Cardiology Flashcards
What are the uses of ACE inhibitors?
1st line <55 y/o and/or T2DM for hypertension
Used in diabetic nephropathy
2ndry prevention in IHD
What is the MOA of ACEi?
inhibit the conversion on Angiotensin 1 to Angiotensin 2
activated by Phase 1 metabolism in the liver
What are the side effects of ACEi?
- cough (due to raised bradykinin levels)
- angioedema
- Hyperkalaemia
- 1st dose hypotension (more common in patient’s taking diuretics)
What are the cautions/ C.I of ACEi?
- breast feeding/ pregnancy - avoid
- hereditary angioedema
- renovascular disease (renal artery stenosis)
- Aortic stenosis - can cause hypotension
What are the monitoring requirements for ACEi?
initial U+Es on initiation and on dose increase
up to 30% increase from baseline in creatinine
up to 25% fall in eGFR
K+ level up to 5..5 mol/l
What is Acute Pericarditis?
the inflammation of the pericardial sac,
lasts <4-6 weeks
list the possible causes of Acute Pericarditis?
- Viral (Coxasckie)
- post MI
>early: fibrinous pericarditis
> late (weeks/months): autoimmune (Dressler’s syndrome) - SLE/Rheumatoid arthritis
- Hypothyroidism
- Lung/ Breast cancer
list the symptoms of pericarditis?
Pleuritic chest pain
non productive cough
dyspnoea
flu-like symptoms
pericardial rub
symptoms improved on sitting forward (worse on lying flat)
What are the common ECG changes seen in Pericarditis?
- global/widespread ST and PR segment changes
> ST: saddle-shaped ST elevation
> PR: PR depression
What is the most specific ECG changes for Pericarditis
widespread PR depression
What investigation is required for all patients suspected of pericarditis
ECG
transthroacic echo
bloods: infection markers + troponin
What is the management of acute pericarditis?
NSAIDS + colchicine (until symptom resolution and normalisation of inflammatory markers)
What is the main use of adenosine?
to terminate SVT
What drug enhances the affects of Adenosine?
Dipyridamole (Antiplatelet)
What drug blocks the effects of Adenosine?
Theophylline’s
In what patient group should Adenosine be AVOIDED in?
Asthmatics
What is the MOA of Adenosine
transient heart block in AV node (agonist of A1 receptor)
List the possible side effects of Adenosine
- chest pain
- bronchospasm
- Transient flushing
- enhances conduction down accessory pathways –> increases ventricular rate (WPW syndrome)
List the possible side effects of Adenosine
- chest pain
- bronchospasm
- transient flushing
- enhance conduction down accessory pathways - increase ventricular rate (WPW syndrome)
What type of drug is Amiodarone?
Class III anti-arrhythmic
used to repeat atrial, nodal and ventricular tachycardias
What type of drug is Amiodraone?
Class III anti-arrhythmic
used to repeat atrial, nodal and ventricular tachycardias
What is the MOA of Amiodraone
- blocks potassium channels inhibiting depolarisation (hence prolonged AP)
- also blocks Na channels (class I effect)
What effect does amiodarone have on the P450 system?
P450 inhibitor (reduces metabolism of warfarin)
What is the initial monitoring of Amiodraone?
What are the main monitoring parameters of Amiodarone?
TFTs, LFTs every 6 months
List the possible side effects of Amiodarone?
- Hypo/Hyperthyroidism
- slate-grey appearance
- corneal deposits
- pulmonary fibrosis/ pneumonitis
- liver fibrosis/ hepatitis
- peripheral neuropathy (myopathy)
- photosensitivity
- thrombophlebitis - injection site reaction
- Bradycardia
- QT prolongation
List the possible side effects of Amiodarone?
What is the initial monitoring of Amiodraone?
TFTs, LFTs, U+E + CXR prior
What is the MOA of Amiodarone?
- blocks potassium channels inhibiting depolarisation (hence prolonged AP)
- also blocks Na channels (class I effect)
What is the MOA of Amiodarone?
- blocks potassium channels inhibiting depolarisation (hence prolonged AP)
- also blocks Na channels (class I effect)
What is the initial monitoring of Amiodarone?
TFTs, LFTs, U+E + CXR prior
Define Angina pectoris
clinical syndrome of chest pain on exertion, secondary to myocardial ischaemia. It is due to the narrowing of the arteries, secondary to coronary heart disease
NICE defines as:
1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2. precipitated by physical exertion
3. relieved by rest or GTN in about 5 mins
What are the features of stable angina
- classically left sided chest pain, may radiate to the left arm/neck
- dyspnoea
- nausea, lightheadedness and fatigue
what artery and ECG leads correlate to the anterolateral area of the heart?
artery: left coronary artery
ECG: I aVL, V3-6
what artery and ECG leads correlate to the anterior area of the heart?
artery: left anterior descending
ECG: V1-4
what artery and ECG leads correlate to the lateral area of the heart?
artery: circumflex
ECG: I, aVL, V5-6
what artery and ECG leads correlate to the inferior area of the heart?
artery: inferior
ECGL II, III, aVF
What can happen if you use verapamil and a beta-blocker together
risk of complete heart block
What is the common management of all patients with ACS?
- Aspirin 300mg
- O2 if stats <94%
- IV morphine + anti-emetic
- Nitrates sublingually or IV - be cautious in hypotension
How do you define a STEMI?
- clinical symptoms consistent with ACS (generally of >20 minutes)
- with persistent (>20 minutes) ECG features in 2 contiguous leads
What are the ECG changes that define a STEMI?
ECG features in >2 contiguous leads of:
- 2.5 mm (i.e. >2.5 small squares) ST evolution in leads V2-3 in men <40 yrs
—> OR >2 mm (>2 small squares) ST elevation in leads V2-3 in men >40 yrs
- 1.5 mm ST elevation in V2-3 in women
- 1mm ST elevation in other leads
- new LBBB (LBBB should be considered new unless there is evidence otherwise)
When should primary percutaneous coronary intervention be offered to patient with confirmed STEMI?
- if the presentation is within 12 hours of the onset of symptoms
- PCI can be delivered within 120 minutes
NB: if patients present after 12 hours and still have evidence of ongoing ischaemia - then PCI should still be considered
When should fibrinolysis be offered to patients with confirmed STEMI?
within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes
HOWEVER if an ECG taken 90 minutes after fibrinolysis shows no resolution of the ST elevation - the patient requires PCI
What medications must be given prior to pPCI
dual anti platelet therapy i..e Aspirin + another drug
- if the patient is NOT taking an oral anticoagulant: Prasugrel
- if patient IS taking an oral anticoagulant: Clopidogrel
What drug therapies are given during pPCI?
patients undergoing PCI with radial access:
- unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI) - this is the action of using a GPI during the procedure when it was not intended from the outset, e.g. because of worsening or persistent thrombus
patients undergoing PCI with femoral access:
- bivalirudin with bailout GPI
following fibrinolysis what should be performed
an ECG after 60-90 minutes to see if the ECG changes have resolved. if the patient haves persistent myocardial ischaemia, then PCI should be considered
What medication is given alongside fibrinolysis
antithrombin
what medication is given after fibrinolysis
Ticagrelor
What is the medical management of an STEMI?
HINT: BATMAN
B - Base the decision about angiography and PCI on the GRACE score
A- Aspirin 300mg stat dose
T - Ticagrelor 180 mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M - Morphine titrated to control pain
A- Antithrombin therapy with fondaparinux (unless high bleeding risk of immediate angiography)
N-Nitrate (GTN)
Give oxygen only if their saturation drops
What is the GRACE score
the GRACE score gives a 6-month probability of death after having an NSTEMI
- age
- heart rate, BP
- cardiac (Fillip class) and renal function (serum creatinine)
- cardiac arrest on presentation
- ECG findings
- troponin levels
3% or less is considered low risk
>3% is considered edict to high risk
what medications are used as a secondary prevention for ACS?
HINT: 6 A’s
Aspirin 75mg OD indefinitely
Another Anti-platelet e.g. ticagrelor or clopidogrel0 for 12 months
Atorvastatin 80mg OD
ACEi
Atenolol (or another beta blocker - usually bisoprolol)
Aldosterone antagonist for those with clinical heart failure 9i.e. eplerenone tirade to 50mg OD)
list some possible complications of myocardial infarction
- cardiac arrest
- cardiogenic shock (may require inotropic support and/or an intra-aortic balloon pump)
- chronic heart failure (loop diuretics e.g. furosemide will decrease fluid overload, ACEi +BBB are shown to improve long-term prognosis)
-VF/VT
AV node block is more common following inferior MI
