Cardiology

Question 1

Thrombolytics for AMI

Answer 1

Indications:
STEMI or equivalent (STE >1mm in two contiguous limb leads or > 2mm in two contiguous chest leads)
New or presumed new LBBB
Chest pain > 30m and < 12hrs
No PCI within 90minutes of first medical contact

Contraindications:
Active bleeding
Suspected aortic dissection
Closed head trauma within 3 months
Prior ICH
Ischaemic stroke within 3 months
Cerebral vascular lesion or neoplasm

Anticoagulants
Major surgery < 3 weeks
Traumatic CPR > 10 minutes
Recent internal bleeding
Uncontrolled HTN > 180s 110d
Ischaemic stroke > 3 months
Pregnancy

Tenecteplase dosing:
<60kg 6000u 30mg
>60 <70 7000u 35mg
>70 <80 8000u 40mg
>80 <90 9000u 45mg
> 90 10000u 50mg

Question 2

Sgarbossa criteria

Answer 2

Diagnosis of STEMI in LBBB:
Concordant STE in leads with positive QRS > 1mm
Concordant STD in leads V1-3 > 1mm
Discordant STE > 5mm in leads with negative QRS

Modified Sgarbossa:
Concordant ST elevation ≥ 1 mm in ≥ 1 lead
Concordant ST depression ≥ 1 mm in ≥ 1 lead of V1-V3
Proportionally excessive discordant STE in ≥ 1 lead anywhere with ≥ 1 mm STE, as defined by ≥ 25% of the depth of the preceding S-wave

Question 3

ECG in syncope

Answer 3

AV block
Brugada
C QTc prolongation
Delta waves
Epsilon waves
Left - LVH (HOCM)
Right - RV strain

Question 4

Syncope causes

Answer 4

CHESS mnemonic
- Congestive cardiac failure
- HCT < 30%
- ECG changes
- Systolic < 90
- Shortness of breath

Head
- vasovagal
- epilepsy
Heart
- ABCDE left right
- aortic stenosis
Vessels
- aortic dissection
- PE

Question 5

Causes of Bradycardia

Answer 5

Intrinsic cardiac causes: cardiomyopathy, sick sinus, conduction system disease, ischaemia
Infection: endocarditis, rheumatic heart disease
Hypothermia - Osborn J waves
Electrolytes: hyper/hypokalaemia
Drugs
Raised ICP
Hypothyroidism

Question 6

Osborn J waves

Answer 6

Hypothermia
Hypercalcaemia

Question 7

AF management

Answer 7

PIRATES mnemonic
- pulmonary
- ischaemia
- rheumatic heart disease
- alcohol or anaemia
- thyrotoxicosis and stimulanta
- electrolytes and endocarditis
- sepsis

Steps:
Identify and treat reversible pathology such as sepsis or electrolyte correction.
Decide on rate or rhythm control
Prevent thromboembolism

Consider if stable or unstable
- if unstable DC cardioversion

If stable:
Consider rate or rhythm control:
- if AF < 48hrs and healthy can rhythm control with amiodarone 150-300mg over 20 minutes or dc cardioversion.
- if > 48 hrs or unknown then give beta blockers 25mg metoprolol.
- if poor LV function give digoxin loading 250-500mcg IV

Consider CHADSVASC and HASBLED score for anticoagulation.

Question 8

CHADS VASC score

Answer 8

CCF
Hypertension
Age > 75
Diabetes
Stroke
Vascular disease

If score 1 or more are moderate to high risk for stroke

Question 9

HAS BLED score

Answer 9

Hypertension
Abnormal LFTs or renal function
Stroke
Bleeding diathesis
Labile INR
Elderly
Drugs or alcohol

Score > 3 high risk