Cardiology Flashcards
Describe the chest pain in stable angina.
- Brought on by exercise;
- Resolves with resting.
Describe the pain in pulmonary embolism
- Pleuritic in nature;
- Dyspnoea;
- Cough
- Tachycardia;
- Hypoxia
- Haemoptysis
- Leg swelling & other features of DVT.
Describe the pain in acute coronary syndrome.
- Pain for > 10min;
- Pain on rest or minimal exertion;
- Radiates to left arm and left jaw;
- Retrosternal pain (tightness, pressure);
- Diaphoresis;
- Dyspnoea;
- Nausea and vomiting.
Describe the pain and other symptoms of aortic dissection.
- Sudden tearing chest pain irradiating to the back in between the scapulas;
- Diaphoresis;
- Hypontension;
- Tachycardia;
- Different blood pressures and pulses in between arms;
- Abnormal or absent periphereal pulses.
Describe the symptoms of pericarditis.
- Pericardial friction rub
- Sharp pleuritic pain;
- Relieved by sitting forward;
- Worse with inspiration and body movements
- Fever;
- Cough;
- Similar to angina pain (but it changes with body position/movement unlike in angina).
What are the causes of pericarditis?
- (Post) viral infections: Coxsackie virus;
- Post MI: Dressler’s syndrome;
- Tuberculosis;
- Uraemia
- Trauma
- Connective tissue disease;
1st two are most important for the exam.
What is the ECG presentation in pericarditis?
Limb leads (I, II, III, aVL and aVF) and precordial leads (V2-V6)
* Concave ST elevation (saddle shape) of 0.5 - 1mm;
* PR depression
aVR lead
* ST depression
* PR elevation
Describe what is acute mitral regurgitation after MI.
- Seen 2-10 days after MI;
- Caused by papillary muscle dysfunction or partial rupture;
- (More) associated with inferior MI;
What are the symptoms of acute mitral regurgitation after MI?
- Dyspnoea;
- Haemodynamic instability.
Acute MR after MI
What is the 1st line for diagnosis?
Echocardiogram.
What is the treatment in pericarditis?
- NSAIDS: in most cases;
- Colchicine: prevents recurrence
Describe the management of adult tachycardia.
- ABCDE
Haemodynamically unstable tachycardia:
* Synchronised DC (direct shock) cardioversion
Haemodynamically stable tachycardia:
1. QRS ≥0.12 s (broad)
2. QRS <0.12s (narrow)
Broad QRS
* Regular: VT (amiodarone IV)
* Irregular: VF, Torsades de pointes, polymorphic VT, Wolff-Parkinson-White syndrome
Narrow QRS
* Regular: SVT
* Irrgular: AF
Describe ventricular tachycardia
- It is a broad complex (QRS) tachycardia;
- It impairs CO leading to hypotension, acute cardiac failure
- HR: 100 - 250 bpm
TREATMENT
1. With pulse:
Stable
* Amiaodarone
* Procainamide
* Lidocaine
* Flecainide
Unstable
Syncronised cardioversion
2. Without pulse:
Defribrillation
What is the function of anticoagulants?
They disrupt the coagulation cascade, reducing the frequency and extent of clot formation.
Describe the simplified coagulation cascade.
Intrisic pathway:
* Factor 9 ⟶9a
Extrinsic pathway:
* Factor 7⟶7a
Common pathaway:
* Factor 10⟶10a
* Prothrombin ⟶ Thrombin
* Fibrinogen ⟶ Fibrin
* CLOT FORMATION
Describe the pharmacology of warfarin
Class:
* Vitamin K antagonist.
MOA:
* ↓ the synthesis of vit K dependent clotting factors.
Use:
* Requires monitoring of INR;
* In VTE/PE requires rapid loading so bridge gap cover with LMWH until INR > 2 on two consecutive days.
* In AF slow loading so no bridge gapping with LMWH needed.
* Many interacion with medicines, food and herbals.
Reversal agent
* Vitamin K
* Prothrombin factor
* Fresh frozen plasma
Describe the pharmacology of DOAC’s:
-Apixaban
-Rivaroxaban
-Edoxaban
MOA: Factor Xa inhibitor.
Use:
* Baseline renal & liver function tests to start the administartion;
* No INR monitoring;
* Rivaroxaban needs to be taken with food to ↑ bioavailability.
Reversal agent:
* Andexanet alfa
Describe the pharmacology of DOAC’s:
* Dabigatran
MOA: Thrombin inhibitor
Use:
*Baseline renal & liver function tests to start the administartion;
* No INR monitoring;
* Needs to be taken with food to ↓ GI side effects.
Reversal agent:
* Idarucizumab
Describe the pharmacology of unfractioned heparin (UFH):
MOA:
* Inactivation of factor Xa
* Inactivaction of thrombin
* Inactivation of factor IXa
* Inactivation of 7a
Use:
* Imediate action after administration
* Short life
* Immediate reversibility
* Preferred on those at risk of bleeding
Reversal agent:
* Protamine
Describe the pharmacology of LMWH:
* Enoxiheparin
* Dalteparin
* Tinzaparin
MOA:
* Inactivation of factor Xa
* Inactivaction of thrombin
Use:
* Can be used SC
* Easier than UFH in terms of monitoring
* Can be used in pregnancy (doesn’t cross the placenta)
* Low risk of HIT
* Contraindicated in renal impairment (eGFR < 30 ml/min)
Reversal agent:
* Protamine
Name the causes of aortic stenosis.
1st world causes
- Degenerative calcification (older patient > 65YO);
- Bicuspid aortic valve (younger patients).
3rd world: Rheaumatic heart disease.
Symptoms of aortic stenosis
- Angina: ↓EF causing ↓ myocardial perfusion;
- Syncope: ↓EF causing ↓ cerebral perfusion
- Dyspnoea: fluid buildup
Describe the murmur of aortic stenosis
- Ejection systolic murmur
- Heard at 2nd intercostal space (right sternal border)
- Louder in expiration
- Radiates to the carotids
What is the investigation of choice in aortic stenosis?
Echocardiogram.
Describe the step by step classification of ACS
Ischaemic chest pain present
* Left sided, substernal or central;
* Radiates to the left arm, shoulder or jaw
* Can be silent MI in diabetic patients (without pain)
* Sweating
* Hypotension
12 lead ECG
ST elevation
* ST elevation MI (STEMI)
No ST elevation
* Measure troponin
Raised troponin
* Non-ST elevation MI (NSTEMI)
Normal troponin
* Unstable angina
Treatment for ACS upon arrival and confirmation
Dual antiplatelets aggregation
* AAS 300 mg
* Clopidogrel 300 mg
Anticoagulation
* Fondaparinux SC
* If on DOAC’s use LMWH (dalteparin/enoxiheparin) instead of fondaparinux
Antihypertensives
* ACEI
* Beta blockers
Statins
* Atorvastatin 80mg
STEMI: Describe the different ECG changes.
Inferior wall MI:
* ST elevation in lead II, III and aVF
* Coronary artery affected: Right Coronary Artery (80%) and Left Circumflex (20%)
Anterior wall MI
* ST elevation in leads V1-V4
* Coronary artery affected: LDA
Lateral wall MI:
* ST elevation in leads I, aVL, V5-V6
* Coronary artery affected: LCX
Posterior wall MI
* ST elevation in leads V7-V9
* Coronary artery affected: LCX and RCA
Describe the initial / immediate management for STEMI.
MONA
* Morphine IV
* O₂
* Nitrates (avoid in low BP and inferior wall MI)
* Antiplateletes (AAS 300 mg & consider clopidogrel 300mg)
Describe the definitive / GOLD standard management for STEMI.
Percutaneous coronary intervention:
* Within 12 h of symptoms onset
Thrombolysis:
* If PCI in not available within 120 min
* Perform within 12h of symptoms onset
* Alteplase or tenecteplase
Angiography with follow up rescue PCI: if persistent ST ↑ after thrombolysis.
Describe the long term management for STEMI.
- AAS for life
- Statins for life
- ACEi’s or ARB’s for life
- Beta blockers for 12 months
- Clopidogrel/Ticagrelor/Prasugrel for 12 months.
Define what is the CHA₂DS₂-VASc score
- It’s a score used to assess a person’s stroke risk.
- It used in AF to determine the most appropriate anticoagulation strategy.
Based on CHA₂DS₂-VASc score, when to offer anticoagulation treatment?
- When score is ≥ 2 (both men and women).
- When score is = 1(in men).
CHA₂DS₂-VASc score
≥ 65 YO or at least 1 comorbidity
Give DOAC.
CHA₂DS₂-VASc score
<65 and no comorbidities
Don’t give DOAC.
What is the management of AF with unstable vitals?
Signs of shock, syncope, acute cardiac failure or ischaemia.
Electric cardioversion.
What is the management of AF with stable vitals?
- Rate control (B-blockers)
- Rhythm control / chemical cardioversion
- Anticoagulation (CHA₂DS₂-VASc 1st)
Management of AF with stable vitals
Describe how rate control is done.
1st line:
* B-blockers: metoprolol/atenolol
OR
* (Rate limiting) Calcium channel blocker : Verapamil/Diltiazem
2nd line
If rate is refractory to 1st line
* Add digoxin
* If patient has heart failure digoxin is 1st line (or calcium channel blocker).
If patient has asthma choose calcium channel blockers
Management of AF with stable vitals
Describe how rhythm control (chemical cardioversion) is done.
- Amiodarone
- Flecainide
If patient on AF >48h, rate control and LMWH instead.
Management of AF with stable vitals
When to choose/do rhythm control (chemical cardioversion)?
Flecainide / Amiodarone
Patients that are:
- Symptomatic
- Young
- Presenting with lone AF for the 1st time.
Management of AF with stable vitals
When to choose/do rate control?
Patients that are:
* > 65 YO
* Stable and AF started > 48h (chemical cardioversion might cause thromboembolism)
* History of multiple failed cardioversions.