Cardiology Flashcards by Andrew Westripp

STEMI:

1) Initial assessment
2) Initial management
3) Intervention
4) Long term management

1) 12-lead ECG, brief history and exam
Blood tests: FBC, U+Es, glucose, Troponin, cholesterol
(Chest x-ray)
2) 300mg aspirin if not given already
300mg clopidogrel/ ticagrelor
5-10mg morphine + 10mg metoclopramide
Oxygen if sats < 95%
3) Primary PCI if available, if not thrombolysis
4) 5mg Beta blocker, 2.5mg ACEi, 75mg/day clopidogrel

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NSTEMI:

Prescriptions (including high risk and low risk)

5mg Beta blocker, Nitrates
Fondaparinux if low bleeding risk/ no angiography planned. If not, LMWH for 8 days

High risk: GPIIb/IIIa antagonist Tirofiban, Clopidogrel and Aspirin
Low risk: Clopidogrel and discharge if repeat troponin -ve

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MI:

Discharge drugs

ACEi (ARB if not tolerated) - Indefinitely
Beta blocker for 12 months
Statin - Indefinitely
Antiplatelet (aspirin + ..grel.. for 12 months

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Angina:

1) Symptom relief
2) First line therapy
3) 2nd line/ 1st line not tolerated

1) GTN spray
2) Beta blocker or Calcium channel blocker
3) Long acting nitrate (Isosorbide mononitrate) or Ivabradine

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Secondary prevention for stable angina

Antiplatelet therapy - aspirin or clopidogrel

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Secondary prevention for stable angina with Diabetes

and Why?

ACEi

Slows renal disease in DM as well as benefits in angina

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Atrial fibrilation

Diagnosis

Pulse palpation for irregularly irregular pulse

12 lead ECG to look for absence of P waves

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Atrial Fibrilation

Scores to assess risks

CHADSVASc for risk of stroke

HAS-BLED for risk of major bleed

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Atrial Fibrillation

Rate control

Beta blocker (propanolol/ atenolol) or 
Calcium channel blocker (verapamil/ diltiazem)

Digoxin can be considered in people with sedentary lifestyle

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Atrial Fibrillation

Rhythm control

Amiodarone
By specialists: Cardioversion, sotalol
Atrial ablation

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Atrial Fibrillation

Anticoagulation

Depends on CHADSVASc score (1 or more) and HAS-BLED risk

Offer a choice of warfarin or a NOAC

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Hypertension

Modifiable risk factors

Obesity
Stress
Dietary salt
Oral contraceptive
Sedentary lifestyle

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Hypertension

Non-modifiable risk factors

Increasing age
Ethnicity (African American)
Men <65
Women 65+
Family history

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Hypertension
Stages:
1)
2)
3)

1) 140/90
2) 160/100
3) Severe 180/110

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Endocrine causes of Hypertension

Cushing’s (Raised cortisol = vasoconstriction)

Conn’s (Increased sodium/ water retention, Potassium excretion = hypervolaemia)

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What is Conn’s syndrome?

Primary hyperaldosteronism
Increases activity of Na+/ K+ pumps in the distal tubule and collecting duct
Na+ absorption and K+ excretion

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Investigations in Hypertension and differential diagnosis it is investigating

Urine test for cortisol - Cushing’s
Bloods - decreased K+? - Conn’s, Cushing’s, renal disease
Bloods - Thyroid function - Hyperthyroidism
Examination - Radio-femoral delay? - Coarctation

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Management of Hypertension
1st
2nd
3rd
4th

1st: ACEi <55, Ca blocker or thiazide Diuretic >55
2nd: A+C or A+D
3rd: A+C+D
4th: A+C+D+ Beta blocker/ alpha blocker/ ARB

First line management of hypertension in diabetics

ACE inhibitor

Common causes of Heart Failure

Ischaemic heart disease
Hypertension
Valvular disease: Aortic stenosis = increased afterload
Aortic regurgitation = Increased preload

Presentation of Left heart failure

Fluid backs up on lungs: Breathlessness, bibasal crackles, orthopnoea, nocturnal dyspnoea
Pulsus alternans (strong and weak alternating beats)
Breathlessness and fatigue
Tachycardia

Presentation of Right heart failure

Fluid backs up in tissues: Peripheral oedema, ascites, hepatomegaly and raised JVP
Tachycardia

Investigations in Heart failure
General tests
Specific pathway for MI/ non-MI sufferers

ECG, CXR
Bloods: FBC (anaemia), TFTs (hyperthyroid), U+Es (renal causes), LFTs (liver failure caused by oedema)

Past MI - Doppler Echo
No previous MI - B type natriuretic peptide. High = Doppler echo. Low = unlikely heart failure

Management of Heart failure

1) Management of fluid overload
2) Cardiac support

1) Loop diuretic (Furosemide)
K+ sparing diuretic if needed (Spironolactone)
2) ACEi + Beta-blocker
Calcium channel blockers should be avoided in those with reduced ejection fraction

Assessment of a DVT

Well's score (2+ = likely DVT) D-dimer: -ve result = exclude DVT +ve result = Compression ultrasound

Prescribing for DVT

NOAC (Warfarin) LMWH (Dalteparin): Contraindicated in recent stroke and GI ulcer Fondaparinux: contraindicated in renal impairment, bacterial endocarditis

Main acute and chronic cause of Peripheral vascular disease?

``` Acute = thrombosis Chronic = atherosclerosis ```

Risk factors for peripheral vascular disease?

``` Smoking HTN Obesity Sedentary Diabetes Dyslipidaemia ```

Acute Presentation of peripheral vascular disease

``` Pain (constant) Pulseless Pallor Perishingly cold Paraesthesia Paralysis ```

Presentation of chronic peripheral vascular disease - Claudication

Pulses disappear on exertion | Calf pain/ cramp on walking predictable distance

Presentation of Critical limb ischaemia

Pain at rest Absent pulses Patient hangs foot out of bed to relieve pain Rubor

Investigations for Peripheral vascular disease

Bloods (lipids, glucose, FBC, CRP) ECG ABPI - Normal = 1, Claudication <0.9, Rest pain <0.6

Treating Claudication

1) Exercise programme - exercise to the point of pain 2) Angioplasty/ bypass 3) Naftidrofluryl oxalate if patient doesn't want surgery

Causes and Risk factors of varicose veins

Caused by valve insufficiency and retrograde blood flow Genetic component Pregnancy, getting older and obesity are all risk factors

Presentation of varicose veins

Tortuous superficial veins Itching and swelling Discomfort after prolonged standing Discomfort relieved by elevation or compression

Complications of varicose veins

Venous ulcer Skin pigmentation/ venous eczema Thrombophlebitis

Treating varicose veins | What mistake should you be careful not to make?

Stripping or ablation (surgical) Compression stockings can relieve symptoms You MUST rule out arterial disease by ABPI before issuing compression stockings

Causes of Abdominal Aortic Aneurysm

``` Inflammatory (vasculitis) Infective (TB, endocarditis, syphillis) Congenital (Ehler's Danlos, Marffan's) Trauma Atheroma ```

Risk factors for abdominal aortic aneurysm

``` Smoking HTN Male Increasing age FHx Atherosclerosis COPD ```

Symptoms of unruptured AAA

Often asymptomatic Can get pain from the pressure (back, loin, abdo) Expansile, pulsatile abdominal mass

First investigation you should do for an AAA

Ultrasound

How do you manage an AAA that is: 1) 3 - 4.4cm 2) 4.5 - 5.4cm 3) 5.5cm+

1) Annual ultrasound 2) 3month ultrasound 3) ?Surgery or ultrasound every 3 months

Key biochemical finding in Conn's syndrome?

Low Potassium (K+)