Cardiology Flashcards
What is ischaemic heart disease
- Term used to describe heart problems caused by narrowed coronary arteries which leads to cardiac myocyte damage
- MI + angina
What is stable angina
Chest pain caused by an insufficient blood supply to the myocardium
Give 3 characteristics of stable angina
- Central constricting chest pain that may radiate to arms/jaw
- Brought on by exertion of stress
- always relieved by rest or GTN (glyceryl trinitrate)
3 non-modifiable RFs of ischaemic heart disease
- Increasing age
- Male gender
- Family history
5 modifiable RFs of ischaemic heart disease
- Smoking
- Diabetes mellitus
- Hypertension
- Hypercholesterolaemia
- Obesity
Describe the investigations and diagnosis of stable angina
1st line = ECG - Normal or ST depression
GS: CT Angiography - stenosed atherosclerotic arteries (70-80% occluded)
How is stable angina managed
- All patients: statin + aspirin in the absence of contraindications
- Lifestyle: smoking cessation, exercise, weight loss
- sublingual glyceryl trinitrate to abort angina attacks
- 1st: beta blocker or CCB monotherapy
- 2nd: if patient is still symptomatic with monotherapy, add the other drug i.e. BB + CCB
- revascularisation
When managing stable angina, if a patient is on monotherapy and cannot tolerate the addition of a CCB or a BB what drugs should be added
One of the following:
* a long-acting nitrate (Isosorbide mononitrate)
* ivabradine
* nicorandil
* ranolazine
When managing stable angina, what calcium channel blockers should be used as monotherapy
rate limiting:
* verapamil
* diltiazem
When managing stable angina, what calcium channel blockers should be prescribed when combined with a beta blocker
Longer-acting dihydropyridine CCB:
* amlodipine
* modified-release nifedipine
Describe the 2 types of coronary revascularisation
- PCI (Percutaneous coronary intervention): balloon stent. Less invasive but risk of stenosis
- CABG (coronary artery bypass graft): bypass graft. Has better prognosis but is more invasive
What physical sign identifies a patient who’s had a previous CABG
A midline sternotomy scar
What is acute coronary syndrome
Umbrella term covering acute presentations of IHD, including:
* Unstable angina
* ST elevation MI (STEMI)
* Non-ST elevation MI (NSTEMI)
How does acute coronary syndrome present
- central constricting chest pain that may radiate to the jaw or the left arm
- dyspnoea
- sweating
- palpitations
- nausea and vomiting
- typically last over 20 minutes
What is silent myocardial infarction and who are they more likely to be seen in
- May not experience any chest pain during an ACS
- More likely in the elderly, females and diabetics
How is acute coronary syndrome investigated
- ECG
- cardiac markers e.g. troponin
- CT coronary angiogram - extent of occlusion
ECG changes in leads V1-V4 would indicate damage to which coronary artery
Left anterior descending
ECG changes in leads II, III, aVF would indicate damage to which coronary artery
Right coronary (inferior)
ECG changes in leads I, V5-6 would indicate damage to which coronary artery
Left circumflex (lateral)
What investigation results would indicate unstable angina
- ECG: normal or may show changes indicative of ischaemia
- Troponin: normal
What investigation results would indicate a NSTEMI
- ECG: ST depression, pathological Q waves and T wave inversion
- Troponin: Raised
What investigation results would indicate a STEMI
- ECG: ST elevation in leads consistent with an area of ischaemia / new LBBB
- Raised troponin
- Complete occlusion of a major coronary artery
What is the common management of all patients with acute coronary syndrome
MONA
* morphine - only if severe pain
* oxygen - only if O2 sats < 94%
* Nitrates: sublingually or IV (should be used in caution if patient hypotensive)
* Aspirin 300mg
What is the first step of management once a STEMI has been confirmed?
Immediately assess eligibility for coronary reperfusion therapy
What are the two types of coronary reperfusion therapy?
- Percutaneous coronary intervention (PCI)
- Fibrinolysis
When should percutaneous coronary intervention be offered for STEMI?
If the presentation is within 12 hours of symptom onset and PCI can be delivered within 120 minutes of when fibrinolysis could have been given
What type of stents are used in percutaneous coronary intervention for STEMI?
Drug-eluting stents.
What type of access is preferred for Percutaneous Coronary Intervention?
Radial access
When should fibrinolysis be offered for STEMI?
Within 12 hours of symptom onset if Percutaneous Coronary Intervention cannot be delivered within 120 minutes.
What should be done if an ECG 90 minutes after fibrinolysis shows no resolution of ST elevation?
The patient should be transferred for Percutaneous Coronary Intervention
What dual antiplatelet therapy should be given prior to Percutaneous Coronary Intervention?
aspirin + another drug:
* if patient not taking an oral anticoagulant: prasugrel
* if taking an oral anticoagulant: clopidogrel
What is the recommended drug therapy for patients during Percutaneous Coronary Intervention
- radial access: Unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor
- femoral access: bivalirudin with bailout GPI
What should be given to patients undergoing fibrinolysis for STEMI?
antithrombin drug (e.g. alteplase + Fondaparinux)
When should an ECG be repeated after fibrinolysis for STEMI?
After 60-90 minutes to check for resolution of the ECG changes
What is the initial management once a NSTEMI/ unstable angina is identified
aspirin 300mg and one other drug:
* no bleeding risk/ no immediate PCI planned: Fondaparinux.
* immediate PCI planned/ creatinine >265 µmol/L: Unfractionated heparin.
What is the most widely used tool for risk assessment in NSTEMI and unstable angina?
The Global Registry of Acute Coronary Events (GRACE)
What key decisions are made based on the risk assessment in NSTEMI/unstable angina?
Decisions are made regarding whether the patient should undergo coronary angiography (with follow-on PCI if necessary) or receive conservative management.
Which patients with NSTEMI/unstable angina should have immediate coronary angiography?
Patients who are clinically unstable (e.g., hypotensive).
Which patients with NSTEMI/unstable angina should have coronary angiography within 72 hours?
Patients with a GRACE score greater than 3%, i.e., those at intermediate, high, or highest risk.
What is the role of Percutaneous Coronary Intervention for patients with NSTEMI/unstable angina?
It is performed when coronary angiography reveals significant coronary artery disease, and the procedure can restore blood flow if needed.
What further drug therapy is given to patients undergoing Percutaneous Coronary Intervention for NSTEMI/unstable angina?
- Unfractionated heparin (regardless of prior fondaparinux use)
- Dual antiplatelet therapy - aspirin + another drug:
if the patient is not taking an oral anticoagulant - prasugrel or ticagrelor
if taking an oral anticoagulant - clopidogrel
What further drug therapy is given to patients managed conservatively for NSTEMI/unstable angina?
Dual antiplatelet therapy I.E. aspirin + another drug:
* if the patient is not at a high risk of bleeding: ticagrelor
* if the patient is at a high risk of bleeding: clopidogrel
Give 3 poor prognostic factors in acute coronary syndrome
- cardiogenic shock
- age
- development/ history of heart failure
Complications of myocardial infarction
- Cardiac arrest
- Cardiogenic shock
- Tachyarrhythmias - Ventricular fibrillation
- Bradyarrhythmias - AV block is mc following inferior MI
- Pericarditis
- Dressler’s syndrome
Following a myocardial infarction, what should all patients be offered as secondary prevention
- Dual antiplatelet therapy: Aspirin + prasugrel or ticagrelor. stop second antiplatelet after 12 months
- ACE inhibitor
- beta-blocker
- statin
What is heart failure
clinical syndrome where the heart is unable to pump enough blood to meet the metabolic needs of the body
Describe HF with reduced ejection fraction
- left ventricular ejection fraction < 35 to 40%
- systolic dysfunction
Describe HF with preserved ejection fraction
- left ventricular ejection fraction >50%
- diastolic dysfunction
Give 4 conditions that cause diastolic dysfunction
Hypertrophic obstructive cardiomyopathy
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive pericarditis
Give 4 conditions that cause systolic dysfunction
Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
Arrhythmias
Signs of left ventricular failure
- pulmonary oedema
- dyspnoea
- orthopnoea
- paroxysmal nocturnal dyspnoea
- bibasal fine crackles
Signs of right ventricular failure
- peripheral oedema: ankle/sacral oedema
- raised jugular venous pressure
- hepatomegaly
- weight gain due to fluid retention
- anorexia (‘cardiac cachexia’)
What is high output heart failure
where a ‘normal’ heart is unable to pump enough blood to meet the metabolic needs of the body
3 causes of high output heart failure
- severe anaemia
- pregnancy
- thyrotoxicosis
What is de-novo acute heart failure?
De-novo acute heart failure occurs without a previous history of heart failure
What is decompensated acute heart failure?
occurs in patients with a history of chronic heart failure and accounts for the majority (66-75%) of acute heart failure cases.
At what age does acute heart failure typically present?
after the age of 65
What causes de-novo acute heart failure?
often caused by increased cardiac filling pressures and myocardial dysfunction, usually due to ischaemia
What are the most common precipitating causes of decompensated acute heart failure?
- Acute coronary syndrome
- Hypertensive crisis
- Acute arrhythmia
- Valvular disease
What are the general symptoms of acute heart failure?
- Breathlessness
- Reduced exercise tolerance
- Oedema
- Fatigue
What are the signs of acute heart failure?
- Cyanosis
- Tachycardia
- Elevated jugular venous pressure
- Displaced apex beat
- Bibasal crackles or wheeze
- S3 heart sound (LHF)
What is the most common blood pressure finding in patients with acute heart failure?
Over 90% of patients with acute heart failure have normal or increased blood pressure.
Investigations for acute heart failure?
- Blood tests: check for anaemia, electrolyte abnormalities, or infection
- Chest XR: look for pulmonary venous congestion, interstitial oedema, and cardiomegaly
- Echocardiogram
- B-type natriuretic peptide: raised levels >100mg/litre indicate myocardial damage
When is an ECHO indicated in the investigation of acute HF
- new-onset HF
- cardiogenic shock
- suspected valvular problems
- post-myocardial infarction complications
Features of chronic heart failure
- cough: may be worse at night and associated with pink/frothy sputum
- orthopnoea
- paroxysmal nocturnal dyspnoea
- wheeze (due to pulmonary oedema)
- weight loss
- bibasal crackles on examination
- signs of right-sided heart failure
What is the recommended treatment for all patients with acute heart failure?
Intravenous loop diuretics (e.g., furosemide or bumetanide).
What is the recommended oxygen target for patients with acute heart failure?
Oxygen should be administered to keep oxygen saturations at 94-98%
When should vasodilators like nitrates be used in acute heart failure?
if there is concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease
What is the treatment for patients with respiratory failure due to acute heart failure?
Continuous positive airway pressure (CPAP).
How should acute heart failure with hypotension (e.g., < 85 mmHg) or cardiogenic shock be managed?
- inotropic agents (e.g., dobutamine) -severe left ventricular dysfunction
- Vasopressor agents (e.g., norepinephrine)
- mechanical circulatory assistance
What should be done with regular heart failure medications in patients with acute heart failure?
Regular heart failure medications, such as beta-blockers and ACE inhibitors, should be continued unless contraindicated.
When should beta-blockers be stopped in patients with acute heart failure?
if the patient has a heart rate of less than 50 beats per minute, second or third degree atrioventricular block, or shock.
What is atrial fibrillation
most common sustained cardiac arrhythmia, characterised by an irregularly irregular pulse and an increased risk of stroke, particularly in older patients
What are the types of atrial fibrillation?
- First detected episode – first time AF is diagnosed.
- Paroxysmal AF – episodes of AF that terminate spontaneously, usually within 24 hours (but less than 7 days).
- Persistent AF – AF episodes that last more than 7 days and do not self-terminate.
- Permanent AF – continuous AF that cannot be cardioverted or when attempts are deemed inappropriate.
What are the typical symptoms of atrial fibrillation?
Palpitations
Dyspnoea
Chest pain
What is the key sign of atrial fibrillation?
An irregularly irregular pulse.
What is the primary investigation for diagnosing atrial fibrillation?
An ECG - diagnose AF and differentiate it from other conditions with an irregular pulse, such as ventricular ectopics or sinus arrhythmia.
ECG signs of AF
- Irregular and rapid QRS complexes (<120ms)
- Absent P waves
What are the two key management goals for atrial fibrillation?
- Rate or rhythm control.
- Reducing stroke risk.
What is the difference between rate control and rhythm control in AF management?
- Rate control: Accepting an irregular pulse but using medications to slow the heart rate (first-line treatment).
- Rhythm control: Attempting to restore normal sinus rhythm, using either pharmacological or electrical cardioversion.
What is the preferred approach to atrial fibrillation management according to NICE?
Rate control should be offered as the first-line treatment strategy for most patients with atrial fibrillation
When is rate control not first line in the management of atrial fibrillation
- AF has a reversible cause
- HF primarily caused by atrial fibrillation
- new-onset atrial fibrillation (< 48 hours)
- with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
- when a rhythm-control strategy would be more suitable based on clinical judgement
What drugs are used for rate control in atrial fibrillation?
- Beta-blockers (e.g., metoprolol).
- calcium channel blockers (diltiazem)
- If additional control is needed, combination therapy with digoxin may be used.
When should rhythm control be considered in atrial fibrillation?
may be considered in patients with persistent symptoms, or in those who initially started with rate control but continue to experience symptoms or high heart rates
What is the management approach for atrial fibrillation (AF) with onset < 48 hours?
- heparinised
- If the patient has RFs for ischaemic stroke, initiate lifelong oral anticoagulation.
cardioverted using either: - electrical - ‘DC cardioversion’
- pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease
- Post-cardioversion: no further anticoagulation is required
What is the management for atrial fibrillation (AF) with onset > 48 hours?
- rate control initially
- if considered for long term rhythm control: stable on Anticoagulation for at least 3 weeks prior to cardioversion.
What drugs are used for long term rhythm control in atrial fibrillation
- beta-blockers
- dronedarone: second-line in patients following cardioversion
- amiodarone: particularly if coexisting heart failure
What should be done for patients with atrial fibrillation who present with signs of haemodynamic instability (e.g., hypotension or heart failure)?
should be electrically cardioverted
What criteria must be fulfilled before attempting cardioversion in atrial fibrillation?
Patients must either have had AF for less than 48 hours or be adequately anticoagulated for a period of time to reduce the risk of stroke from embolism.
How is the stroke risk in atrial fibrillation assessed?
The CHA2DS2-VASc score is used to stratify stroke risk and determine the need for anticoagulation.
How is anticoagulation determined based on the CHA2DS2-VASc score?
- Score 0: No treatment (for males).
- Score 1: Consider anticoagulation (for males), no treatment (for females).
- Score 2 or more: Offer anticoagulation.
What anticoagulants are typically offered to patients with atrial fibrillation?
- 1st: direct oral anticoagulants (DOACs)
- 2nd: warfarin
Give 4 DOACs used for reducing stroke risk in atrial fibrillation
apixaban
dabigatran
edoxaban
rivaroxaban
In AF, if a CHA2DS2-VASc score suggests no need for anticoagulation what imaging should be done and why
ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which in combination with AF is an absolute indication for anticoagulation.
What does NICE recommend regarding anticoagulation in patients, particularly older adults or those at risk of falls?
warns against withholding anticoagulation solely based on age or risk of falls. Anticoagulation decisions should still be made based on a thorough risk assessment.
What tool is used to formally assess bleeding risk in patients who may be considered for anticoagulation therapy
Orbit score
What does NICE recommend for long-term stroke prevention in patients with atrial fibrillation post-stroke or TIA?
warfarin or a direct thrombin inhibitor or factor Xa inhibitor (DOACs) for long-term stroke prevention.
When should anticoagulation be started for a patient with atrial fibrillation after a transient ischaemic attack (TIA)?
Anticoagulation should be started immediately following a TIA, once imaging has excluded haemorrhage.
When should anticoagulation therapy be started for patients with atrial fibrillation following an acute stroke?
- For acute stroke patients, anticoagulation should be started 2 weeks after the stroke, in the absence of haemorrhage
- Antiplatelet therapy should be used in the intervening period
Give 5 causes of atrial fibrillation
S – Sepsis
M – Mitral valve pathology (stenosis or regurgitation)
I – Ischaemic heart disease
T – Thyrotoxicosis
H – Hypertension
