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Medicine > Cardiology > Flashcards

Cardiology Flashcards

cardiac arrest ACS HF

1
Q

Approach to Cardiac Arrest

A

Assess for responsiveness — if no response + No HR = call for help + ask someone to bring AED or crash cart

commence good quality CPR — if sufficient people, switch every 2 mins

once help arrives — set up AED and check ABCDs

for ABCDs,
bag and mask patient — if expertise present, can consider intubation
for adult = breath every 5-6s; for child = breath every 3s
insert IV cannula if not alr present — once set = give 1mg IV epinephrine

for AED
connect patient to AED
stop CPR to check rhythm
if pulseless VT or VF = start charging up AED machine to 120J — commence CPR while waiting — once charged up — check for all clear then administer shock – continue CPR for another 2 mins

if PEA or asystole = continue CPR (non-shockable rhythms)

give 1mg IV epinephrine every 3-5 mins (ie every 2 cycles of pulse check)

pulse check every 2 mins

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2
Q

what is the NYHA Classification

A

it is the new york heart association’s classification of heart failure symptoms

it is sometimes used to gauge exercise tolerance in elderly

class I: no symptoms & limitations in ordinary physical activity
Class II: slight limitation of physical activity —- ordinary physical activity causes mild symptoms (eg. fatigue, SOB, angina)
Class III: marked limitation of physical activity —- less than ordinary physical activity leads to symptoms
class IV: severe limitation of physical activity —- symptoms even at rest

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3
Q

compare STEMI vs NSTEMI vs unstable angina

A

cardiac sounding chest pain: all 3 yes

ECG Changes
STEMI = ST elevation or new LBBB
NSTEMI = ST depression or T wave inversion
UA = normal or non-specific changes

troponin rise
STEMI + NSTEMI = Y
UA = N

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4
Q

risk factors for acute coronary syndrome

A

prior Hx of ACS
fam Hx — 1st degree relative <55 y/o M OR <65 y/o F
smoking, alcohol
gender — M&raquo_space; F
hypercholesterolaemia
HTN
DM
obesity

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5
Q

presentation of acute coronary syndrome

A

symptoms (Hx)
chest pain — acute + central + crushing +/- radiation to left jaw, neck, arm
palpitations
syncope
nausea & diaphoresis
SOB
exercise-related angina
bilateral LL swelling

signs (exam)
levine’s sign +ve — individual holding a clenched fist over his chest
implies ischaemia

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6
Q

Ix for suspected ACS acute coronary syndrome

A

bloods
FBC — r/o low platelets as C/I to thrombolysis
serial cardiac biomarkers – trops + CKMB
U&E
CRP
fasting lipids
HbA1c
d-dimers

CXR
ECHO – TTE/TOE
ECG

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7
Q

____ infarct = ST elevation in ___ leads = ____ coronary A is blocked

A

inferior infarct = leads II III avF = RCA right coronary A blocked

lateral infarct = leads I aVL V5 V6 = LCx or diagonal

septal infarct = leads V1 V2 = proximal LAD

anterior infarct = leads V3 V4 = distal LAD

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8
Q

diagnostic criteria of STEMI or NSTEMI

A

raised troponin above ULN + at least 1 of following

symptoms of acute MI — ie acute onset central crushing chest pain for at least several mins

new ischaemic ECG changes

ST elevation in 2 contiguous leads
>1mm in all leads except V2-V3
V2-V3:
F = >1.5mm
M >40 y/o = >2 mm
M <40 y/o = > 2.5 mm

ST depression or T wave inversion
ST depression = >0.5mm in 2 contiguous leads
T wave inversion = >1mm in 2 contiguous leads

imaging evi of new loss of viable myocardium or new regional wall motion abnormality

identification of coronary thrombus by angiography or autopsy

development of pathological Q waves

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9
Q

risk stratification scoring system for UA unstable angina and NSTEMI non-ST elevation myocardial infarction

A

TIMI score — thrombolysis in MI score

predicts likelihood of further thrombotic events in UA or NSTEMI

acc to age, risk factors (hypercholesterolaemia, DM), ECG changes, angina events, cardiac biomarkers

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10
Q

Tx of ACS acute coronary syndrome

A

conservative Tx — prevention
lifestyle changes — increased exercise, reduced salt & fat intake
smoking cessation
tighter glycaemic control (if DM)

acute Tx

ABCDEs
2 wide bore 14-16G IV Cannulas
supplementary O2 if SpO2 <90%

call senior help

if ACS suspected = DAPT — aspirin 300 mg + ticagrelor 180mg
if high bleeding risk = clopidogrel 600 mg + aspirin 300 mg

definitive Tx:

if STEMI = call cardiology
<120mins from symptom onset = PCI
>120 mins = thrombolysis as long as no C/I

if NSTEMI = call cardiology
continue ECGs if ongoing pain
serial data (ECG + trops)
if persistent pain despite analgesia = consider urgent revascularisation
or if high NSTEMI/UA = PCI within 72 hrs

other than definitive Tx:

anticoagulate — LMWH pr UFH

place defibrillator pads on patient – in case of arrest, VFib or VT

analgesia — 2.5mg cyclomorph IV and/or IV paracetamol
if SBP >90 + not inferior MI = consider GTN spray sublingually or patch

+/- rate control or anti=arrhythmics — beta blockers of amiodarone
C/I: anterior or lateral infarcts

monitor for ventricular failure
if acute LV decomp = IV diuresis, nitrates, CPAP
if hypotension = consider inotropes, intra-aortic balloon pump, LVAD

long term Tx

conservative
physio — exercise
cardiac nurse specialist – symptoms + care
dietician — healthy eating + tighter glycaemic control + lowering lipids
MSW
OT

medical Tx
rhythm control — beta blocker
antihypertensive – ACEI
continue antiplatelets for at least 12 months following PCI
lipid lowering agents
review comorbidities — DM, HF, etc

surgical tx = consider CABG if required

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11
Q

what is HF heart failure

A

structural or functional cardiac abnormality — causing reduced CO or elevated intra-cardiac P at rest or during stress

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12
Q

types of HF heart failure + diagnostic criteria

A

HFrEF HF reduced ejection fraction
LVEF <40%
criteria: S&S of failure + LVEF <40%

HFpEF HF preserved EF
LVEF >50%
criteria: elevated BNP + at least 1 of
LV hypertrophy/LA enlargement
diastolic dysfunction

HF mid-range EF
LVEF 40-50%
same criteria as HFpEF

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13
Q

cause of HF heart failure

A

diseased myocardium:
IHD
toxicity — chemo, alcohol, thiamine deficiency
infiltrative — amyloidosis, sarcoidosis, haemochromatosis
genetics — HOCM, dilated cardiomopathy

abnormal loading conditions:
HTN
congenital — AV septal defect, valvular disease
constrictive pericarditis
fluid overload — renal failure or iatrogenic

arrhythmia

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14
Q

risk factors for HF heart failure

A

CVS Hx
prev MI
arrhythmia
valvular patho
HTN
congenital – HOCM, dilated cardiomyopathy

endocrine – DM

renal failure

drug use — cocaine

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15
Q

presentation of HF heart failure

A

symptoms (Hx)
SOB — acc to NYHA classification
orthopnoea, PND
cough — productive
chest discomfort
weight gain

signs (exam)
bilateral LL oedema
dyspnoea
peripheral cyanosis
raised JVP

chest
scars — prev CABG or valve replacement
parasternal heave — ? right HF
displaced apex beat — ?LV hypertrophy
3rd heart sound or gallop rhythm
pulmonary oedema

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16
Q

Ix for HF heart failure

A

bloods
BNP — ?acute decomp HF
cardiac biomarkers — troponin, CKMB
FBC
U&E
CRP

CXR — ?pulmonary oedema, LRTI, pneumothorax
cardiac MRI or ECHO
ECG
coronary angiogram

17
Q

Tx of HF heart failure

A

acute decomp HF

ABCDEs
supplementary O2 — consider CPAP if continuing to desaturate
2 wide bore 14-16 G IV Cannulas
urinary catheters – monitor U/O

call for senior help

ask patient to sit upright

medical Tx
IV loop diuretics — only if SBP > 100 mmHg
analgesia
if SBP >90 + no inferior MI = GTN — vasodilator
if SBP <90 = inotropes — eg. dobutamine

xfer to resus/CCU/HDU — if failing to respond to Tx

chronic Tx

conservative Tx
reduced cholesterol
control BP
stop smoking, reduce alcohol intake
maintain healthy BMI
strict glycaemic control
education re HF

medical Tx
acc to HFrEF vs HFpEF; symptomatic vs asymptomatic

if asymptomatic + HFpEF = no specific medical Tx
monitor EF w regular ECHO

if asymptomatic + HFrEF
if prior MI = ACEI + beta blocker
if severely reduced EF (<30% = insert ICD implantable cardiac defibrillator
reduce risk of sudden cardiac death

if symptomatic + HFpEF
symptomatic relief = diuretics
address co-morbidities w MDT

if symptomatic + HFrEF
ACEI/ARB + beta blockers
if stil cmi = ARNIs
ARNIs = angiotension neprilysin inhibitors — sacubitril/valsartan
if still symptomatic = spironolactone
diuretics
cardiac devices: ICDs, CRT cardiac resnchronisation therapy

surgical Tx = LVAD or transplant
indication: NYHA class IV + either of
failing therapy w intractable symptoms
increasingly recurrent hospital admissions required inotropes

18
Q

diagnostic criteria for chronic HF

A

framingham criteria

interpretation:
2 major criteria
OR 1 major + 2 minor criteria

major criteria — SAW PANIC
S: S3 heart sound
A: acute pulmonary oedema
W: weight lost > 4.5kg in 5 days when Tx
P: PND
A: abdominojugular reflux — ie hepatojugular reflux (JVP remains elevated)
N: neck V distended — ie elevated JVP
I: increased cardiac diameter on CXR
C: bibasal crackles of lungs

minor criteria — HEART ViNo
(cannot be attributable to other medical conditions)
H: hepatomegaly
E: pleural effusion
A: bilateral ankle oedema
R: exeRtional dyspnoea
T: tachycardia
Vi: vital capacity decreased by 1/3 max value
No: nocturnal cough

19
Q

CXR findings of HF

A

ABCDE
A: alveolar oedema
B: kerley B lines
C: cardiomegaly
D: upper lobe diversion
E: pleural effusion

20
Q

causes of severe pulmonary oedema

A

cardiogenic: MI, arrhythmia
fluid overload — cardiogenic, renal, iatrogenic
ARDS — sepsis, post-op, trauma
upper airway obstruction
neurogenic: head trauma

21
Q

Tx of severe pulmonary oedema

A

ABCDs
get patient to sit up
supplementary O2 if SpO2 <94%
ensure IV cannula inserted

call for senior help

furosemide 40-80mg IV
If SBP >90 = GTN 2 puffs or 2x 300 micrograms sublingually
If SBP >100 = IV nitrates

analgesia — diamorphine 2.5-5mg IV + metochlopramide 10mg

others
VTE prophylaxis
monitor weight, daily CXR

22
Q

causes of cardiac tamponade

A

trauma
lung/breast ca
pericarditis
MI
bacteria

23
Q

presentation of cardiac tamponade

A

signs (exam)

Beck’s triad
reduced BP – despite fluid resus
increased JVP
muffled heart sounds

kussmaul’s sign: increased JVP on inspiration
also seen in constrictive pericarditis

pulsus paradoxus — >10 mmHg SBP drop on inspiration

others:
SOB
increased HR
absent Y descent of JVP
impalpable apex beat

24
Q

Ix for cardiac tamponade + expected findings

A

ECG — findings
low voltage QRS
+/- electrical alternans (changing QRS magnitude between beats)

CXR — large globular heart

ECHO/eFAST —- equal diastolic P in all 4 chambers

25
Q

Tx of cardiac tamponade

A

ABCs
2 wide bore 14-16G IV Cannulas — fluid resus

pericardiocentesis under US guidance
eq: 20ml syringe + long 18G IV cannula
location: 45 degrees + just left of xiphisternum — aiming for tip of left scapula
aspirate continuously
monitor: ECG
send fluid for: cytology, Ziehl-Neelson stain, culture

Medicine (18 decks)

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