Cardiology Flashcards
1
Q
What are the types of AF as defined by duration?
A
Paroxysmal (comes and goes - usually less than 48hrs)
Persistent (more than a week or needs cardioversion)
Long standing persistent (more than a year)
Permanent (all the time)
2
Q
How is the need for anticoagulation determined in AF? How is it interpreted?
A
C - congestive heart failure (1) H - hypertension (1) - includes on current tx A - age over 65 (1) D - diabetes mellitus (1) - includes on current tx S - previous stroke, TIA or VTE (2) V - vascular disease (1) A - age over 75 (1) S - sex female (1)
0 - low risk, 1 - mod risk, >1 high risk
Don’t offer anticoagulation just off female gender, take into account bleeding risk,
3
Q
What score is used to assess bleeding risk for anticoagulation?
A
H - hypertension A - abnormal liver or renal function or alcohol (1,1,1) S - stroke B - bleeding history L - labile INR E - elderly over 65 D - drugs (antiplatelet / NSAID)
4
Q
What INRs should prompt the reassessment of warfarin in AF?
A
After first 6 weeks
2 higher than 5 or 1 higher than 8 in last 6 months
2 less than 1.5 in last 6 months
5
Q
What factors should prompt for AF rhythm control over rate control?
A
Known reversible cause CHF due to the AF New onset AF Able to ablate (flutter) Ineffective rate control Younger, active or symptomatic
6
Q
What factors suggest rate control over rhythm control in AF?
A
Permanent/not responding to rhythm control
Recurrent over 65
7
Q
What drugs can be used to control AF rate?
What should be considered in prescribing?
What can be used if drugs not effective?
A
Beta blockers
Calcium channel blockers
Digoxin (in elderly no ambulant patients only - not effective in young as high catacholamines overwhelm vagus)
Ablation of the AV with pacemaker insertion.
8
Q
What general means can be used to achieve AF rhythm control?
A
DC cardioversion
Amiodarone
Fleccanide
9
Q
What defines unstable AF and how should it be treated?
A
AF with MI, shock, angina or pulmonary oedema
UFH cover, DC cardiovert, 4 weeks of LMWH and anticoagulant
If CHADSVASc is >0 lifelong anticoagulant
Consider amiodarone to maintain NSR for 1 year
10
Q
How should a case of AF that presents within 48 hours of onset be managed if rhythm control is desired?
A
UFH cover
Cardioversion
If CHADSVASc high then lifelong anticoagulants
Consider amiodarone for 1 year to maintain NSR
11
Q
How should a stable case of AF be managed for rhythm control if it presents after 48 hours?
A
3 weeks of anticoagulation
DC cardioversion
LMWH and anticoagulation for 4 weeks
If CHADSVASc high then lifelong oral anticoagulation
Consider amiodarone before and up to a year after to maintain NSR
12
Q
How should a stable but urgent case of AF that presents after 48 hours be managed if rhythm control desired?
A
Transosophageal ultrasound to check for clots
If absent - UFH, cardiovert, 4 weeks LMWH/anticoag
If present anticoagulate then check again after 3 weeks then proceed as for stable presentation out of 48 hours
13
Q
What can be used for chronic rhythm control in AF?
A
Beta blocker
Flecanide
Amiodarone
Pill in pocket stratergy to be taken if symptomatic (if very low risk)
14
Q
What are causes of atrial fibrillation?
A
Hypertension Heart failure MI/ischemia Mitral stenosis/regurgitation Rheumatic heart disease Alcohol Thyrotoxicosis Valve surgery CABG Idiopathic
15
Q
What are the diagnostic criteria for infective endocarditis?
A
Duke criteria
2 major, 1 major and 3 minor, 5 minor
Major - typical or persistent positive blood culture. - positive echo or confirmed regurgitation
Minor - predisposing factor. - fever. - vascular signs. - positive blood culture not meeting major. - positive echo not meeting major
16
Q
What are risk factors for infective endocarditis?
A
Dermatitis IV injection / IVDU Valve disease Valve replacement Patent VSD or ductus arteriosus
17
Q
Signs and symptoms of infective endocarditis
A
Fever/malaise Night sweats Weight loss Splenomegaly Clubbing Splinter haemorrhages New or changed murmur Oslars nodes / janeway lesions Roth spots Abcesses
18
Q
What are oslars nodes, janeway lesions and roth spots?
A
Oslars - vasculitis caused painful infarcts on fingers/toes
Janeways - embolic caused painless palmer or planter abcesses
Roth - vasculitis caused retinal haemorrhages with a pale centre
19
Q
Common causes of native valve infective endocarditis?
A
Streptococcus viridans - mouth
Staphylococcus aureus - skin
Enterococcus faecalis
20
Q
Common causes of prosthetic valve infective endocarditis within one year of surgery?
A
Coagulase -ve staphylococci
21
Q
What fungi can be associated with infective endocarditis?
A
Candidia,
22
Q
What examinations are required in suspected infective endocarditis?
A
Blood cultures x3 from different sites FBC for anaemia / neutrophilia Urinanalysis for microscopic haematauria Cxr for cardiomegally Echo for vegitiations or regurgitations
23
Q
Example of blind therapy for native valve infective endocarditis
A
Amoxicillin and gentamicin
24
Q
Example of blind antibiotic therapy for prosthetic valve infective endocarditis?
A
Vancomycin, gentamicin and rifampicin
25
Signs of heart failure on CXR?
```
Diffuse consolidation (bat wings - perihilar consolidation)
Reticular interstitial consolidation
Increased heart size
Kerley b lines
Bilateral pleural effusion
```
26
Why do you get batwing (perihilar) consolidation in heart failure? When else do you get it?
Better lymphatic drainage peripherally
| Non cardiogenic odema
27
Causes of heart failure?
| Three commonest and 4 others
```
IHD
Dilated cardiomyopathy
Hypertension
Non-dilated cardiomyopathy
Valvular heart disease
Congenital heart disease
Arrhythmia
Alcohol and drugs
```
28
What are the two mechanisms of heart failure? What is happening?
Systolic - decreased contraction strength of the heart reducing cardiac output
Diastolic - failure of the heart to appropriately relax during diastole
29
What type of heart failure would be most vulnerable to a sudden tachycardia? Why?
Diastolic - reduced filling time.
30
What is frank starlings law? What is frank starlings curve? How does it appear normally? Why?
That the higher the end diastolic volume, the greater the ventricle is stretched and the stronger the force of contraction.
The curve is a plot of ventricular performance against filling pressure. It rises initially due to starlings law then falls as the fibrous pericardium will no longer stretch and further filling compresses the arteries
31
How is starlings law effected in a systolic heart failure?
Decreased cardiac output causes increased end systolic volume, increased venous pressure and thus increased end diastolic volume. This would normally cause increased cardiac output back to normal however, in heart failure the starling curve is depressed thus cardiac output must be maintained by other means (e.g. Increasing pulse) .
32
What compensatory factors designed to maintain blood pressure actually end up worsening heart failure?
Increased afterload due to systemic vasoconstriction
Myocardial damage due to high sympathetic tone
Increased wall stretch due to high preload due to high venous return and salt/water retention
33
What physiological process that occurs during heart failure actually aids the heart long term?
ANP and BNP release in response to stress causing sodium and water loss with vasodilation
34
What is the classification method of heart failure?
Nyha classification for heart failure
1 - no limitation, normal exercise does not cause symptoms
2 - mild limitation, comfortable at rest but normal activity causes symptoms
3 - marked limitation, comfortable at rest but mild activity causes marked symptoms
4 - symptoms at rest
35
Symptoms of heart failure
Exertional dysponea
PND
Orthopneoa
Fatigue
36
Abdominal signs of heart failure?
Ascites
| Hepatomegaly
37
Why does heart failure cause pulmonary oedema?
Pulmonary venous hypertension results in increased plural fluid production
Systemic venous hypertension results in decreased lymphatic drainage so decreased pleural fluid reabsorption
38
Primary care tests in heart failure prior to referral?
BNP
CXR
ECG
39
Secondary care tests for heart failure?
Echocardiography
| Cardiac MRI
40
In mild heart failure is cardiac output reduced? What about ejection fraction?
CO normal due to increased preload and tachycardia
| EJ decreased
41
Common causes of right heart failure?
Secondary to left
Cor-pulmonale
Pulmonary hypertension
Right sided valve disease or right sided ischemia
42
Non-medical management of heart failure?
```
Low level exercise
Low salt intake
Stop alcohol
Stop smoking
Prophylactic vaccination
```
43
Drug classes used in heart failure
```
Diuretics
Ace inhibitors
Beta blockers
Aldosterone antagonist
Inotropic agents
Nitrates
```
44
Surgical management of heart failure?
Biventricular pacemaker
Transplantation
Left ventricular assist device
45
If furosemide not working what options are there (confined to diuretics)?
Up titrate dose
Switch to bumetanide
Add a thiazide
46
What drug classes are prognosis altering in heart failure?
Ace inhibitors
Arbs
Beta blockers
Spironolactone
47
What drugs purely cause symptom relief in heart failure with no change to prognosis?
Diuretics
Inotrophs
Nitrates
48
How are beta blockers thought to work to improve heart failure prognosis?
Co reduces then returns to normal
| Pvr decreases long term possibly due to beta 1 blockade of renin release
49
Other than social factors and directly treating the heart failure, what else should be considered in a heart failure patient?
Treating cause
| - revasculisation, antiarrhythmics, antihypertensives
50
What management option can be considered in inpatient treatment of severe heart failure?
Fluid restriction
51
What aldosterone antagonist is used in heart failure? Main side effect?
Spironolactone - gynacomastia
52
Beta blocker for heart failure?
Bisoprolol
| Carvediolol
53
At what point would you consider aspirin for primary prevention of cvd?
Qrisk2 >20
| Bp
54
At what point should statins be considered for cvd primary prevention? Which? How much?
Qrisk2 >10
Atovastatin
20mg
55
Stage 1 hypertension thresholds
Clinic > 140/90
| Home > 135/85
56
Stage 2 hypertension thresholds
Clinic 160/100
| Home 150/95
57
Severe hypertension threshold
>180/110
58
Treatment threshold for hypertension?
All stage 2
| Stage 1 under 80 with - dm, ckd, cvd, qrisk2 >20%, organ damage
59
Under what age should secondary causes of htn be actively sort?
40
60
Secondary causes of htn?
```
Renal artery stenosis
Fibromuscular dysplasia
Phaeochromocytoma
Cushings
Conns
OSA
```
61
Presentation of renal artery stenosis?
Refractory HTN
| Deteriorating renal function worsened by ACEi
62
Treatment options for renal artery stenosis?
Angioplasty with stenting if:
- bilateral
- unilateral with only one kidney
- effecting renal function
63
How does a phaeochromocytoma present?
```
Refractory htn
Sweating
Palpitations
Headache
Anxiety
```
64
How is phaeochromocytoma tested for?
24 hour urine catacholamines
65
How is phaeochromocytoma diagnosed and treated? Waht needs to be considered prior to treatment?
Ct/mri/pet post +ve urine
Surgical removal
Load with sodium and fluids prior to surgery to prevent bp crash
66
How does cushings syndrome present in a htn capacity?
Refractory htn
Hypokalaemia
Central obesity, moon face, dorsocervical fat pad, purple striae, bruising, thin skin, dm, polyuria, polydipsia, hirtuism, baldness
67
How does conns syndrome present?
| What metabolic abnormalities stem from the electrolyte imbalance?
Hypertension
Hypokalaemia
Glucose intolerance and metabolic alkalosis
68
How does conns cause hypokalaemia?
Aldosterone triggers
- uptake of k into cells by na/k atpase
- increased ENaC, ROMK and NaKATPase in principal cells of DT and CD
69
How is conns diagnosed?
Serum aldosterone levels
| 24 hr urinary aldosterone
70
What can cause conns?
Adrenal adenoma
| Idiopathic adrenal hyperplasia
74
How is conns syndrome managed?
Spironolactone
| Adrenalectomy (effective if adenoma cause not hyperplasia)
75
Cause of hypertrophic cardiomyopathy?
Genetic - dominant inheritance or spontanious
76
Symptoms of hypertrophic cardiomyopathy?
```
Sudden death
Palpitations
Angina
Dysponea
Syncope
```
77
Change in apex beat in hypertrophic cardiomyopathy?
Double tap
| NOT. Displaced!
78
What conditions can cause displacement of apex beat?
```
Left ventricular dilation
- dilated cardiomyopathy
- aortic stenosis
- severe hypertension
Mediasteinal shift
```
79
Signs of hypertrophic cardiomyopathy?
Double tap apex beat
Murmur like aortic stenosis
Heart failure symptoms
Systolic thrill left sternal edge
80
ECG changes in hypertrophic cardiomyopathy?
```
LVH
AF
VT
WPW
PVCs
```
81
Complications of hypertrophic cardiomyopathy
LVOT obstruction - syncope, angina
| Disordered myocytes - arrhythmia, PVCs
82
Treatment of hypertrophic cardiomyopathy
```
Exercise limitation
Beta blockers
Amiodarone
Dual chamber pacing
ICD
Septal myomectomy for LVOT obstruction
```
83
Causes of dilated cardiomyopathy?
Unknown but related to alcohol, htn, viruses and genetics
84
Presentation of dilated cardiomyopathy
```
Fatigue
Dysponea
LVF
AF
VT
```
85
Signs of dilated cardiomyopathy
Displaced apex beat
Mitral regurgiation
CHF
86
ECG in dilated cardiomyopathy
Poor r wave progression
87
Treatment of dilated cardiomyopathy
```
Rest
Digoxin
ACEi
Biventricular pacing
Anticoagulation
ICD
transplantation
```
88
Causes of pericarditis?
```
Viral
Bacterial
Idiopathic
MI
Uraemia
Autoimmune
Drug induced
Radiotherapy
Tumour
```
89
Signs of uncomplicated pericarditis?
Pericardial friction rub (hammonds sign)
90
Cardiac enzymes in pericarditis?
Normal unless progresses to myocarditis
91
Treatment of uncomplicated pericarditis?
Treat cause
Aspirin
If no response, corticosteroids
92
Signs of pericardial effusion?
```
Muffled heart sounds
Non-palpable apex beat
Dull percussion note to lower left lung
Raised JVP
Kussmauls sign
Pulsus paradoxus
```
93
What is kussmauls sign in pericardial effusion? Why?
Increased JVP on inspiration
Normally jvp falls with inspiration as decreased pressure aids return to heart. If impaired filling of heart then blood returns, but is pooled into the veins increasing jvp.
94
Signs that a pericardial effusion has progressed to tamponade?
Haemodynamic compromise
95
What is pulsus paradoxus?
Sbp drops on inspiration
Inspiration lowers pressure so increases venous return, dilates right ventricle, compressing left ventricle resulting in decreased blood ejected from the left!
96
What is becks triad of cardiac tamponade?
Low bp, increased jvp, muffled heart sounds.
97
Treatment of cardiac tamponade?
Pericardiocentesis
98
How should repeated pericardial tamponades be treated?
Fenestrations cut into pericardium to allow drainage
99
Causes of cardiac tamponade?
Any of pericarditis
Aortic dissection
Warfarin therapy
Trauma (inc biopsy or puncture during cardiac catheterisation)
100
What is a cardiomyopathy?
An idiopathic myocardial disease
101
How may myocarditis present?
Asymptomatic
| Pain, fatigue, dysponea, palpitations, CHF
102
What would cardiac enzymes show in a myocarditis patient?
Elevation
103
Advice in patients with myocarditis
Bed rest
| Avoid athletic activities for 6months at least
104
Classification method of heart failure?
NYHA
1 - normal exercise does not produce symptoms
2 - mild limitation - normal exercise produces symptoms
3 - marked limitation - gentle exercise produces severe symptoms
4 - symptoms at rest
105
Causes of raised JVP
Fluid overload - RVF (CHF, cor pulmonale), iatrogenic
| Mechanical obstruction of SVC - cancers
106
What does the JVP reflect?
Right atrial pressure
107
Auscultation procedure of the chest in a CVS exam? What murmur are you listening for? What breathing should be performed to increase?
Apex beat - mitral (expiration)
Left axilla - mitral regurgitation (expiration)
Apex rolled left - mitral stenosis (expiration)
4th ICS LSE - tricuspid (inspiration)
2nd ICS LSE - pulmonary (inspiration)
2nd ICS RSE - aortic (expiration)
Neck - aortic stenosis (expiration)
4th ICS LSE leaning forward - aortic regurgitation (expiration)
Base of lungs posteriorly! Bibasal crackles
108
Why would you auscultate the chest of a patient with chest pains?
```
Extra heart sounds - heart failure
Mitral regurgitation - papillary muscle rupture post MI
VSD - post MI
Pericardial friction rub - pericarditis
Aortic stenosis - angina
```
109
What is the first heart sound?
Closure of the AV valves
110
What is the second heart sound?
Closure of the semilunar valves
111
Why may the second heart sound split?
Inspiration - venous return to RV increases so pulmonary closes after aortic
RBBB - delayed RV contraction
ASD - increases RV volume
LBBB - delayed LV contraction
112
What is a third heart sound? Causes?
Sound of rapid ventricular filling in early diastole.
| Normal 40 LVF
113
What is a fourth heart sound? Cause?
End diastolic sound due to atria contracting against an incompliant ventricle
E.g. LVH,
114
Which heart sound should be auscultated with the bell?
Mitral stenosis (leaning left at apex)
115
How are heart murmurs graded?
1 - only heard in optimum conditions by expert
2 - heard in optimum conditions by anyone
3 - heard but no thrill
4 - heard with thrill
5 - heard with partial contact
6 - heard without stethoscope
116
What is the murmur of mitral stenosis?
Mid diastolic murmur best heard with bell rolled to left at apex
Opening snap
117
What is the murmur of mitral regurgitation?
Pansystolic murmur best heard at the axilla
118
What is the murmur of aortic stenosis? How can cause be narrowed down by listening?
```
Ejection systolic murmur best heard at the neck
Ejection click (not calcified as leaflets too stiff)
```
119
What is the usual murmur of aortic regurgitation?
Early diastolic murmur best heard left sternal edge when leaning forwards
120
Causes of ejection systolic murmurs?
Aortic stenosis
| LVOT obstruction
121
Causes of pansystolic murmur?
Mitral regurgitation
Tricuspid regurgitation
VSD
122
Causes of early diastolic murmurs?
Aortic regurgitation
| Pulmonary regurgitation
123
Causes of mid diastolic murmurs
Mitral stenosis
124
Causes of continuous murmurs?
Patent ductus arteriosus
125
Nature of pericarditis pain
Sharp
Worse on inspiration and swallowing
Eased by leaning forward from sitting
126
How can thoracic aortic dissection be classified?
Type a - involving arch and aortic valve proximal to left subclavian
Type b - involving the descending thoracic aorta distal to the left subclavian artery.
127
How can dissecting aortic aneurysm be diagnosed?
CT or transoesophageal echo
128
What management should thoracic dissecting aortic aneurysms recieve?
Type a - antihypertensives if HTN, arch replacement surgery
| Type b - medical management unless complications develop
129
Which type of dissecting aortic aneurysm is more common?
Type a
130
Complications of type a dissecting aortic aneurysms?
Coronary artery occlusion
Aortic incompetence
Cardiac tamponade
131
What sort of replacement heart valves are there? Lifespans? Risks?
Manufactured - lifelong, risk of clots
| Tissue - 10-20 years, no risk of clots
132
Causes of aortic stenosis?
Senile calcification
Rheumatic heart disease
Congenital
133
Symptoms of aortic stenosis?
Exertional dysponea
Angina
Syncope
Heart failure
134
Signs of aortic stenosis?
Ejection systolic murmur loudest on expiration radiating to neck
Slow rising pulse
Heaving apex beat
Heart failure
135
Tests that might show signs of aortic stenosis?
CXR - calcification
Echo - decreased flow
ECG - blocks as calcification spreads, LVH
136
Causes of aortic regurgitation
```
Infective endocarditis
Aortic dissection
Chest trauma
Rheumatic fever
Connective tissue diseases
SLE
RA
```
137
Symptoms of aortic regurgitation
Dysponea
Palpitations
Syncope
Angina
138
Signs of aortic regurgitation
Early diastolic murmur loudest on expiration radiating to sternum
Collapsing pulse with wide pulse pressure
Carotid pulsation
Head nodding with heartbeat
139
Test findings for aortic regurgitation?
Ecg - lvh
Cxr - lvh, pulmonary oedema
Echo - regurgitaiton
140
Causes of mitral stenosis?
Rheumatic heart disease
Congenital
Carcinoid syndrome
Prosthetic valve
141
Symptoms of mitral stenosis?
```
Dysponea
Fatigue
Palpitations
Chest pains
Haemoptysis
Right heart failure
Systemic emboli
```
142
Signs of mitral stenosis
Mid diastolic murmur loudest at apex on expiration and leaning left
Malar flush
Af
Low volume pusle
143
Test findings for mitral stenosis?
Ecg - p mitrale, rvh, rad, af
Cxr - left atrial enlargement
Echo - low flow
144
Causes of mitral regurgitation
```
Lv dilatation
Calcification
Rheumatic fever
Infective endocarditis
Prolapse
Ruptured chordae tendinae or papillary muscle
Congenital
```
145
Symptoms of mitral reguritation
Dysponea
Fatigue
Palpitaitons
146
Signs of mitral regurgitation
Pansystolic murmur loudest at apex radiating to axilla
Displaced hyperdynamic apex
Rv heave
Af
147
Tests showing signs of mitral reguritation
Ecg - af, pmitrale, lvh
Cxr - lv enlargement, calcification
Echo - regurg
148
How can you perform a cardiac stress test in different ways?
Treadmill
Beta agonist like dobutamine
Vasodilator like adenosine
149
What are positive results in a cardiac stress test?
```
Chest pains
Sob
Presyncope
St depression (significant)
Us wall motion changes
Decreased radioisotope distribution on nuclear imaging
```
150
When does troponin begin to rise post insult? Peak? Decline?
3-4 hours, peak at 18-36 hours, decline in 10-14 days
151
When does ckmb begin to rise post insult? Peak? Decline?
3-8 hours, peak at 24 hours, decline at 48-72 hours
152
Causes of raised troponin?
```
AMI
Heart surgery
PE with right ventricular strain
Pericarditis and myocarditis
Aortic dissection
Heart failure
Cardioversion
Trauma
Sepsis
End stage renal disease
Rhabdomyolysis
```
153
What is rheumatic fever?
An inflammatory disease following urti with beta haemolytic streptococcus (pyogenes) caused by antibody cross reactivity
154
What is required for a diagnosis of rheumatic fever?
Throat culture showing strep pyogenes (rare as infection usually passed)
Blood antigen
Antibody titre
Scarlet fever
155
Signs and Symptoms of rheumatic fever?
```
Carditis - tachycadia, mit/aor regurg, ccf, cardiomegally, conduction defect
Arthritis
Erythema marginatum
Subcutaneous nodules
Fever
Raised crp
```
156
Main complication of rheumatic fever? Prevalence?
Rheumatic heart disease
| 60% of those with rheumatic fever and carditis
157
Presentation of rheumatic heart disease?
Aortic and mitral regurgitation progressing to chronic stenosis
158
Treatment for rheumatic fever?
Rest
Penicillin
Aspirin if carditis
Immobilise arthritic joints
159
What treatments are required long term post rheumatic fever? Durations?
Prophylactic penicillin
If valve disease lifelong
If carditis 10 years
Otherwise 5 years
160
Diagnostic criteria for infective endocarditis?
| How many points needed?
Dukes criteria
2 major
1 major 3 minor
5 minor
161
Major dukes criteria for ie
Positive blood culture - typical from 2 sites or atypical from 3
Evidence of endocardial involvement - vegetation, regurgitation
162
Minor dukes criteria for ie?
```
Predisposition
Fever >38
Vascular signs
Positive blood culture not meeting major
Postive echo not meeting major
```
163
Predisposing factors for infective endocarditis
```
Ivdu
Dental work
Prosthetic valve
Valve disease
Structural heart disease
Previous endocarditis
```
164
Vascular signs of infective endocarditis. What are they?
Roth spots - retinal haemorrhage - white centred haemorrhage
Oslars nodes - immune complex - painful, red, raised, fingers/toes
Janeway lesions - septic emboli - nonpainful, palms/soles
Splinter haemorrhages - blood clot under nail - vertical red line
165
2 causative organisms of infective endocarditis?
Strep viridans
| Staph aureus
166
Signs and symptoms of ie not covered in dukes criteria?
```
Night sweats
Weight loss
Anaemia (normochromic normocytic)
Clubbing
Long PR on ECG
Glomerulonephritis with haematuria
Abscesses from emboli
```
167
Key symptoms of angina
Constricting pain to front of chest with classic radiation
Precipitated by physical exertion
Relieved by rest or GTN
168
How can angina be classified diagnostically into typical, atypical and non-anginal
Typical - 3?key symptoms
Atypical - 2
Non anginal - 0-1
169
How should a diagnosis of angina be reached?
Looking at symptoms (typical vs atypical), age and risk factors (low or high) on a table derived by nice. Gives a percentage risk of coronary artery disease.
170
If a patient with angina symptoms has a less than
Look for other causes - aortic stenosis, HCM
171
If a patient has angina type symptoms and a risk of cad of >90% what should be done?
Make the angina diagnosis and treat
172
If a patient with angina type symptoms has a risk of cad between 10 and 90% what tests are available in order from those for patients most likely to have angina to the least
Coronary angiography
Functional imaging
CT calcium scoring
173
What is CT calcium scoring?
Looks for amount of calcification in the coronary arteries
174
Management of angina?
Council re provoking factors
Short acting nitrate for symptom relief
Secondary prevention - aspirin, statin, ACEi
Reduce episodes - beta blocker, long acting nitrate
Surgery - cabg, pci
175
What is cardiac functional imaging?
Moving MRI of the heart
176
What classes as cvd for the purpose of determining if a patient should recieve 80mg atorvostatin?
```
Mi
Angina
Stroke
Tia
Peripheral arterial disease
```
177
How can risk be stratified in unstable angina and NSTEMI
Using the GRACE score
178
What component make up the grace risk score for ua and nstemi
```
Age
Pulse
Sbp
Creatinine
Heart failure
Cardiac arrest
St segment changes
Raised troponin
```
179
What immediate treatments should be offered to ua and nstemi patients? What risks stratifications for each?
- Aspirin - all
- Prasugrel - all except lowest risk ua
- Gp iib/iiia inhibitors - =/>intermediate risk going for angiography in 96 hours
- Fondaparinux - all except renal failure or angiography in 24 hrs
- UFH - all who cant have fondaparinux
- Angiography - =/> intermediate risk within 96 hours
180
Long term medications to add to acute treatments of ua and nstemi
Cardiac rehab
Acei, beta blocker, statin
Lifestyle modification advice (smoking, diet, drinking, exercise)
Consideration for stent or cabg
181
Rules for driving post MI?
Cars - at least one month off and until dr says safe. No need to tell dvla
Trucks - tell dvla. Stop for at least 6 weeks and until dr says safe
182
Non MI causes of raised troponin
```
Myocarditis
Heart failure
Renal failure
PE
Septic shock
Electrical cardioversion
```
183
Causes of raised BNP
```
Heart failure
Myocarditis
Renal failure
Elderly + female
Digoxin
Hyperaldosteronism / cushings
```
