Cardiology Flashcards
Do you give anticoagulation for a single episode of paroxysmal atrial fibrillation?
A single episode of paroxysmal atrial fibrillation, even if provoked, should still prompt consideration of anticoagulation.
Check CHA2DS2-VASc score
Direct oral anticoagulants (DOACs) like apixaban are now advised as the preferred first-line treatment for stroke prevention in individuals with non-valvular atrial fibrillation, including those with paroxysmal atrial fibrillation, rendering it the most suitable management approach.
What is the CHA2DS2-VASc score?
The CHA₂DS₂-VASc score is a risk stratification tool used to estimate the risk of stroke in patients with atrial fibrillation (AF) and guide anticoagulation decisions.
c - congestive heart failure 1
h - hypertension (or treated hypertension) 1
a2 - age >= 75 years 2
65-74 years 1
d- diabetes 1
s2 - prior stroke, TIA, thromboembolism 2
v - vascular disease 1
s- sex 1
What are benefits of DOACs over warfarin?
These have the advantage of not requiring regular blood tests to check the INR and now recommended as the first-line anticoagulant for patients with AF
Why should you never take verapamil and beta-blockers concurrently?
Verapamil and beta-blockers should never be taken concurrently - possibility of heart block and fatal arrest. Risk of Bradycardia, congestive heart failure.
What are the main indications of beta blockers?
Indications
- angina
- post-myocardial infarction
- heart failure: beta-blockers were previously avoided in heart failure but there is now strong evidence that certain beta-blockers improve both symptoms and mortality
- arrhythmias: beta-blockers have now replaced digoxin as the rate-control drug of choice in atrial fibrillation
- hypertension: the role of beta-blockers has diminished in recent years due to a lack of evidence in terms of reducing stroke and myocardial infarction.
- thyrotoxicosis
- migraine prophylaxis
- anxiety
what are the side effects of beta blockers?
Side-effects
- bronchospasm
- cold peripheries
- fatigue
- sleep disturbances, including nightmares
- erectile dysfunction
What are the contraindications of beta blockers?
Contraindications
- uncontrolled heart failure
- asthma
- sick sinus syndrome
- concurrent verapamil use: may precipitate severe bradycardia
What is acute pericarditis?
Acute pericarditis is a condition referring to inflammation of the pericardial sac, lasting for less than 4-6 weeks.
Etiology:
- viral infections (Coxsackie)
- tuberculosis
- uraemia
- post-myocardial infarction
early (1-3 days): fibrinous pericarditis
late (weeks to months): autoimmune pericarditis (Dressler’s syndrome) - radiotherapy
- connective tissue disease
systemic lupus erythematosus
rheumatoid arthritis - hypothyroidism
- malignancy
- lung cancer
- breast cancer
- trauma
What are some features of acute pericarditis?
chest pain: may be pleuritic. Is often relieved by sitting forwards
other symptoms include a non-productive cough, dyspnoea and flu-like symptoms
pericardial rub
When is the left anterior descending artery occluded in STEMIs?
ST elevations in leads V1-4 typically represent an anterior wall myocardial infarction which is commonly associated with occlusion of the left anterior descending artery, which is the likely case here.
What is included in ACS?
Acute coronary syndrome can be classified as follows:
ST-elevation myocardial infarction (STEMI): ST-segment elevation + elevated biomarkers of myocardial damage
non ST-elevation myocardial infarction (NSTEMI): ECG changes but no ST-segment elevation + elevated biomarkers of myocardial damage
unstable angina
How do you determine management for ACS?
The management of ACS depends on the particular subtype. NICE management guidance groups the patients into two groups:
1. STEMI
2. NSTEM/unstable angina
What is teh common management of all patients with ACS?
MOAN
aspirin 300mg
oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines
morphine should only be given for patients with severe pain
previously IV morphine was given routinely
evidence, however, suggests that this may be associated with adverse outcomes
nitrates
- can be given either sublingually or intravenously
- useful if the patient has ongoing chest pain or hypertension
- should be used in caution if patient hypotensive
What are teh STEMI criteria?
clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
new LBBB (LBBB should be considered new unless there is evidence otherwise)
How do you manage a STEMI?
Once STEMI is confirmed, immediately assess eligibility for coronary reperfusion therapy.
Two main types od coronary reperfusion therapy: Percutaneous coronary intervention an Fibrinolysis.
PCI : should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI)
Fibrinolysis: should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given
What types of patients are affected by infective endocarditis?
previously normal valves (50%, typically acute presentation)
the mitral valve is most commonly affected
rheumatic valve disease (30%)
prosthetic valves
congenital heart defects
intravenous drug users (IVDUs)
e.g. typically causing tricuspid lesion)
others: recent piercings
In patients with AF post stroke, should you give them anticoagulant or antiplatelets?
AF and paroxysmal AF both carry an increased risk of stroke. This risk of stroke is most reduced by starting the patient on an anticoagulant.
Apixaban is an example of an anticoagulant. The other medications listed are antiplatelets, not anticoagulants. Although antiplatelets do reduce the risk of stroke in patients with AF, they are less effective than anticoagulant therapy.
what is the most common cause of mitral stenosis?
Rheumatic fever
Intravenous drug use, and later infective endocarditis, can cause mitral stenosis. However, the tricuspid valve is more commonly affected by stenosis first, and regarding mitral stenosis, rheumatic fever is a more common cause.
Rarer causes that may be seen in the exam include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis
What are teh features of mitral stenosis?
Features
dyspnoea
↑ left atrial pressure → pulmonary venous hypertension
haemoptysis
due to pulmonary pressures and vascular congestion
may range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin-walled and dilated bronchial veins
mid-late diastolic murmur (best heard in expiration)
loud S1
opening snap
indicates mitral valve leaflets are still mobile
low volume pulse
malar flush
atrial fibrillation
secondary to ↑ left atrial pressure → left atrial enlargement
Features of severe MS
length of murmur increases
opening snap becomes closer to S2
Why should we be careful with beta-blockers and diabetic patients on insulin?
- Beta-blockers can suppress all of the adrenergically mediated symptoms of hypoglycemia - and can lead to unawareness of hypoglycemic events.
