Cardiology Flashcards
Troponin limits?
When higher than 99%of a reference population- note that 1% does not have ACS so this test is good for those with a high pre test probability!
Which troponins are used for diagnosing ACS?
Cardiac troponins I and T
(cTnI and cTnT)
These are high sensitivity tests, of course at the expense of specificity.
Note: cTnC is also expressed in skeletal muscle, whereas I and T are specific to cardiomyocytes
Cause of raised troponins?
Any sustained or transient ischemic/inflammatory damage to the myocardium: ACS Heart failure/Cardiomyopathies Myocarditis Tacchyarrythmias Pulmonary embolism,severe pulmonary hypertension Renal failure Sepsis,critical illness Extensive burns Stroke and SAH INFILTRATIVE DISEASES EG AMYLOIDOSIS Cardio toxic drugs And..... Healthy individuals after strenuous exercise
Pattern of troponin changes suggesting MI?
They rise within a few hours of MI, and continue to rise before falling again. Raised levels Last 4-7 days (cTnI) and 10-14days (cTnT). Serial testing is most useful to diagnose MI, as there are other causes of raised troponins which don’t rise characteristically like MI.
Typically test 6 hours later, but with latest troponins can do 2-3hourly testing.
Cardiac causes of CP?
Myopericarditis
MI
Cardiac rupture
Aortic dissection
Chest pain aetiologies
- Cardiac (MI,myopericarditis,rupture,aortic dissection,/stent thrombosis)
- Respiratory (pneumonia/pleurisy, pneumothorax,PE)
- GI(reflux disease +/- perforation)
- Oesophagus(spasm)
- Musculoskeletal/costrochondritis(#)
- Other (shingles, panic attack)
Metformin contraindications?
Renal function: (risk of lactic acidosis!)
Excreted really. Small risk of lactic acidosis .03/1000, 50% fatal. Assess renal fx before starting + monitor.
IV contrast can lead to lactic acidosis. Stop before and for 48 hours after if renal fx proven normal.
Stop with any NBM procedures. Any hypoxia States like acute MI, CHF.
Suspect if any sudden deterioration, stop metformin and assess for lactic acidosis.
Diabetics should be on glycemic control and????
ACEi
Acute MI auscultatory findings?
Added heart sounds: S3 and/or S4 (gallop rhythms) Kentucky Tennessee respectively
Paradoxical splitting of S2 (reflects LBBB)
Murmurs:
1. MR (papillary muscle dysfunction or rupture or mitral annular dilatation)
- Ventricular septal rupture (midsternal border holo systolic loud often with thrill)
- Ventricular rupture - 2-12 days post. Loud systolic +thrill. Cardiac tamponade and rapid detoriaration are the consequence.
- New aortic regurgitation (aortic dissection)
- Pericardial friction rub (sliding contact of inflammation roughened surfaces) in 20% at some stage, most commonly 2-4days post MI
Note: bell is for low pitched, diaphragm for higher.
S3/S4 are low pitched.
S3 normal in young fit people but abnormal over 40years. (Rapid filling causing oscillation of blood in (stiff) ventricle or tensing of chordae tendinae when rapidly filling and expanding ventricle)
S4 atrial contraction causing vibrations of LV muscle, MV apparatus and blood mass
S2 physiological splitting with inspiration due to decrease intrathoracic pressure causing increased time needed for pulmonary pressure to exceed RV (AVclosure precedes PV)
Paradoxical split-present at rest, disappears on inspiration. AS. LBBB. LVF.
Metoclopramide
Antiemetic, helps delayed gastric emptying (gastro paresis) by relaxing pyloric sphincter and increasing gut peristalsis
Duride
Isosorbide mononitrate ISMN
Cartia or cartia XT
Cartia = aspirin
Cartia XT = Extended release Diltiazem (heart and vessels CCB)
Verapamil
Similar to diltiazem - CCB with heart and vessel action
Surgical sieve
Metabolic Autoimmune G Infectious Cancer A Drugs Degenerative I Trauma I Vascular Endocrine
beta blocker contraindications
Asthma/COPD
Heart failure/cardiogenic shock
2/3rd degree heart block or severe bradycardia,
PR>.24msecs, HR
Valves affected in IE?
Usually occurs in already abnormal heart.
Right sided in IV drug users
Usually left in the rest of IE. Most common is mitral prolapse and degenerative mitral and aortic regurgitation
Valves affected in rheumatic heart disease?
In order of most common to least:
Mitral
Aortic
Tricuspid
Pulmonary
Usually occurs as mitral + 1 or more of
the other 3
Rheumatic heart disease is the predominant cause of mitral stenosis
Stenosis, insufficiency, Mixed insufficiency and stenosis,
Overdiuresis causes what?
Worsening of renal function - Reduced eGFR, increased creatinine
Hypokalaemia
Hypotension
Potentials toxicity of other agents eg digoxin by decreasing renal function or causing hypokalaemia
Decrease dose of causing renal impairment, if severe impairment then withhold and assess daily, reintroducing at lower doses
EGFR and ACEi?
?
AF MANAGEMENT including FAST AF
90% of clots form in left atrial appendage
?
Cause of pan-systolic murmurs?
Mitral regurg
Tricuspid regurg
VSD
aorto-pulmonary shunts (rare)
Causes of ESM?
Flow murmur Aortic sclerosis Aortic stenosis(including bicuspid ) Pulmonary stenosis HOCM Dilation of aortic root or pulmonary trunk ASD!
Aortic stenosis
Male, older, congenital bicuspid valve
High flow through narrowed valve
Sob, lightheaded, syncope, CP, etc
Echo gives flows and area:
>1.5cm2 mild
1-1.5 moderate
bumetanide?
Loop diuretic
Furosemide, bumetanide
