Cardiology Flashcards
cardiac arrest ACS HF
Approach to Cardiac Arrest
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
what is the NYHA Classification
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
compare STEMI vs NSTEMI vs unstable angina
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
risk factors for acute coronary syndrome
prior Hx of ACS
fam Hx — 1st degree relative <55 y/o M OR <65 y/o F
smoking, alcohol
gender — M»_space; F
hypercholesterolaemia
HTN
DM
obesity
presentation of acute coronary syndrome
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
Ix for suspected ACS acute coronary syndrome
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
____ infarct = ST elevation in ___ leads = ____ coronary A is blocked
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
diagnostic criteria of STEMI or NSTEMI
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
risk stratification scoring system for UA unstable angina and NSTEMI non-ST elevation myocardial infarction
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
Tx of ACS acute coronary syndrome
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
what is HF heart failure
structural or functional cardiac abnormality — causing reduced CO or elevated intra-cardiac P at rest or during stress
types of HF heart failure + diagnostic criteria
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
cause of HF heart failure
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
risk factors for HF heart failure
CVS Hx
prev MI
arrhythmia
valvular patho
HTN
congenital – HOCM, dilated cardiomyopathy
endocrine – DM
renal failure
drug use — cocaine
presentation of HF heart failure
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
Ix for HF heart failure
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
Tx of HF heart failure
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
diagnostic criteria for chronic HF
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
CXR findings of HF
ABCDE
A: alveolar oedema
B: kerley B lines
C: cardiomegaly
D: upper lobe diversion
E: pleural effusion
causes of severe pulmonary oedema
cardiogenic: MI, arrhythmia
fluid overload — cardiogenic, renal, iatrogenic
ARDS — sepsis, post-op, trauma
upper airway obstruction
neurogenic: head trauma
Tx of severe pulmonary oedema
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
causes of cardiac tamponade
trauma
lung/breast ca
pericarditis
MI
bacteria
presentation of cardiac tamponade
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
Ix for cardiac tamponade + expected findings
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
