Monitoring
Examples
Ramipril, enalapril
Side effects
- Dry cough
- Angioedema (can occur up to a year after starting)
- Hyperkalaemia
- 1st dose hypotension (esp if also taking diuretics)
Cautions + CI
- pregnancy/breastfeeding, renovascular disease (can worsen renal impairment), aortic stenosis (-> hypotension), hyperkalaemia
Interactions
- Hypotension (esp w/ diuretic use)
Monitoring
- U&Es before treatement + after any dose increase
- Increase in serum creat up to 30% from baseline + increase in K+ up to 5.5 is acceptable
- (N.B. significant renal impairment can occur in undiagnosed B/L renal artery stenosis)
ALS
- Give possible reversible causes of cardiac arrest
- Describe the ALS algorithm
Reversible causes
- 4 Ts: Thrombus, Tamponade, Tension pneumothorax, Toxins
- 5 Hs: Hypokalaemia (electrolyte imbalance), Hypoglycaemia, Hypothermia, Haemorrhage
ALS Algorithm
- Chest compressions: 30:2
- Every 2 mins check rhythm + shock as needed:
‘Shockable’ - VF, pulseless VT
‘Non-Shockable’ - Asystole, PEA
- Drugs
IV or IO
Adrenaline 1mg (1:10,000) ASAP for non-shockable OR after 3rd shock in shockable. Repeat every 2 cycles (4 mins)
Amiodarone 300mg after 3rd shock
Other
- Consider thrombolytic drugs if PE is suspected as cause
- If witnessed cardiac arrest whilst on monitor - give up to 3 successive shocks prior to CPR (f shockable rhythm)
Chronic Heart Failure
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
Causes: dilated cardiomyopathy, AF, ischaemia, HTN, valve abnormalities, myocarditis
Presentation
- SOBOE
NYHA
I - no limitation/symptoms
II - mild sx, ok at rest, ordinary activity leads to fatigue, SOB or palps
III - moderate - less than ordinary activity leads to symptoms
IV - severe, symptoms at rest
- PND, orthopnoea, wheeze, pink frothy sputum
Investigations
- BNP
>400 or >2000 NTproBNP = high = r/v within 2/52
>100-400 or >400-2000 - raised - r/v within 6/52
- Echo (if raised BNP)
Management
- Medications
- 1st: ACEi and B-blocker (start one at a time. Improve mortality in those w/ reduced EF)
- 2nd: aldosterone antagonist e.g. spironolactone or eplerenone (monitor K+ as both these + ACEi can increase it)
3rd: Specialist (eg. ivarbradine, Sacubitril-valsartan (NOT with ACEi/ARB), hydralazine, nitrate, digoxin)
(dig good w/ co-existant AF, Hydralazine + nitrate good for black ethnicity)
Other
- Cardiac Resynchronisation therapy - if wide QRS complex and EF <35%
- Annual influenza + one-off pneumococcal vaccine
- Exercise training
Describe the management of acute heart failure
1st: IV loop diuretics e.g. furosemide or bumetanide
Possible additional:
- O2
- Resp failure –> CPAP
- Hypotension (<85) –> inotropic agents, vasopressors, mechanical circulatory assistance
- Severe HTN, ischaemia or mitral/aortic regurg -> vasodilatros (nitrates)
N.B. continue normal reg HF meds alongisde. Only stop B-blockers if HR <50 or 2nd/3rd AV block
Atrial Fibrillation
- Presentation
- Investigation
- Management
Presentation
- Palpitations +/- SOB, tired, lightheaded, chest pain
- paroxysmal (self-terminating)
- Persistent (>7 days OR needs intervention to convert to sinus)
- Long-standing persistent - >1yr
- Permanent - patient/physician stop deciding to convert (acceptance)
Investigation
- ECG - irregularly irregular, no p waves
Management
Rhythm Control
- Emergency electrical cardioversion (if unstable)
- Elective pharm or electrical cardioversion:
Onset <48h –> heparinise PLUS electrical or pharm (amiodarone if structural heart disease OR flecainide) cardioversion
Onset >48h -> anticoag for 3/52 prior to electrical cardioversion. (or TOE to exclude left atrial appendage thrombus)
Then anticoag at least 4/52 (ongoing duration depends on risk of recurrence)
maintenance of rhythm control: B-blockers, dronedarone or amiodarone
**Rate Control **
Rate control is 1st line except: AF w/ reversible cause, HF primarily due to AF, new onset (<48h), flutter (ablation instead)
Can use:
B-blocker (CI in asthma)
CCB (verapamil or diltiazem)
DIgoxin (if person does little exercise or coexistent HF)
Catheter Ablation
- If AF doesn’t respond or who which to avoid antiarrhythmic meds
- Give Anticoags for 4/52 prior + continue after based on stroke risk (ablation controls rhythm but doesn’t alter stroke risk)
**Anticoagulation **- consider w/ any hx of AF (not just current AF)
- CHADVASC >/=1 in men or >/=2 in women
- Balance w/ bleeding risk: ORBIT score
- 1st: DOAC (apixaban, dabigatran, edoxaban, rivaroxaban)
- 2nd: warfarin (if DOAC CI or not tolerated)
N.B. Anticoagulation w/ DOAC should be started 2/52 after an ischaemic stroke
Aortic Stenosis - causes, presentation, management
Aortic Regurgitation - causes, presentation, management
Aortic Stenosis
Causes
- <65yo- bicuspid valve
- >65yo - degenerative calcification
- Other: William’s syndrome, post-rheumatic, HOCM
Presentation
- chest pain, SOB, syncope, extertional dizziness, ejection systolic murmur
- Narrow pulse pressure, slow rising pulse
Management
- asymptomatic - observe (UNLESS valv gradient >40 w/ LVSD)
- Symptomatic -> valve replacement or balloon valvuloplasty (if unfit for replacement)
Aortic Regurgitation
Causes
- Valve disease: rheumatic fever, calcification, IE, connective tissue disease
- Aortic root disease: aortid dissection, HTN, syphilis, Marfarn’s, Ehler Danlos
Presentation
- Early diastolic murmur, collapsing pulse, wide pulse pressure, quincke’s (nailbed pulsation), Dr Musset (head bobbing)
Echo to diagnose
Mangement
- Medical mx of associated HF
- Surgery if symptomatic severe AR OR asymptomatic w/ severe AR + LVSD
Hyperlipidaemia
- Lifestyle measures
- Primary Prevention
- Secondary Prevention
Lifestyle measures
- Cardioprotectice diet
- Physical activity
- Weight management
- Smoking cessation
**Primary Prevention **
Who to give it to?
-40-84yo w/ QRISK > 10%
-anyone >85
- Don’t use QRISK in T1DM OR CKD:
- T1DM - give primary prevention if: >40yo, DM for more than 10yrs, established nephropathy, other CVS risk factors (eg. HTN or obesity)
- CKD - atorvastatin 20 to all patients
(QRISK may underestimate risk in: HIV, serious mental health, meds causing dyslipidaemia eg. antipyschotic, steroids; or autoimmun disorders)
Primary prevention: Atorvastatin 20mg OD (if non HDL hasn’t falled by 40% then consider increasing to 80mg)
Secondary Prevention
- All patients w/ known IHD OR cerebrovascular disease OR peripherl arterial disease
- Atorvastatin 80mg
Measuring lipids
- results feed into QRISK score BUT if v high then need to conisder familial hypercholesterolaemia + Ix further if:
- Total cholesterol >7.5mmol/l and/or
- personal/fam hx of premature coronary heart disease (event before 60)
Statins
- Adverse Effects
- Contraindications
- Follow up/Monitoring
Adverse Effects
- Myopathy (myalgia, myositis, rhabdomyolysis, asymptomatic rise in CK)
- Liver Impairment - check LFTs at baseline, 3/12 and 12 months. Discontinue if transaminase conc 3x upper limit.
- Increased risk intracerebral haemorrhage in patient w/ prev stroke
Contraindications
- Macrolides (e.g. erythromycin, clarithromycin)
- Pregnancy (for all lipid lowering drugs - women w/ familial hypercholesterolaemia should stop meds 3/12 prior to trying to conceive)
Follow up
- At 3/13 should:
- repeat full lipid profile and LFTs
- If non-HDL cholesterol not dropped by at least 40% consider increasing dose to 80mg
What is Buerger’s Disease?
Buerger’s Disease (aka thromboangiitis obliterans) is a small/medium vessel vasculitis strongly associated w/ smoking
–> Extremity ischaemia (intermittent claudication + ischaemic ulcers)
–> Superficial thrombophlebitis
—> Raynaud’s phenomenom
Suspect in young smoking patients w/ symptoms similar to limb ischaemia
Wolff-Parkinson White
Pathophysiology
Presentation + ECG findings
Management
Pathophysiology
- congenital accessory conducting pathway (-> AVRT)
- Accessory pathway does not slow conduction so risk of AF –> VF
Presentation
- Asymptomatic
- Exertional dizziness, palpitations, SOB, chest pain, syncope
- arrest
ECG Findings
- Short PR interval
- Wide QRS complex w/ slurred upstroke (delta wave)
- LAD (if right sided pathway)
- RAD + dominant R wave in V1 (if left sided pathway)
Management
- Definitive: ablation of accessory pathway
- Medical: Sotalol (unless coexistent AF), amiodarone, flecainide
Dont give AV node blockers as risk of VF
DVLA Guidance. What are the rules in the following situations?
- Hypertension
- Elective Angioplasty
- CABG
- ACS
- Angina
- Pacemaker insertion
- ICD
- Successful catheter ablation for arrhythmia
- Aortic aneurysm >6cm
- Heart transplant
Also for the acute MI how long till return to sexual intercourse? How long till return to work?
Hypertension
- drive as normal BUT if bus/lorry no driving if BP consistently >180 syt or 100 diastolic
Angioplasty (elective)
- 1/52 off
CABG
- 4/52 off
ACS
4/52 off OR 1/52 if successfully treated w/ angioplasty
Angina - stop if symptoms at rest/at wheel
Pacemaker - 1/52 off
ICD - if done for sustained ventricular arrhythmia no driving for 6/12. If done prophylactically no driving for one month.
Successful catheter ablation - 2 days off
Aortic aneurysm >6cm - notify DVLA. Annual review. If >6.5cm no driving.
Heart transplant - no driving for 6/52
MI - return to SI after 1/12. Return to work (most jobs) after 2/12.
Prolonged QT interval
- Presentation, ECG findings + complications
- Causes
- Management
Causes
Congenital
- Long QT Syndrome. 3 subtypes: QT1, 2, 3.
- Jervell-Lange-Nielsen syndrome
- Romano - ward syndrome
Drugs
Amiodarone
Sotalol
TCAs, SSRIs (esp citalopram)
Methadone
Erythryomycin
Haloperidol
Ondansetron
Other
Hypocalcaemia, hypokalaemia, hypomagnesaemia
Acute MI
Myocarditis
Hypothermia
Subarachnoid
Presentation
Long QT syndrome:
QT1 - exertional syncope, often swimming
QT2 - syncope following emotional stress, auditory stimuli or exercise
QT3 - events often at night or at rest
Sudden cardiac death
Management
- Avoid drugs which prolong QT interval + other precipitants if appropriate
- B-Blockers
- ICDs in high risk cases
Prolonged QT interval
- Presentation, ECG findings + complications
- Causes
- Management
Causes
Congenital
- Long QT Syndrome. 3 subtypes: QT1, 2, 3.
- Jervell-Lange-Nielsen syndrome
- Romano - ward syndrome
Drugs
Amiodarone
Sotalol
TCAs, SSRIs (esp citalopram)
Methadone
Erythryomycin
Haloperidol
Ondansetron
Other
Hypocalcaemia, hypokalaemia, hypomagnesaemia
Acute MI
Myocarditis
Hypothermia
Subarachnoid
Presentation
Long QT syndrome:
QT1 - exertional syncope, often swimming
QT2 - syncope following emotional stress, auditory stimuli or exercise
QT3 - events often at night or at rest
Sudden cardiac death
Management
- Avoid drugs which prolong QT interval + other precipitants if appropriate
- B-Blockers
- ICDs in high risk cases
Cardiac Tamponade
Causes
Presentation
Management
Causes
- Left ventricular free wall rupture (post-MI)
- Dissecting aortic aneurysm
- Post-surgery
- Pericarditis
- Trauma
Presentation
Beck’s Triad: Raised JVP, muffled heart sounds, hypotension
Other: SOB, tachy, pulsus paradoxus (drop in BP in inspiration)
ECG: electrical alternans (alternating amplitude of QRS between beats)
