Cardiology Flashcards
Acute coronary syndrome (ACS)
Myocardial ischaemia commonly caused by plaque rupture and thrombosis, inc:
- STEMI
- NSTEMI
- Unstable angina
pathophysiology of ACS?
- atherosclerotic plaque
- gradual narrowing - less blood to myocardium - angina on exertion
- sudden plaque rupture - sudden occlusion - MI
STEMI: infarction with ST elevation on ECG
NSTEMI: infarction without ST elevation on ECG
Unstable angina: ischaemia causing chest pain at rest or minimal exertion OR in a crescendo like fashion
types of MI?
Type 1 – spontaneous e.g. atherosclerotic plaque rupture
Type 2 – secondary to ischaemic imbalance eg coronary artery vasospasm, hypotension, severe anaemia
Type 3 – MI resulting in death without biomarkers
Type 4a – MI from PCI
Type 4b – MI from stent thrombosis
Type 5 – MI from CABG
ACS risk factors?
Unmodifiable
- Older age, male, FHx
Modifiable
- Smoking, DM, HTN, hypercholesterolaemia, obesity
ABCDEF
- Age, BP, cholesterol, diabetes, exercise, fags / fat / family
ACS Px?
- > 20mins sx
- chest pain - central/left side, may radiate to jaw/L arm, heavy, like dyspepsia
- silent MI - diabetics/elderly
- palpitations, SOB, sweaty, clammy, pale, faint
- N+V
- HF sx
- tachycardia, hypotensive
ACS Ix?
Bloods
- FBC, U/E, LFTs, lipids, glucose
Serial troponins - I/T - take at px, 3hrs, 6hrs
12 lead ECG
Coronary angiography if high risk for CV event mortality
stemi ecg findings?
- ST elevation, tall/hyperacute T waves, new LBBB
- pathological Q waves after >6hrs
- long term - ST normal/depressed, T wave inversion, Q waves persist
- inf MI - PR prolongation (RCA -> AVN)
NSTEMI ECG findings?
- ST depression, T wave flattening / inversion
- normal ECG
unstable angina ECG findings?
- normal
ECG coronary territories?
Anterior – V1-4 – LAD
Inferior – II, III, aVF – RCA (LCx in minority of pts)
Lateral – I, V5-6 – LCx
Posterior – horizontal ST depression in V1-3, STEMI V7-9 – RCA / LCx
ACS general Mx?
- morphine
- O2
- nitrates - sublingual GTN
- aspirin 300mg
- insulin infusion to keep BM<11
- cardiac rehab
- stop smoking, drink less, healthy eating, regular exercise, lose weight
STEMI Mx?
ABCDE
Analgesia
Nitrates
Aspirin 300mg
Primary PCI - if <12hrs since sx onset and possible in <2 hours
- Prasugrel/Ticagrelor 180mg / Clopidogrel 300mg
Thrombolysis if available - alteplase / streptokinase / tenecteplase
- + give antithrombin - heparin/fondaparinux
CABG
- consider if multivessel coronary artery disease…
NSTEMI / unstable angina diagnostic criteria?
NSTEMI
- raised trop, may have normal ECG / ST depression / T wave inversion
Unstable angina
- sx of ACS, normal trop, normal ECG / ST depression / T wave inversion
NSTEM / unstable angina Mx?
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)
GRACE risk assessment
>3% (intermediate, high, highest) - is high risk
Coronary angiography +/- PCI - for the following:
- immediate - hypotensive
- <72hrs - GRACE >3%
- sx of ischaemia after admission
PCI - give:
- heparin
- DAPT
Conservative
- DAPT
ACS secondary prevention medication?
- Aspirin 75mg once daily indefinitely
- Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
- Atorvastatin 80mg once daily
- ACE inhibitors (e.g. ramipril) titrated as high as tolerated
- Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
ACS complications?
D: Death
A: Arrhythmia
R: Rupture of the heart septum or papillary muscles
T: Tamponade
H: Heart failure
V: Valve disease
E: Embolism
D: Dressler’s syndrome
A: Aneurysm
R: Recurrence or mitral regurgitation
what is Dressler’s syndrome?
2-6wks - autoimmune reaction - fever, pleuritic pain, pericardial effusion, raised ESR/CRP, tx with NSAIDs/steroids
stable angina?
- chest pain caused by insufficient blood supply to myocardium
- cause by atherosclerosis
- demand for O2 greater than supply
- stable - pain on exertion, relieved by rest/GTN
- unstable - angina of increasing frequency/severity, present at rest
angina presentation?
All 3 core features – typical angina, 2 features – atypical, 0-1 – non-anginal chest pain
Core features
- constricting, heavy chest pain, radiation to jaw/neck/L arm
- Sx on exertion
- relieved by rest <5mins/GTN
- sweaty, clammy, SOB, N+V, faint
angina investigations?
- ECG
- BP
- Bloods - FBC, U/E, LFTs, lipids, TFTs, HbA1c, fasting glucose
[ cardiac stress testing
- CT coronary angiography
- invasive coronary angiography]
angina management?
- refer to cardio - rapid access chest pain clinic
- stop smoking, eat healthily, exercise, healthy weight, limit alcohol
Short-term
- sublingual GTN - 1 to 2 puffs and repeat after 5 mins
Long-term
- BB - bisoprolol
- CCB - diltiazem / verapamil (amlodipine if adding to BB)
Secondary prevention
- aspirin 75mg OD
- atorvastatin 80mg OD
- ACEi
- BB
Secondary care
- isosorbide mononitrate
- ivabradine (HCN channel blocker, slows HR)
- nicorandil
- ranolazine
persistant Sx? Surgical
- PCI - angioplasty + stent
- CABG
admit if - pain at rest / minimal exertion
acute pericarditis?
- inflammation of pericardial sac <4-6wks
- may lead to effusion/tamponade
acute pericarditis risk factors?
- Idiopathic (no underlying cause)
- Infection (e.g., TB, HIV, coxsackievirus, EBV)
- Autoimmune and inflammatory conditions (e.g., SLE & RA)
- Injury to the pericardium (e.g., after myocardial infarction, open heart surgery or trauma)
- Uraemia (raised urea) secondary to renal impairment
- Cancer
- Medications (e.g., methotrexate)
acute pericarditis presentation?
KEY Sx = chest pain + low grade fever
Chest pain is:
* Sharp
* Central/anterior
* Worse with inspiration (pleuritic)
* Worse on lying down
* Better on sitting forward
- pericardial rub on ausc
acute pericarditis investigations?
- ECG - diffuse saddle-shaped ST elevation, PR depression
- ECHO - effusion
- Bloods - FBC, raised CRP/ESR, trops
acute pericarditis management?
- can tx as OP
1. tx cause - no strenuous activity until resolution
2. NSAIDS or aspirin + gastroprotection
3. Colchicine - may need prednisolone
- pericardiocentesis if indicated
constrictive pericarditis?
- pericardium becomes rigid
- fibrosis, calcified, impairs diastolic filling of heart
- eg post-pericarditis, viral, TB, idiopathic
constrictive pericarditis presentation?
- SOB
- RHF - elevated JVP, ascites, oedema, hepatomegaly
- pericardial knock - loud S3
- Kussmaul’s sign - rise in JVP on insp
constrictive pericarditis Ix?
- CXR - pericardial calcification
- ECG - low voltage QRS
- ECHO - thickened pericardium, small ventricles
- CT / MRI
constrictive pericarditis Mx?
pericardiectomy
pericardial effusion?
- fluid in pericardial sac
cardiac tamponade?
- life threatening pericardial effusion that constricts heart, drops CO
causes of pericardial effusion?
- any cause of pericarditis
- myocardial rupture, aortic dissection, trauma, TB, malignancy
- post-cardiac surgery, central line insertion
pericardial effusion Px?
- muffled heart sounds
- apex beat obscured
- JVP raised
- Ewart’s sign - bronchial breathing at left base (compressed LL lobe)
- SOB, chest pain, nausea, tachycardia
cardiac tamponade Px?
Beck’s
- low BP
- muffled HSs
- raised JVP
- Kussmaul’s sign - rise in JVP with inspiration
- Pulsus paradoxus - >10mmHG reduction in BP with inspiratio
pericardial effusion Ix?
- CXR - large globular heart
- ECG - low voltage QRS, sinus tachy, electrical alternans
- ECHO
Mx of pericardial effusion?
Effusion
- spontaneously resolve
- pericardial fenestration
- pericardiocentesis - can be diagnostic or therapeutic
Mx of tamponade?
ABCDE
- pericardiocentesis
- cardiac surgery - midline sternotomy / thoracotomy
myocarditis definition and causes?
- inflammation of myocardium
Causes - Viral – coxsackie B, HIV
- Bacteria – diphtheria, clostridia
- Lyme disease, Chagas, toxoplasmosis
- Autoimmune
- Drugs – doxorubicin
myocarditis Px?
- acute onset
- chest pain
- SOB
- arrhythmias, palpitations
- faint, dizzy
- recent flu-like sx
myocarditis Ix?
- bloods - raised CRP/ESR / trops / BNP
- ECG - non specific abnormalities: tachycardia, arrhythmias, ST elevation, T wave inversion, other S/T changes
- CXR
- ECHO - to rule out valve dysfunction and dilated cardiomyopathies
myocarditis Mx?
- tx cause, eg abx
- supportive tx - of HF / arrhythmias
- avoid exercise until recovered
infective endocarditis?
- infection of endocardium, most commonly heart valves
- mitral mostly, tricuspid in IVDU
- valves have no direct blood supply
- septic emboli / immune complexes thrown off
IE causes?
- S aureus - most common
- Strep - viridans - mouth/dental
- Staph epidermidis - indwelling lines
- Strep bovis - colorectal cancer
- enterococcus
- pseudomonas, HACEK, fungi
- SLE, malignancy, CKD, malnutrition
IE risk factors?
Normal valves:
- IVDU
- skin breeches e.g. recent piercing
- immunosuppression
- DM
- CKD
Abnormal valves:
- Rheumatic fever
- structural heart pathology - eg valvular disease, HOCM
- prosthetic heart valves
- PDA
IE Px?
- fever, fatigue, night sweats, myalgia, anorexia
- new/changing murmur
- aortic root abscess -> long PR / AV block
- splinter haemorrhages
- petechiae
- Osler’s nodes
- Roth spots
- AKI / glomerulonephritis
- Janeway lesions
- Organ abscesses
- splenomegaly / finger clubbing
IE Ix?
- Bloods - FBC, U/E, CRP, cultures (3 sets from 3 sites at 3 different times >6hrs)
- urinalysis - haematuria
- ECHO - TOE more accurate
- ECG - ?HB
- CXR
- CT - for emboli
IE modified Duke’s criteria - to Dx?
Dx requires either
- 1 major + 3 minor
- 5 minor
Major criteria
- Positive blood cultures on 2+ samples
- Specific imaging findings – eg vegetation on ECHO
Minor criteria
- Predisposition – eg IVDU, valve pathology
- Fever >38
- Vascular phenomena – splenic infarct, intracranial haemorrhage, Janeway lesions, petechiae, splinter haemorrhages
- Immunological phenomena – Ostler’s nodes, Roth spots, glomerulonephritis
- Microbiological phenomena – eg positive cultures 1x
IE Mx?
IV abx for 4-6 weeks:
native valve: amoxicillin + gentamicin
NB if pen allergic give vancomycin
prosthetic valve: vancomycin + rifampicin + gentamicin
Surgery to repair valve if:
- severe valvular incompetence, resistant to tx, abscesses
chronic heart failure definition and pathophysiology?
- heart unable to pump enough blood to meet metabolic demands of the body
- cor pulmonale - right heart enlargement - from disease of lungs/pulmonary vessels
- also RAAS activation and salt/fluid retentio
key causes of HF?
IHD, valvular heart disease (AS), HTN, arrhythmias, cardiomyopathy
classification of HF?
left ventricular failure: caused by IHD, MI
right ventricular failure: chronic lung disease, pulmonary stenosis, LVF
HF Px?
Breathlessness - worsened by exertion
Cough - produce frothy white/pink sputum
Orthopnoea - breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use)
Paroxysmal nocturnal dyspnoea
Peripheral oedema
Fatigue
LVF: dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, low exercise tolerance
RVF: peripheral oedema
HF patho in terms of ejection fraction and cardiac output ?
HF-rEF - inability of ventricle to contract normally - reduced CO, EF<40% - systolic dysfunction
- IHD, MI, dilated cardiomyopathy, arrhythmias, myocarditis, AS
HF-pEF - inability of ventricle to relax + fill normally, SV decreased, EF>50% - diastolic dysfunction
- HOCM, restrictive cardiomyopathy, tamponade, constrictive pericarditis
High-output HF - increased metabolic demands of body
- anaemia, AV malformation, Paget’s disease of bone, pregnancy, thyrotoxicosis
Low-output HF - CO reduced, fails to increase normally with exertion
HF signs on examination?
Tachycardia
Tachypnoea
Hypertension
Murmurs - valvular heart disease
3rd heart sound
Bilateral basal crackles (sounding “wet”) - indicating pulmonary oedema
Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck
Peripheral oedema of the ankles, legs and sacrum
HF Ix?
- CXR
- ECG
- ECHO
- Bloods: BNP, U&Es, LFTs, fbCC, TFTs
BNP 400-2000 = echo in 6 weeks
BNP >2000 = echo in 2 weeks
HF CXR findings?
Alveolar oedema – ‘bat’s wing shadowing’
Kerley B lines – interstitial oedema
Cardiomegaly – cardiothoracic ratio >50%
Dilated prominent upper lobe veins (upper lobe diversion)
Pleural Effusions
New York Heart Association (NYHA) HF classification?
Class I – no symptoms on ordinary physical activity
Class II – mild sx, slight limitation of physical activity
Class III – moderate sx, comfortable at rest but less than ordinary activity leads to sx
Class IV – severe sx, inability to carry out any activity without s
HF Mx - all patients?
R – Refer to cardiology
A – Advise them about the condition
M – Medical treatment
P – Procedural or surgical interventions
S – Specialist heart failure MDT input e.g. heart failure specialist nurses, for advice and support
Medical 1st line:
A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated
B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated
L – Loop diuretics (e.g., furosemide or bumetanide)
Medical 2nd line:
A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone)
HF-pEF Mx
- manage comorbidities
- tx cause
HF-rEF Mx
1st line
- ACEi (ramipril) + BB (bisoprolol)
- ARB (candesartan) if not tolerating ACEi
- hydralazine + nitrate if intolerant of ACEi/ARB
- add MRA (spironolactone/eplerenone) if sx continue
- check U/E (before/after each drug + dose change)
Specialist mx if sx continue
- replace ACEi/ARB with sacubitril valsartan if EF<35%
- add ivabradine if sinus rhythm >75, EF<35%
- add hydralazine + nitrate, esp if Afro-Caribbean
- digoxin
- SGLT2 inhibitor - dapagliflozin
- amiodarone
Specialist procedures
- cardiac resynchronisation therapy (CRT) - triple chamber pacemaker
- implantable cardioverter defibrillator (ICD)
- heart transplant
HF complications?
- arrhythmias, depression, cachexia, CKD, sexual dysfunction, sudden cardiac death, VTE, hepatic dysfunction
acute HF / acute pulmonary oedema pathology?
- acute deterioration in cardiac function
- LVF -> CO reduced, backlog of blood, excess fluid leaks -> pulm oedema - lung/alveoli filled with interstitial fluid - impaired gas exchange
De-novo AHF - AHF w/o hx of HF - eg ischaemia, viral, toxins, valvular
causes of AHF / pulmonary oedema?
Cardiac
- acute LVF, ACS, arrhythmias, valvular heart disease, HTN, cardiomyopathy, tamponade
Non-cardiac
- fluid overload, high-output HF, ARDS, RAS
Triggers
- preload increase - eg IV fluids, retention
- contractility decrease - ischaemia, infarction, arrhythmias, valvular, cardiomyopathy
- afterload increase - HTN
- direct lung damage
AHF Px?
- acutely SOB
- cough - frothy white / pink sputum
- hypoxia, cyanosis, increased RR/HR
- bibasal creps on ausc
- peripheral oedema
- fatigue, raised JVP
- 3rd HS
- chest pain, fever, palpitations (depends on cause)
- BP normal / increased
AHF Ix?
- A-E
- ECG
- Bloods - FBC, U/E, BNP, ?trop, ABG, Mg, Ca, TFTs
- CXR
- ECHO
AHF Mx?
S – Sit up
O – Oxygen (15L)
D – Diuretics (IV furosemide 40mg)
I – Intravenous fluids should be stopped
U – Underlying causes need to be identified and treated (e.g., myocardial infarction)
M – Monitor fluid balance
- IV morphine 2.5-10mg
- IV GTN 1mg/ml at 2ml/hr - if BP not low
- cardiogenic shock - dobutamine (inotrope) / noradrenaline (vasopressor)
- CPAP
- intubate
- continue regular HF meds
HTN?
- high BP
- clinic reading >140/90, 24hr BP avg >135/85
HTN causes?
Primary / essential HTN
- 90%, no cause
Secondary
- Renal - glomerulonephritis, chronic pyelo, PKD, RAS
- Endocrine - hyperaldosteronism, phaeo, Cushing’s, Liddle’s, CAH, acromegaly
- other - glucocorticoids, NSAIDs, pregnancy, coarctation of aorta, cOCP
[ROPED]
HTN RFx?
- older, ethnicity, FHx, overweight, sedentary, smoking, alcohol, diabetes, stress
HTN Px?
- asym
- headaches
- visual disturbance
- seizures
HTN Ix?
- BP monitoring - clinic / 24hr ABPM / home BP monitoring
- Stage 1 - >140/90 / >135/85 at home
- Stage 2 - >160/100 / >150/95 at home
- Stage 3 - >180/120
- BP both arms
- urine albumin:creatinine ratio
- urine dipstick
- Bloods - HbA1c, U/E, lipids
- fundoscopy
- ECG
- QRISK
HTN general Mx?
- healthy diet, stop smoking, reduce alcohol, lower caffeine/salt, exercise
- <40yo, ?refer to r/o secondary causes
BP targets
<80yo - <140/90 in clinic, <135/85 at home
>80yo - <150/90 in clinic, <145/85 at home
- if stage 1 - tx if <80yo AND organ damage / CV disease / renal disease / DM / QRISK>10%
- stage 2 - drug tx regardless of age
- stage 3 - same day assessment for retinal haemorrhage / papilloedema / phaeo / life-threatening sx
HTN Mx algorithm?
Step 1
<55yo / T2DM
- ACEi (ramipril)
- if T2DM Afro-Caribbean - ARB (candesartan)
- change to ARB if ACEi not tolerated
> 55yo / Afro-Caribbean
- CCB (amlodipine)
Step 2
- if on ACEi/ARB - add CCB / thiazide-like (indapamide)
- if on CCB - add ACEi/ARB / thiazide-like (ARB in Afro-Caribbean)
Step 3
- add the 3rd drug left
Step 4
- K<4.5 - low dose spironolactone
- K>4.5 - add alpha/beta blocker
- specialist review if still not controlled
HTN complications?
- IHD, CVA, PAD, aortic dissection, AAA, atherosclerosis
- hypertensive retinopathy
- hypertensive nephropathy
- LVH
- HF
- malignant HTN / hypertensive emergency
