Cardiology Flashcards
What is angina
classic cardiac pain that is felt when there is a reduction in blood supply to the heart.
What are the conditions that cause angina?
coronary spasm
severe ventricular hypertrophy
severe aortic stenosis
What other cardiac event can angina lead to?
Myocardial infarction (MI)
Cardiac arrest
Death
What is the difference between stable and unstable angina?
Stable angina:
- Pain that occurs predictably with physical/emotional exertion
- last no longer than 10 min
- reliever within minutes of rest/ use of GTN spray
Unstable angina:
-deterioration in stable
- increases with frequency and severity
- pain experienced at rest
Risk factors of angina
High cholesterol
Hypertension
Smoking
Diabetes
Obesity
Age
Family history
Male sex
Premature menopause
What are the steps in atherosclerosis?
endothelial dysfunction
plaque formation
plaque rupture
Clinical features of Angina?
- Constricting pain experienced in the chest +/- typical radiation to the arm/neck/jaw
- Precipitated by physical exertion
- Relieved by rest or GTN within 5 minutes
what are the features that can indicate Coronary heart disease?
Dyspnoea
palpitation
syncope
What are the features that require immediate medical attention?
Chest pain that lasts > 10min
Chest pain not relieved by 2 does of GTN
significant worsening/deterioration in angina
investigations for Angina
- Physical examination (e.g., heart sounds, signs of heart failure, blood pressure and BMI)
- ECG (a normal ECG does not exclude stable angina)
- FBC (anaemia)
- U&Es (required before starting an ACE inhibitor and other medications)
- LFTs (required before starting statins)
- Lipid profile
- Thyroid function tests (hypothyroidism or hyperthyroidism)
- HbA1C and fasting glucose (diabetes)
- Cardiac stress testing
- invasive coronary angiography
- CT coronary angiography
What is the management for angina?
Refer to cardiology
Advise them about the diagnosis, management and when to call the ambulance
Medical treatment
Procedural/surgical intervention
Secondary prevention
What is the fist-line medical management when experiencing angina?
sublingual glyceryl trinitrate (GTN)
How should a patient use the medication when experiencing angina?
Take the GTN when the symptoms start
Take a second dose after 5 minutes if the symptoms remain
Take a third dose after a further 5 minutes if the symptoms remain
Call an ambulance after a further 5 minutes if the symptoms remain
What are the side effects of using medication for angina?
GTN side effects:
- headaches
- dizziness
What are the medications for long-term symptomatic relief in angina?
Bisoprolol (beta-blocker)
Diltiazem/Verapamil (CCB)
What are the secondary prevention medications for angina?
A – Aspirin 75mg once daily
A – Atorvastatin 80mg once daily
A – ACE inhibitor (if diabetes, hypertension, CKD or heart failure are also present)
A – Already on a beta blocker for symptomatic relief
What are the surgical interventions offered to people with angina/CAD?
Percutaneous coronary intervention (PCI)
Coronary artery bypass graft (CABG)
Where does the catheter insert in a percutaneous coronary intervention (PCI)?
brachial/femoral artery
What are the 3 main options for graft vessels in Coronary artery bypass graft (CABG)
Saphenous vein (harvested from the inner leg)
Internal thoracic artery, also known as the internal mammary artery
Radial artery
How can you tell that a patient may have coronary artery disease?
Check for:
- midline sternotomy scar
- Great saphenous vein harvesting
- brachial artery access
- femoral artery access
What is Acute coronary syndrome (ACS) caused?
The result of a thrombus from an atherosclerotic plaque blocking a coronary artery.
What are the three types of acute coronary syndrome?
- Unstable angina
- ST-elevation myocardial infarction (STEMI)
- Non-ST-elevation myocardial infarction (NSTEMI)
what arteries does the right coronary artery(RCA) supply?
- Right atrium
- Right ventricle
- Inferior aspect of the left ventricle
- Posterior septal area
What arteries does the left coronary artery(LCA) supply?
- Circumflex artery
- Left anterior descending (LAD)
What arteries does the circumflex artery supply?
- Left atrium
- Posterior aspect of the left ventricle
What arteries does the left anterior descending (LAD) supply?
Anterior aspect of the left ventricle
Anterior aspect of the septum
What are the presentation of acute coronary syndrome?
Typically presents with central, constricting chest pain with:
- Pain radiating to the jaw or arms
- Nausea and vomiting
- Sweating and clamminess
- Dizziness
- syncope
- Shortness of breath
- Palpitations
What is the condition in a condition where someone does not experience typical chest pain during acute coronary syndrome?
What risk factor can it cause?
Silent myocardial infarction
likely cause with people with diabetes
List the ECG changes in acute coronary syndrome for STEMI and NSTEMI
STEMI
-ST-segment elevation
- New left bundle branch block
NSTEMI
- ST segment depression
- T wave inversion
What does the mnemonic ‘CPAIN’ stand for, and what is it used for?
Initial management for acute coronary syndrome
Call an ambulance
Perform an ECG
Aspirin 300mg
Intravenous morphine for pain relief
Nitrate (GTN)
Patients with STEMI presenting within _________ of onset should be discussed urgently with the local cardiac centre.
Patients with STEMI presenting within 12 hours of onset should be discussed urgently with the local cardiac centre.
What medication is given in Preparation for PCI?
Aspirin & prasugrel
What emergency test to test for STEMI?
Cardiac myosin-binding protein (cMyC)
1st-line treatment for STEMI
Aspirin 300mg
What management do you do if the patient has a STEMI within 12hrs?
Percutaneous coronary intervention (PCI) within 90min of arrival
Thrombolysis (if PCI is not available)
What management do you do if the patient has a STEMI after 12 hours?
BATMAN
B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg 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 or immediate angiography)
N – Nitrate (GTN)
What is a STEMI?
Complete acute blockage of coronary artery
What are the tools that find the probability of death after having an ACS?
GRACE score
What are the 4 types of MI?
Type 1: Traditional MI due to an acute coronary event
Type 2: Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension)
Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event
Type 4: MI associated with procedures such as PCI, coronary stenting and CABG
Hypertension
- Stages
- when will you do further investigation?
- What investigation?
- tool that help calculates risk of having a MI/stroke in the next 10 yrs
- what treatment / management
-ABPM/HBPM
1- 135/85-149-94
2- 160/100-180-120
3- 180/120
- if bp 140/90 - 180/120
- ABPM/HBPM, bloods, urine acr
- QRISK3
- lifestyle changes & medication
What medication would you give for patient that is 49, white and no Type 2 BM with hypertension?
ACE / ARB
Ramipril / candesartan
What medication would you give for patient that has type 2 BM
ACE / ARB
75F African has hypertension, what’s the first-line treatment you’ll give her?
CCB
68-year-old patient complaining of worsening SOBOE and bilateral ankle swelling. She has to sleep on 3 pillows at night or he finds himself getting breathless.
She has a history of poorly controlled hypertension and hyperlipidaemia.
Never smoked and she only drinks the occasional glass of wine with dinner.
What’s your suspecting?
Heart failure
What are the signs of heart failure?
Shortness of breath with activity or when lying down
Fatigue and weakness
Swelling in the legs, ankles, and feet
Rapid or irregular heartbeat
Reduced ability to exercise
Confusion or forgetfulness
Dry cough
Unexplained weight gain
Con. lets say the pt denies all the symptoms then what you do?
What is the management if the bp is >= 180/120?
What after if result are:
Positive?
Negative?
admit for specialist assessment if :
signs of retinal hemorrhage / papilledema (accelerated hypertension)
or
Life-threatening symptoms –> new-onset confusion, chest pain signs of heart failure or acute kidney injury
arrange urgent investigation for end-organ damage (bloods, urine ACR and ECG)
Negative - repeat clinic blood pressure within 7 days
What are the attempts when using adenosine?
what are the contraindication condition from using adenosine?
Asthma
COPD
Heart failure
Heart block
Severe hypotension
Potential atrial arrhythmia with underlying pre-excitation
initially 6mg -> 12mg -> 18mg
ECG signs in Wolff-Parkinson-White syndrome
Management for supraventricular tachycardia
Short PR interval, less than 0.12 seconds
Wide QRS complex, greater than 0.12 seconds
Delta wave
Step 1: Vagal manoeuvres
Step 2: Adenosine
Step 3: Verapamil or a beta blocker
Step 4: Synchronised DC cardioversion
What is your management if patient is having chest pain, loss of consciousness and on the ECG its shows SVT?
- Loss of consciousness (syncope), heart muscle ischaemia (e.g., chest pain), shock or severe heart failure
^ These are life-threatening features
synchronised DC cardioversion under sedation or general anesthesia
*IV amiodarone if initial DC shock doesn’t work
what are the long term management for paroxysmal SVT
radiofrequency ablation
long-term meds (beta blockers, calcium channel blockers or amiodarone)
Infective endocarditis
- Risk factors
- causes
- investigations
- screening tool
- management
- prophylaxis
- IV use, chronic kidney disease (dialysis), immunocompromised, PMH of infective endocarditis
- Staphylococcus aureus
- blood cultures, Echo, PET/CT, SPECT-CT
- Duke criteria
- IV broad-spect antibiotics (amoxicillin / gentamicin) for 4 weeks
surgery if HF, large vegetation / not responding to antibiotics - antibiotics but not routinely, advice on taking good care of oral health
What are the end results of atherosclerosis?
Angina
Myocardial infarction
Transient ischaemic attacks
strokes
peripheral arterial disease
chronic mesenteric ischaemia
