Cardiology Flashcards
central, pleuritic chest pain and fever 4 weeks following a myocardial infarction suggests what?
Dresslers - Pericarditis following MI
traumatic accident with respiratory distress, hypotension, jugular venous distension, and absent lung sounds suggests what?
Tension pneumothorax
A third heart sound is considered normal
in patients under what age?
<30 years old
What are the common causative organisms of infective endocarditis?
Most common/IVDU - Staph aureus
Those with poor dental hygiene/post dental proceudure - Strep viridans
Following prosthetic valve surgery - Staph epidermidis
Widened mediastinum on CXR with severe chest pain suggests what?
Aortic dissection
In ALS, if IV drugs cannot be given, how should they be given?
Intraosseous
What is the most specific ECG finding in acute pericarditis?
PR depression
Type A (ascending) vs Type B (descending) aortic dissection?
A - chest pain
B - upper back pain
tall R waves in leads V1-3 are a classic finding for what?
Posterior MI
What score should be used to assess the risk of bleeding when starting someone on anticoagulation in AF?
Orbit
What are reversible causes of cardiac arrest?
Hypoxia
Hypovolaemia
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
Hypothermia
Thrombosis (coronary or pulmonary)
Tension pneumothorax
Tamponade – cardiac
Toxins
When should warfarin be stopped prior to surgery?
5 days before
What is the key diagnostic finding of aortic dissection on CT?
False lumen
What are C/I to thrombolysis?
active internal bleeding
recent haemorrhage, trauma or surgery (including dental extraction)
coagulation and bleeding disorders
intracranial neoplasm
stroke < 3 months
aortic dissection
recent head injury
severe hypertension
weak or absent carotid, brachial, or femoral pulse
variation in arm BP suggests what?
Aortic dissection
When can electrical cardioversion be considered for patients with AF?
If presenting within 48 hours
What medication should be stopped when patients are given a course of macrolides e.g. clarithromycin?
Statins
Thiazide-like diuretics should not be used in patients with what?
Gout
ST elevation and acute pulmonary oedema in a young patient with a recent flu-like illness suggests what?
Myocarditis
When should rhythm control be used for AF instead of rate control?
coexistent heart failure, first onset AF or an obvious reversible cause
Which medication can reduce hypoglycaemia awareness?
Beta blockers
Which medication can impair glucose tolerance?
Thiazides
Widespread ST elevation in V1-4 suggests what?
100% occlusion of the LAD
Erythromycin can cause which cardiac abnormality?
QT prolongation
What kind of bacteria is staph aureus?
Gram positive cocci
How should a patient with minor bleeding with INR > 8 be managed?
Stop warfarin and give IV Vitamin K with repeat dose of Vit K after 24 hours if INR still high
What drugs can cause hypokalaemia?
Loop diuretics e.g. furosemide
A new left bundle branch block should raise alarms for what?
ACS
What scoring system should be used to identify patients with a pulmonary embolism that can be managed as outpatients?
Pulmonary Embolism Severity Index (PESI)
How does fondaparinux work?
Activates antithrombin III
What is the management of AF if ChadsVasc is 0?
Echo to rule out valvular causes
What are ecg findings of hypokalaemia?
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
U waves
What is the second-line therapy in patients with HFrEF?
SGLT-2 inhibitors e.g Empagliflozin
inferior myocardial infarction and AR murmur suggests what?
Proximal aortic dissection
High dose statins should be commenced in stroke patients when?
48 hours after stroke
What criteria should be used for infective endocarditis?
Duke criteria
What criteria should be used for rheumatic fever?
Jones criteria
What drugs should be used for anticoagulation in those with mechanical heart valves?
Warfarin/LMWH
Complete heart block following an MI suggests the lesion is where?
Right coronary
Investigation of choice for aortic dissection?
CT Angio
Management of aortic dissection
Control BP with IV Labetalol and surgery
Most common ECG change of PE?
Sinus tachycardia
CP of pericarditis?
- pleuritic chest pain: worsen lying flat and relieved by sitting forward
- fever
- pericardial rub
- tachycardia and tachypnea
- non-productive cough
- dyspnoea
- flu-like symptoms
What may a pericardial rub indicate? (friction of heart against pericardium, sounds like sandpaper rubbed on wood)
pericarditis
Ix for pericarditis?
- all pts with suspected= TRANSTHORACIC ECHO
- ECG
- bloods: inflam markers, only 30% have elevated troponin
Pericarditis is associated with what?
pericardial effusion that can sometimes worsen to cardiac tamponade
ECG findings for pericarditis?
- PR depression
- ‘saddle-shaped’ ST elevation
PeRicardiTiS
Management of pericarditis?
NSAIDs plus colchicine
Until CP resolution and normal inflam markers (usually 1-2w) followed by tapering of dose recommended
PR Depression on ECG is indicative of what?
Pericarditis
Medical management of NSTEMI?
dual antiplatelet therapy, an ace inhibitor, a beta-blocker, and a statin
What is Beck’s triad?
- Raised JVP
- Muffled heart sounds
- Falling BP
What is Beck’s triad a sign of?
Cardiac tamponade
Management of major bleed with someone on warfarin?
stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate
How should episodic palpitations be investigated?
Holter monitoring
notching of the inferior border of the ribs suggests what?
Aortic coarctation
Management of PE with low PESI score?
Can be managed as an outpatient with DOAC
Nitrates for MI are contraindicated when?
Patients with hypotension
What is the treatment for torsades de pointes?
IV Mag Sulph
What is a normal cardiac variant in athletes?
First degree heart block
Investigation of choice for someone with PE and renal impairment?
V/Q scan
What is normal in an athlete and does not require any intervention?
First degree heart block
If angina is not controlled by a beta blocker, what should be added?
Amlodipine
What should be used if atropine if not helping with bradycardia?
- transcutaenous pacing
- transvenous pacing
Sydenham’s chorea is a complication of what?
Rheumatic fever
Management of persistent myocardial ischaemia following fibrinolysis
PCI even if time elapsed
What on echo is used to determine the severity of aortic stenosis?
Trans-valvular pressure gradient
What is Buerger’s disease?
aka thromboangiitis obliterans
- A small/medium vasculitis which is associated with smoking
- CP: intermittent claudication, Raynaud’s, ischaemic ulcers, superficial thrombophelbitis
What is the mode of action of statins?
Decrease intrinsic cholesterol synthesis by inhibiting HMG-CoA reductase enzyme
How to manage a strong suspicion of PE whilst waiting for scan?
Start treatment dose anticoagulant
Electrical alternans is a sign of what?
Cardiac tamponade
J waves are associated with what?
Hypothermia
Hypertrophic obstructive cardiomyopathy is associated with what?
Wolf-Parkinson-White
Management of acute heart failure not responding to furosemide?
Consider CPAP
What is a complication of MI?
Pulmonary oedema
SVT Management?
- Valsalva
- IV Adenosine upto 3 doses
- Electrical cardioversion
Criteria for rate control vs anticoag/cardioversion?
- Under 65
- No Hx of IHD
Thrombus in aVL, which artery?
Left circumflex
What is Framingham risk score?
estimate the 10-year risk of heart attack
severe hypertension and bilateral retinal hemorrhages and exudates
Malignant HTN
Endocarditis - which valves are affected?
Mitral - most common
Aortic
Tricuspid - IVDU
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination
VSD
Treatment for cardiac tamponade?
Urgent pericardiocentesis: Pericardial needle aspiration
What is Kussmaul sign?
- JVP rises on inspiration
- Sign of constrictive pericarditis
holosystolic murmur, high-pitched and ‘blowing’ in character
Mitral regurg
Tachycardia and tachypnoea with no signs
Think PE
Can warfarin be used when breast feeding?
Yes
What electrolyte abnormality do thiazide diuretics cause?
- Hypokalaemia
- Hyponatraemia
- Hypercalcaemia
- Gout
- Impaired glucose tolerance
Management of irregular broad complex tachycardia
Seek cardiology input
What is Takayasu’s arteritis?
- Systemic features of vasculitis
- Unequal BP in upper limbs
- Carotid tenderness
- Absent/weak peripheral pulses
- Associated with renal artery stenosis
- MRA/CTA to treat with steroids
Low pitched diastolic murmur?
Mitral stenosis
Acute mitral valve regurg + pulmonary oedema
Think MI
What is the dose of adrenaline used in cardiac arrest?
1mg of IV adrenaline
Breathing problems with clear chest
PE
What is Brugada syndrome?
- AD disorder which can cause sudden death
- autosomal dominant; more common in Asians
- can be caused by mutation in SCN5A gene (encodes for myocardial sodium ion channel protein)
- ECG shows ST elevation and T wave inversion (may become clearer after giving flecainide- Ix of choice)
- Mx is implantable cardioverter-defib
Most common place of inhaled foreign body?
Right inferior bronchus
Findings for aortic stenosis?
narrow pulse pressure
slow rising pulse
a thrill palpable over the cardiac apex
a fourth heart sound (S4) indicative of left ventricular hypertrophy
a soft/absent S2
Which medications can cause torsades de pointes?
Macrolides e.g. azithromycin
What condition are ACE inhibitors C/I with?
Renovascular disease
What causes the acute mitral regurg following MI?
Rupture of the papillary muscle/ischaemia
When can you commence spironolactone for HTN?
When already taking ACE, CCB and thiazide-like diuretic + K is below 4.5
When should adrenaline be given for shockable rhythms?
After 3 unsuccessful shocks
Pericarditis vs Myocarditis?
Myocarditis -> elevated troponin
Which markers can you test for STEMI?
Troponin, CK, AST, LDH
What ECG changes might be seen following STEMI?
T wave inversion, pathological Q waves
Driving rules post MI
- No need to inform DVLA
- Can drive after1 week if successful angioplasty
- Can drive after 4 weeks if no angio/unsuccessful angio
Complication of coronary angio
Bleeding, haemorrhage, infection, MI, stroke, damage to coronary vessels, death
What triggers are there for angina?
Exertion, cold weather, emotions such as anger, vivid dreams
How does aspirin work?
Inhibits COX which inhibit thromboxane which inhibits platelets aggregation
Abnormally large drop in BP during inspiration?
Pulsus paradoxus -> Cardiac tamponade
How should diabetes be managed following MI?
Use IV insulin infusion and stop the oral diabetes meds
patients with a GRACE score > 3% should have what?
Coronary angio within 72 hours
Management of persistent MI following fibrinolysis
PCI
What is the treatment of broad complex tachycardias?
- Amiodarone
Single episode of paroxysmal AF?
ChadsVasc and consider DOAC
Management of IE causing congestive cardiac failure
Emergency valve replacement
What is the alternative to 3 weeks of anticoagulation for someone having cardioversion with AF?
Transoeseophageal echo to exclude left atrial appendage thrombus
What are warfarin INR targets for mechanical valves?
Aortic - 3.0
Mitral - 3.5
What is the NYHA heart failure classification?
Class 1 - no symptoms and no limitations
Class 2 - mild symptoms with slight limitation (some fatigue, dyspnoea)
Class 3 - moderate symptoms with marked reduction in activity (symptoms anytime except rest)
Class 4 - severe symptoms and symptoms of HF present even at rest
When is AAA screening done?
Men aged 65
How is AAA screening managed?
< 3 cm - normal
3 - 4.44cm - rescan every 12 months
4.45 - 5.4cm - rescan every 3 months
>5.5 - refer to vascular surgery within 2 weeks
Other referral criteria
- Rapidly growing (>1cm per year)
What is the biggest indicator of a poor prognosis in someone with MI?
Cardiogenic shock
What would an ABG for pulmonary embolism show?
Respiratory alkalosis -> hyperventilation
When is staph epidermidis the most common organism causing endocarditis?
If <2 months post valve surgery
Why is verapamil C/I in heart failure + VT?
It can slow down contractility of the heart even further
What is the most common cause of death in patients post MI?
V Fib
Haemoptysis can be a symptom of what?
Mitral stenosis
mid-diastolic low-pitched rumbling murmur
mitral stenosis
Management of BP > 180/120 in GP
If unstable/signs of papilloedema/retinal haemorrhages -> refer to specialist
If stable then arrange urgent investigations for organ damage eg. bloods, urine ACR, ECG
What is the normal QRS value?
<0.12s / 3 small squares
What are signs of left ventricular failure?
Dyspnoea, reduced exercise tolerance, fatigue, paroxysmal nocturnal dyspnoea, orthopnoea, wheeze, cough (worse at night), pink, frothy sputum
What are signs of right ventricular failure?
Peripheral oedema, facial engorgement and abdominal distension
What are causes of AF?
Pneumonia, MI, PE, Alcohol excess, HF, Endocarditis
What are signs of aortic regurg?
- Collapsing pulse
- Early diastolic murmur
- Wide pulse pressure
- Displaced apex
- Carotid pulsation: Corrigans sign
- pulsation of nail bed: Quincke’s sign
Absent arm pulses in a young woman?
Think Takayasu’s arteritis
AF + mass in left atrium
Cardiac myxoma - bengin tumour of the heart
Patients with aortic valve IE are at risk of what?
Developing aortic valve abscess (prolongation of PR can be first sign)
What pulse can you get with heart failure?
Pulsus alternans - strong and weak beats due to varying systolic pressure
When is rhythm control used in AF treatment over rate control?
- Coexistent HF
- First onset AF
- Obvious reversible cause
- Use amiodarone/flecainide
What is the inheritance of HOCM?
AD
What is the pathophysiology of HOCM?
- Diastolic dysfunction as LVH causes decreases compliance and decreased CO
- Biopsy shows myofibrillar hypertrophy with disarrayed myocytes
ECG findings for hypercalcaemia?
Short QT
What are the components for JONES criteria?
Joint involvement
<3 - Myocarditis
Nodules
Erythema marginatum
Sydnehams chorea
Post MI patient develops pulmonary oedema and has pansystolic murmur?
Think acute mitral regurg
What can cause orthostatic hypotension?
- Excercise induced
- After meals
- After prolonged bed rest
- Drugs such as CBB, Levodopa
QT prolongation with no electrolyte abnormalities?
Think hereditary long QT syndrome -> caused by loss of function/blockage of K+ channels
When should LFTs be checked with statins?
Baseline, 3 months and 12 months
What murmur do you get with VSD?
Pansystolic murmur - entire systolic period
Which drug when used alongside clopidogrel can make it less effective?
Omeprazole/Esomeprazole
What dose of amiodarone is given in ALS?
Initially 300mg
After 5th shock, an additional 150mg can be given alongside 1mg of adrenaline
What will type A aortic dissection cause?
Acute aortic regurg
What is the treatment for rheumatic fever?
IM BenPen or Oral PenV with NSAIDs
Patients taking isosorbide mononitrate should use what dosing regime?
Asymmetric dosing interval to prevent nitrate tolerance
NSTEMI in an unstable patient?
Immediate coronary angio
Which antihypertensive cause hyperkalaemia?
ACE
What is tongue and facial swelling?
Angioedema -> ACE inhibitor
What are examination signs of pericarditis?
-Pericardial rub
- Quiet heart sounds
- Raised JVP
What are causes of pericarditis?
- Infective: coxsackie, TB
- Trauma
- Malignancy eg. lung/breast
- MI complication
- SLE
- RA
- hypothyroidism
3 main investigations for IE?
- Blood cultures
- Echo
- ECG
What are some triggers for worsening pulmonary oedema?
- Arrhythmia
- MI
- Sepsis
What is the most common cardiomyopathy?
Dilated
management of mitral stenosis?
Asymptomatic - Monitor with regular echo
Symptomatic - Percutaneous mitral commissurotomy
When fibrinolysis is done for ACS, when should ECG be repeated?
60-90 minutes
What are the ChadsVasc categories?
Congestive HF
HTN
Age >75 (2), >65 (1)
Diabetes
Stroke/TIA/VTE
Vascular disease
Sex (Female)
Where is access preferred for PCI?
Radial artery
Which medications can worsen glucose tolerance?
Thiazides
widespread pansystolic murmur, hypotension, pulmonary oedema post MI?
Acute mitral regurg
Management of suspected HF in GP?
Measure BNP and refer for TTE if elevated
What does a loud opening snap indicate?
The mitral valve leaflets are still mobile in mitral stenosis
What can indicate the severity of the mitral stenosis?
Length of murmur increases
What are components of orbit score?
- Haemoglobin
- Age
- Bleeding history
- Renal impairment
- Treatment with anti platelets
Nailed pulsation?
Quincke’s sign -> aortic regurgitation
Rate control for AF?
Beta blocker
CCB
Digoxin
Management of continued pain post PCI for MI?
Urgent CABG
Reverse nike sign?
Digoxin
Persistent ST elevation post MI?
Left ventricular aneurysm
What are signs of aortic coarctation?
- radio-femoral delay
- mid systolic murmur
- weak peripheral pulses in legs
- Left ventricular heave
Investigations to confirm aortic coarctation?
- Echo
- CT aorta
- Cardiac catheterisation
Management options for aortic coarctation?
- Open surgery
- Balloon angioplasty and stent insertion
- Mild cases can be controlled with antihypertensives
What carries the worst prognosis in symptomatic aortic stenosis?
Exertional syncope
What medication should be avoided in someone with aortic stenosis?
Nitrates
When should adenosine be avoided?
Asthmatics
What is the definitive management of bradycardia?
Permanent pacemaker
Which organisms often cause rheumatic fever?
Strep pyogenes
Stroke + AF?
2 weeks of aspirin then warfarin/DOAC
ADPKD is associated with what?
Mitral valve prolapse
S3 vs S4 sounds
CCF - 3 letters - S3
HOCM - 4 letters - S4
What does aortic dissection cause?
Weak/absent carotid, brachial or femoral pulses
HF with rEF vs HF with pEF?
rEF - systolic dysfunction e.g. IHD, arrythmias
pER - diastolc dysfunction e.g. HOCM, cardiac tamponade
What can be done for patients not responding to medications for HF?
Cardiac resynchronisation therapy if wide QRS
Raised JVP, ankle oedema, hepatomegaly
Right sided HF
What are causes of torsades de pointes?
- Congenital
- Macrolides
- Subarachnoid haemorrhage
- Hypothermia
- Electrolyte disturbances
What is torsades de pointes?
Polymorphic VT
Heart failure management
- ACE + BB
- Spironolactone/Eplerenone
3rd lines
- Ivabradine if HR > 75 and reduced EF
- Hydralazine with nitrate for Afro-Caribbean patients
- Sacubitrtil-valsartan for patients with reduced EF after ACE/ARB wash out period
- Digoxin if sinus rhythm
What vaccines should be given to HF patients?
Annual flu
One off PCV
Sudden heart failure, raised JVP, pulsus parodoxus post MI?
Left ventricular free wall rupture
What ABG picture will hyperaldosteronism cause?
Metabolic alkalosis with hypokalaemia
What can cause high output heart failure?
Anaemia
When is DC cardioversion done for arrhythmias?
Systolic < 90
How to manage HTN when patient is on ACE/CCB/Thiazide and K+ > 4.5?
Add alpha/beta blocker
AF with sudden onset abdo pain?
Think acute mesenteric ischaemia -> treat with immediate laparotomy
Management of ruptured AAA?
Crossmatch 6 units of blood
When is amiodarone preferred for pharmacological cardioversion?
Evidence of structural heart disease
Chest pain + neurology?
Think aortic dissection
new BP >= 180/120 mmHg + new-onset confusion, chest pain, signs of heart failure, or acute kidney injury
Refer for assessment
CCB side effects
headache, flushing, ankle oedema
Amlodipine can cause what?
Gingival hyperplasia
What is the cut off for aortic valve surgery if no symptoms?
Valvular gradient > 40 with features of left systolic dysfunction
pre-excitation syndrome that occurs due to the presence of an accessory electrical pathway between the atria and ventricles
Wolf-Parkinson-White
Gallop rhythm is a sign of what?
Left sided heart failure
Prosthetic vs mechanical valve?
Mechanical last longer so are given to younger patients
What can be considered in CPR if a PE is supected?
Thrombolytic drugs such as alteplase
How should 80+ year olds with raised BP be managed?
Lifestyle advice
Nifedipine can cause what?
Peripheral vasodilation which can cause reflex tachycardia
What is an alternative to amiodarone in arrest?
Lidocaine
What drugs are an alternative to atropine?
Isoprenaline/adrenaline infusion
How long should CPR be continued when thrombolytic drugs are being given?
60-90 minutes
Tension pneumothorax can cause what?
Pulseless electrical activity
Clinically unstable aortic dissection?
Transoesophageal echo
What is the most common cause of aortic stenosis in young patients?
Congenitally bicuspid valve
Hyperlipidaemia can cause what?
Pseudohyponatremia -> serum osmolality will be normal
Premature supraventircular beats vs premature ventricular betas on ECG?
Supraventricular - narrowed QRS complexes
Ventricular - widened QRS complexes
What is cardiac tamponade?
Accumulation of pericardial fluid causing increased pericardial pressure which compromises ventricular filling, resulting in a
reduced cardiac output.
cardiomyopathy + diabetes + joint pain + hepatomegaly
Think haemochromatosis
What antibiotic is recommended in COPD patients who continue to have exacerbations?
Azithromycin
Chronic infection with Pseudomonas and Bulkholderia in CF
Increased risk of morbidity or mortality
Pericarditis vs STEMI ECG?
STEMI will have ST elevation greater in lead III than lead II
Aortic dissection can cause what?
Neuro deficits
Persistent ST elevation with fatigue
Left ventricular aneurysm
When do CK levels normalise after an MI?
48-72 hours -> good to check if suspecting a reinfarction
When should sacubitril-valsartan be initiated?
Following an ACE/ARB wash out period
What part of the QRS is electrical cardioversion synchronised to?
R wave
Mitral regurg is associated with which conditions?
- Marfans
- Ehlers-Danlos
DC cardioversion vs unsynchronised cardioversion?
DC- Tachyarrhythmias
Unsynchronised - Cardiac arrest (VT, VF)
What is the management of atrial flutter?
- Beta blocker/CCB
- Consider cardioversion
- Catheter ablation curative
Sudden increase in BP associated with ACS?
Treat with IV GTN
Elderly patient with ECG with periods of sinus bradycardia + atrial tachycardia?
Sick sinus syndrome
What is a normal PR interval?
0.12-0.20s
3-5 small squares
Absent P waves + regular rhythm of QRS
SVT
What stroke is most likely during cardiac catheterisation?
Embolic -> debris can be scraped from aortic wall
Most common cause of left ventricular hypertrophy in a healthy person?
Hypertrophic cardiomyopathy
Heart failure + wide QRS?
Consider resynchronisation pacemaker device
2nd line investigation for endocarditis if echo is negative but high suspicion?
PET CT
What is the PR interval?
Start of P wave to start of QRS complex
Indications for DC cardioversion in tachyarrhythmias except shock?
- Syncope
- MI
- Heart failure
What are the 2 options for aortic valve replacement?
Surgical - low risk patients
Transcatheter - high risk patients
When to do 1 shock vs 3 shocks in shockable rhythms?
3 shocks - if witness cardiac arrest
1 shock - if not witnessed
What is a common cause of tricuspid regurg?
Pulmonary HTN e.g. COPD
Investigation of choice for cardiac tamponade?
Echo
When in CABG indicated?
More significant coronary artery disease e.g. triple vessel
Abx for MRSA resistant endocarditis?
Prosthetic valve - Vancomycin, Rifampicin and Gentamicin
Normal valve - Vancomycin and Rifampicin
Thiazides can precipitate what?
Digoxin toxicity
De Musset sign is a sign of what?
Aortic regurgitation
What is acute coronary syndrome? (ACS)
umbrella term covering number of acute presentations of ischaemic heart disease
Presentations of acute coronary syndrome?
1) STEMI
2) NSTEMI
3) unstable angina
As a rise in troponins may take hrs, it may be hard to distinguish between unstable angina and NSTEMI initally so what do you do?
Treat like NSTEMI until troponin result is known
When is unstable angina considered to be present in patients? (an acute coronary syndrome)
pts with ischaemic symptoms suggestive of ACS and NO elevation in troponins, with or without ECG changes indicative of ischaemia
ACS generally develops in what patients?
Those with known or unknown ischaemic heart disease
What are other terms for ischaemic heart disease (all have the SAME meaning)?
coronary heart disease, coronary artery disease, IHD all mean same thing
What causes IHD?
gradual build up of fatty plaques within walls of coronary arteries
What does IHD lead to?
1) gradual narrowing of coronary arteries therefore less oxygen reaching myocardium at times of increased demand -> angina
2) risk of sudden plaque rupture -> sudden occlusion of coronary artery -> no oxygen reaching area of myocardium
Unmodifiable RFs for IHD
increasing age, male, FHx
Modifiable RFs for IHD
smoking, DM, HTN, obesity, hypercholesterolaemia
IDH pathophysiology: inital endothelial dysfunction is triggered by what?
factors eg. smoking, HTN, hyperglycaemia
Inital endothelial dysfucntion results in what changes to the endothelium in IHD?
pro-inflammatory, pro-oxidant, proliferative and reduced nitric oxide bioavailability
IHD pathophysiology: endothelial dysfunction is triggered and there are a number of changes to the endothelium; fatty infiltration of the subendothelial space by what then occurs?
Low-density lipoprotein (LDL) particles
IHD pathophysiology: role of monocytes in the progagation of the inflammatory process?
monocytes migrate from the blood and differentiate into macrophages; these then phagocytose oxidised LDL, slowly turning into large ‘foam cells’. As these macrophages die, the result can further propagate the inflamm process
IHD pathophysiology: what forms the fibrous capsule covering the fatty plaque?
smooth muscle proliferation and migration from tunica media into intima results in formation of fibrous capsule covering fatty plaque
What pathophysiological changes can be seen in IHD over number of years?
- intial endothelial dysfunction
- results in a number of changes to endothelium
- fatty infitration of subendothelial space by LDL
- formation of ‘foam cells’ and inflammatory process
- smooth muscle proliferation and migration to form fibrous capsule covering fatty plaque
Cx of atherosclerosis?
angina
MI
How does atherosclerosis cause angina?
plaque forms physical blockage in lumen of coronary artery; may cause reduced blood flow (and so oxygen) to myocardium, partically at times of increased demand
How can atherosclerosis cause myocardial infarction?
plaque may rupture, potentially causing a complete occlusion of coronary artery
Function of endothelium of arteries?
protects vessel wall and prevents clotting
Pathophysiology of atherosclerosis?
- damage to endothelium wall allows LDL to enter
- monocytes enter and break LDL down by oxidation, causes macrophage to die
- then deposits under damaged endothelium: called foam cells
- when macrophages die, also release cytokines that causes more monocytes to enter endothelium and break down more LDL
- foam cells build up to form a lesion called a fatty streak
- fatty streak is thrombogenic meaning blood can clot on it
- platelets gather at damaged endothelium and release platelet dervived growth factor which encourages growth of smooth muscle cells
- smooth muscle meant to stay in middle layer (tunica media) but starts to growth in tunica intima where they multiply
- smooth muscle cells secrete collagen, proteoglycans, elastin fibrous cells that form a wall around fatty streak preventing blood clotting= extracellular matrix wall of fibrous cap
- fibrous cap + fatty streak = plaque
Why in atherosclerosis do the walls of the arteries become stiff?
- smooth muscle also starts depositing calcium into the plaque creating crystals
- Ca crystals normally deposited by LDL and removed by HDL, but plaque stops HDL removing Ca
- causes build up of Ca in vessel wall and crystallises= stiffens walls of arteries
Why might a high CRP indicate atherosclerosis?
atherosclerosis is an inflamm disease as immune sysytem invl (macrophages). Therefore high CRP
CPS of acute coronary syndrome?
- left-sided/central chest pain
- may radiate to jaw or L arm
- ‘crushing’ ‘heavy’
- dyspnoea
- sweating
- nausea
What pts with ACS may not experience any chest pain?
Diabetics; elderly
Physical signs of ACS
- BP, HR, T, O2 often normal or mild eg. tachy
- unless HF
- pale, clammy
Most important Ix when assessing pt with chest pain
- ECG
- cardiac markers eg. troponin
Deep and widespread ST depression is associated with what?
very high mortality because it signifies severe ischaemia usually of LAD or left main stem
Aims of treatment of ACS?
1) prevent worsening (further occlusion)
2) revascularise (unblock) vessel if occluded (STEMI)
3) Mx pain
Acute Mx of ACS
M.orphine (IV)
O.xygen (if <94%)
N.itrates (IV or subling)
A.spirin (300mg)
When should oxygen be given in Mx of ACS?
if sats <94%
Secondary prevention for pts who have had an ACS?
Aspirin
Antiplatelet eg. clopidogrel
BB
ACE inhibitor
Statin
STEMI?
ST-elevation MI= ST-segment elevation + elevated biomarkers of myocardial damage
NSTEMI?
non ST-elevation MI= ECG change but no ST-segment elevation + elevated biomarkers of myocardial damage
Groups of Mx for acute coronary syndromes?
- STEMI
- NSTEMI/unstable angina
- Secondary prevention
Dose of aspirin to give in acute Mx?
300mg
Acute Mx of ACS: nitrates should be used in caution if the pt is…
Hypotensive
Overview of Mx in pt with suspected ACS?
1) acute Mx
2) ECG findings- ?STEMI
3) STEMI confirmed= eligability for coronary reperfusion therapy
STEMI criteria?
CP consistent with ACS ≥ 20mins with persistent >20mins ECG features in ≥ 2 contiguous leads
STEMI ECG criteria in men?
ECG features in ≥ 2 contiguous leads of….
Men <40yrs=
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3
Men >40yrs= ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3
PLUS 1 mm ST elevation in other leads & new LBBB (LBBB should be considered new unless there is evidence otherwise)
STEMI ECG criteria in women?
ECG features in ≥ 2 contiguous leads of…
1.5 mm ST elevation in V2-3
STEMI Mx?
1) 300mg aspirin (+other acute Mx)
2) PCI OR Fibrinolysis
3) dual antiplatelet therapy: Clopidogrel + aspirin (if high bleeding risk) or tricagrelor + aspirin (low risk)
4) stenting indicated? Cardiac rehab and secondary prevention
2 types of coronary reperfusion therapy in STEMI?
1) PCI: dual antiplatelet therapy before; then during give either unfractionated heparin with bailout GPI if radial access or bivalirudin with bailout GPI if femoral access
2) Fibrinolysis + antithrombin drug
In STEMI Mx when should pt get PCI?
<12hrs of symptoms and can be delivered in 120mins. Consider >12hrs if CG shock or continue ischaemia.
PCI for Mx of STEMI?
1) dual antiplatelet therapy before PCI:
aspirin + prasugrel or clopidogrel
2) PCI with radial access: + unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
OR
2) PCI with femoral access: bivalirudin with bailout GPI
Dual antiplatelet therapy to give pt with STEMI prior to PCI?
Aspirin +
clopidogrel if taking oral anticoag
or
prasugrel if not taking oral anticoag
In STEMI Mx when should pt get fibrinolysis?
if <12hrs and PCI not possible in 120mins
Patients undergoing fibrinolysis should also be given what?
Antithrombin drug eg. fondaparinux or LMWH
When should ECG be done after fibrinolysis?
60-90mins after
STEMI Mx: is radial or femoral access preferred?
Radial
What if pt with STEMI gets ECG 90mins after fibrinolysis and it fails to show resolution of ST elevation?
PCI
Mx of NSTEMI/unstable angina overview?
1) 300mg aspirin + fondaparinux or unfractionated heparin
2) GRACE score
3) low risk= dual antiplatelt therapy (aspirin + ticagrelor or clopidogrel)
3) intermediate/high risk= PCI immediately/within 72hrs; give aspirin + prasugrel or ticagrelor (if pt on oral anticoag give clopidogrel); give unfractioned heparin; use drug-eluting stents
4) assess LV function and consider angiography (eg. if develop ischaemia)
5) cardiac rehab and secondary prevention
What is dual antiplatelet therapy (DAPT)?
aspirin + P2Y12 inhibitor eg. clopidogrel, prasugrel or ticagrelor
How to know what drugs to use for DAPT?
Apirin +
prasugrel (during PCI) if not taking anticoag
clopidgorel (during PCI) if taking anticoag
ticagrelor if low bleeding risk
clopidogrel if high bleeding risk
How do you decide if you use fonaparinux or unfractionated heparin initally in the Mx of NSTEMI/unstable angina?
- fondaparinux= low risk of bleeding and no immediate angiography
- unfractionated heparin= immediate angiography planned or creatinine is > 265 µmol/L
What does GRACE score stand for?
The Global Registry of Acute Coronary Events
What is the GRACE score?
Predicts 6m mortality and risk of cardiovascular events
In Mx for NSTEMI/unstable angina, as well as the GRACE risk score what else needs to be included in the risk assessment?
history, examination; ECG; bloods (troponin I or T, creatinine, glucose, Hb); balance possible benefits of Mx against bleeding risk
What factors does the GRACE score account for?
age
HR, BP
cardiac (Killip class) and renal function (serum creatinine)
cardiac arrest on presentation
ECG findings
troponin levels
GRACE score: what is low risk?
predicted 6m mortality ≤ 3%
GRACE score: what is intermediate or higher risk?
predicted 6-month mortality > 3%
Which patients with NSTEMI/unstable angina should have coronary angiography (with follow on PCI if necessary) immediateley?
clinically unstable eg. hypotensive
Which patients with NSTEMI/unstable angina should have coronary angiography (with follow on PCI if necessary) within 72hrs?
pts with GRACE score >3%
When should coronary angiography be considered for pts with NSTEMI/unstable angina?
if ischaemia is experienced after admission
What is cardiac rehabilitation used as the final Mx for ACS?
before discharge; assessment 10days after discharge
physical activity, lifestyle advice, stress management and health education
Drug therapy for secondary prevention for ACS (STEMI, NSTEMI, unstable angina)?
- ACE inhibitor
- DAPT
- Beta-blocker
- Statin
DAPT for secondary prevention of ACS?
Aspirin + second antiplatelet for up to 12m
Drug titration of beta-blockers for secondary prevention of ACS?
titrate to max tolerated or target dose
Drug titration for ACE inhibitors for secondary prevention of ACS?
titrate up (with monitoring) every 12-24hrs; complete titration in 4-6w of hospital discharge.
What should you monitor in pts before starting and 1-2w after starting an ACE inhibitor?
renal function, electrolytes and BP
Secondary prevention for ACS: if pt already on anticoag, offer clopidogrel for how long?
Up to 12m if had PCI
Poor prognostic factors of ACS?
age; Hx or development of HF; PVD; reduced systolic blood pressure; Killip class; inital serum creatinine conc; elevated initial cardiac markers; cardiac arrest on admission; ST segment deviation
What is the name of the system used to stratify risk post MI?
Killip class
Killip class features and 30 day mortality?
I= no signs HF (6%)
II= lung crackes, S3 (17%)
III= frank pulmonary oedema (38%)
IV= cardiogenic shock (81%)
Cx of myocardial infarction?
Cardiac arrest
Cardiogenic shock
Chronic heart failure
Tachyarrhythmias
Bradyarrhythmias
Pericarditis
Left ventricular aneurysm
LV free wall rupture
Ventricular septal defect
Acute mitral regurgitation
Most common cause of death following MI
Cardiac arrest
Why can cardiac arrest occur after MI?
pt develops ventricular fibrillation
Cardiac arrest Mx
ALS with defibrillation
Why may pt develop cardiogenic shock after MI?
if large part of V myocardium damaged by infarction the EF may decrease to the point the pt develops CG shock
Causes of cardiogenic shock?
post MI; mechanical Cx (LV free wall rupture)
Pt with cardiogenic shock may require what?
Inotropic support and/or intra-aortic balloon pump
Cardiogenic shock?
Heart suddenly can’t pump enough blood to meet body’s needs as it has been damaged so much. Life-threatening- can lead to organ failure.
Why may MI lead to chronic HF?
ventricular myocardium may be damaged and dysfunctional
Arrhythmias that may develop post MI?
Ventricular fibrillation (most common cause of death following MI); ventricular tachy; bradyarrhythmias
Atrioventricular block is more common following what type of MI?
Inferior
What is common (10%) in first 48hrs following a transmural MI?
Pericarditis
Pain worse lying flat and better leaning forward; pericardial rub may be heard; may see pericardial effusion on echo
Pericarditis
Dressler’s syndrome?
Pericarditis that can occur 2-6w following an MI.
Fever, pleuritic pain, pericardial effusion and raised ESR?
Dressler’s
Pathophysiology of Dressler’s?
autoimmune reaction against antigenic proteins formed as myocardium recovers
Mx of dressler’s?
NSAIDs
Ischaemic damage following MI may weaken the myocardium and result in LV aneurysm forming. What is this associated with?
Persistent ST elevation and LV failure.
Why may LV aneurysm increase risk of stroke?
thrombus may form within the aneurysm
Pts with LV aneurysm are what?
Anticoagulated
When could a LV free wall rupture occur after MI?
1-2w after (3% of MIs)
Acute HF secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds)?
LV free wall rupture
Mx for LV free wall rupture?
urgent pericardiocentesis and thoracotomy
Pulsus paradoxus?
When BP decreases with inhalation eg. in cardiac tamponade
When would rupture of interventricular septum occur post MI (1-2% pts)?
in 1st week
Features of ventricular septal defect post MI?
Acute HF associated with pan-systolic murmur
Diagnosis of ventricular septal defect post MI?
ECHO diagnostic and will exclude acute mitral regurg (presents similar)
Mx of ventricular septal defect post MI?
Urgent surgical correction
What may cause acute mitral regurgitation post MI?
infero-posterior infarction and may be due to ischaemia or rupture of papillary muscle
CP of mitral regurg post MI?
acute hypotension, pulmonary oedema; early-mid systolic murmur
Mx for pt with mitral regurg post MI?
vasodilator therapy but often require emergency surgical repair.
Secondary prevention of ACS: dietary advice?
Mediterranean style diet; switch butter and cheese for plant oil based products; do NOT recommend eating oily fish
Secondary prevention of ACS: exercise advice?
20-30mins a day until pt slightly breathless
When can sexual activity resume after an uncomplicated MI?
4w after. Sex does not increase likelihood of further MI
When can PDE5 inhibitors eg. sildenafil be used in pts post MI?
6m after MI but avoid in pts prescribed nitrates or nicorandil
DAPT post ACS?
aspirin + ticagrelor (stop T after 12m)
DAPT post PCI?
aspirin + prasugrel or ticagrelor (stop P or T after 12m)
When might the 12m period for DAPT be altered in patients?
If at high risk of bleeding or high risk of further ischaemic events
What should be initiated after ACE inhibitor theraoy in pts who had an acute MI and have symptoms/signs of HF and LV systolic dysfunction for secondary prevention?
Aldosterone antagonists eg. eplerenone 3-14days post-MI
Abdominal aortic aneurysm (AAA)?
Permanent pathological dilation of abdominal aorta with diameter >1.5 times the expected anteroposterior diameter of the segment given the person’s sex and body size
Threshold for diagnosis of AAA?
abdo aortic diameter of 3cm or more
RFs for AAA?
male, age, smoking, HTN, FHx, DM, COPD, hyperlipidaemia
When is screening for AAA offered?
All men the yr they become 65yrs
AAA screening test?
abdo USS to detect any bulging or swelling of aorta
AAA screening: no aneurysm found?
<3cm- no further scans requried
AAA screening: small AAA?
3-4.4cm. Placed under surveillance and repeat scan in 12m (repeat every 12m)
AAA screening: medium AAA?
4.5-5.4cm. Under surveillance and repeat scan in 3m (repeat every 3m)
AAA screening: large AAA?
5.5cm+. Referred to vascular surgeon within 2w for probable intervention.
How long does AAA screening take?
15mins; told results at appointment
Why is there screening for AAA?
majority asymptomatic and if rupture then high mortality.
What AAA have a low rupture risk?
asymptomatic, diameter <5.5cm (small and medium)
High rupture risk AAA?
Symptomatic, diameter >=5.5cm or rapidly enlarging (>1cm/yr)
How are large high risk AAA surgically managed?
Elective endovascular repair (EVAR) or open repair. EVAR stent placed into abdo aorta via femoral artery to prevent blood from collecting in aneurysm
Cx of EVAR for AAA?
endo-leak: stent fails to exclude blood from aneurysm; asymptomatic on routine follow up
Why do AAA occur?
As result of the failure of elastic proteins in the matrix.
Loss of intima with loss of elastic fibres from the media, associated with increased proteolytic activity and lymphocytic infiltration.
Normal diameter abdo aorta in men and women >50yrs?
F: 1.5cm
M: 1.7cm
Aneurysms typically represent dilation of…
all layers of the arterial wall; most caused by degenerative disease
Rare causes of AAA?
Syphilis; connective tissue disorders eg. Ehlers Danlos type 1 and Marfan’s
Peripheral arterial disease (PAD)?
narrowing or occlusion of peripheral arteries affecting blood supply to lower limbs
Types (symptoms) of peripheral arterial disease?
Acute limb ischaemia
Intermittent claudication
Chronic limb-threatening ischaemia
Asymptomatic
PAD: acute limb ischaemia?
sudden decrease in limb perfusion that threatens limb viability- CP <2w
PAD: intermittent claudication?
diminished circulation leads to pain in lower limb on walking or exercise, relieved on rest
Most common symptom of PAD?
Intermittent claudication