Acute central chest pain lasting more than 20mins Nausea, sweatiness, dyspnoea, palpitations May be silent or present atypically - syncope, pulmonary oedema, epigastric pain and vomiting, post-operative hypotension, oliguria, acute confusional state, stoke, diabetic hyperglycaemic states

In hospital management of ACS - ST segment elevation

O2, IVI, morphine, aspirin - primary angioplasty/thrombolysis if not CI - B-blocker (atenolol) - ACE-i if normotensive - consider clopidogrel 300mg loading dose, 75mg/day for 30 days

Cardiology Flashcards by Phoebe Creswell

Causes of angina

atheroma
anaemia
Aortic Stenosis 
tachyarrhythmias
hypertrophic cardiomyopathy 
arteritis/small vessel disease (microvascular angina/cadiac syndrome X)

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Types of angina

Stable- induced by effort, relieved by rest
Unstable - angina of increasing frequency or severity, occurs on minimal exertion. Associated with increased risk of MI
Decubitus angina precipitated by lying flat
Variant (Prinzmetal’s) angina - coronary artery spasm, pain during rest

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Variant Angina (prinzmetal’s)

coronary artery spasm
pain during rest
ECG during pain shows ST elevation that resolves as pain subsides
Rx- CCB ± long acting nitrates
avoid B-blockers

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ECG in angina

usually normal
may show ST depression

exclude precipitating factors - anaemia, DM, hyperlipidaemia, thyrotoxicosis, temporal arteritis

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Management of Angina

Modify risk factors- smoking, exercise, HTN, DM
aspirin
B-Blockers- atenolol
Nitrates - GTN or isosorbide mononitrate
long acting calcium agonists - amlodipine
K+ channel activator- nicorandil

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Definitions of ACS

unstable and evolving MI
ACS with ST segment elevation or new onset LBBB
ACS without ST segment elevation

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Risk Factors for ACS

Non-modifiable- age, male, FHx of IHD
Modifiable- smoking, HTN, DM, hyperlipidaemia, obesity, sedentary lifestyle, cocaine use

Controversial - stress, type A personality, LVH, raised fibrinogen, hyperinsulinaemia, homocystiene

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Diagnosis of ACE

Raise and then fall in cardiac biomarkers (troponin) and:
- symptoms of ischaemia, ECG changes of new ischaemia, development of pathological Q waves or loss of myocardium on imaging

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Symptoms of ACS

Acute central chest pain lasting more than 20mins
Nausea, sweatiness, dyspnoea, palpitations

May be silent or present atypically

syncope, pulmonary oedema, epigastric pain and vomiting, post-operative hypotension, oliguria, acute confusional state, stoke, diabetic hyperglycaemic states

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Signs of ACS

Distress, anxiety, pallor, sweatiness, raised or low pulse or BP, 4th heart sound
May be signs of heart failure (raised JVP, 3rd heart sound)
pansystolic murmur- papillary muscle dysfunction/ rupture, `VSD

Later- pericardial friction rub or peripheral oedema

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ECG changes in ACS

Hyperacute tall T waves
ST elevation or new LBBB
T wave inversion + pathological Q waves over hours-days

ST depression, T wave inversion , non-specific changes

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CXR in ACS

cardiomegaly
pulmonary oedema
widened mediastinum (aortic rupture)

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Differential diagnosis in ACS

Angina
Pericarditis
Myocarditis
Aortic dissection
Pulmonary embolism 
Oesophageal reflux/ spasm

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Pre-hospital managment of ACS

300mg aspirin chewed
GTN sublingual
analgesia- 5-10mg morphine iV + metoclopramide 10mg IV

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In hospital management of ACS

ST segment elevation

O2, IVI, morphine, aspirin

primary angioplasty/thrombolysis if not CI
B-blocker (atenolol)
ACE-i if normotensive
consider clopidogrel 300mg loading dose, 75mg/day for 30 days

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In hospital management of ACS

ACS without ST segment elevation

O2, IVI, morphine, aspirin
-B-Blocker
- antithrombotic (fondaparinux or LMWH)
- Assess risk e.g. GRACE score
-High risk pts- GPIIb/IIIa agonist (tirofiban) or bivalirudin
angiography within 96hrs
clopidogrel

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Subsequent management of ACS

Bed rest
Daily examination 
Prophylaxis against thromboembolism until fully mobile 
Aspirin
Long term B-Blockade
Continue ACE-i
Start a statin
Address modifiable risk factors 
Assess LV function 
Return to work 2/12
avoid sex for 1/12
exercise daily

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Complications of MI

Cardiac arrest, cardiogenic shock 
unstable angina
Bradycardias or heart block 
Tachyarrhthmias
Consider implantable cardiac defibrillator
RV failure/infarction 
pericarditis
DVT/PE
systemic embolism 
Cardiac tamponade 
Mitral regurgitation
VSD
Late malignant ventricular arrhythmias 
Dressler's syndrome 
LV aneurysm

Dressler’s syndrome

Recurrent pericarditis
pleural effusions
fevere
anaemia 
elevated ESR 1-3/52 post MI

Treat with NSAIDs or steroids

Causes of arrhythmias

Cardiac

MI 
Coronary artery disease
LV aneurysm
Mitral valve disease 
Cardiomyopathy
Pericarditis
Myocarditis
Abberant conduction pathways

Causes of Arrhythmias

Non-cardiac

Smoking
Alcohol
Pneumonia
Drugs (B2agonists, digoxin, L-dopa, tricyclics, doxorubicin)
Metabolic imbalance (K+/Ca2+/Mg2+/ hypoxia/hypercapnia/ metabolic acidosis/ thyroid disease)
Phaeochromocytoma

Presentation of Arrhythmias

Palpitations
Chest pain 
presyncope/syncope
Hypotension 
Pulmonary oedema

Tests for arrhythmias

FBC
U&amp;Es
glucose 
Ca2+
Mg2+
TSH 
ECG (24hr monitoring)
ECHO
Provocation tests- exercise ECG, cardiac catheterisation + electrophysiological studies

Treatment of Bradycardia

Asymptomatic, HR >40 bpm - no treatment
Look for causes - drugs, sick sinus, hypothyroifism
stop B-Blockers, digoxin

Symptomatic, HR<40 - atropine, pacing wire, isoprenaline infusion or external cardiac pacing

Sick sinus syndrome treatment

causes bradycardia ± arrest, sinoatrial block or SVT alternating with bradycardia/asystole (tachy-brady syndrome) AF and thromboembolism may occur Pace if symptomatic

Treatment of SVT

Narrow complex tachycardia (rate >100bpm, QRS with <120ms) Acute management- vagotonic manouvers followed by IV adenosine or verapamil DC shock compromise if compromised Maintenance therapy- B-Blockers or verapamil

Treatment of AF/atrial flutter

control ventricular rate with B-blocker or verapamil alternatives- digoxin or amiodarone DC shock if compromised

Treatment of VT

Broad complex tachycardia acute management IV amiodarone or IV lidocaine No response/compromise - shock Amiodarone loading dose then maintenance (Monitor LFT &TFT)

Narrow complex tachycardias Definition

ECG shows rate of >100bpm and QRS complex duration of <120ms

Differential diagnosis Narrow complex tachycardias

Sinus tachycardia - normal p wave follwoed by normal QRS SVT - P wave absent or inverted after QRS AF- absent P wave, irregular QRS Atrial flutter

Definition of heart failure

Cardiac output is inadequate for the body's requirements | Prognosis is poor with ~25-50% pts dying within 5yrs of diagnosis

Systolic heart failure

inability of the ventricle to contract normally results in reduced cardiac output Ejection fraction <40% Causes- IHD, MI, cardiomyopathy

Diastolic heart failure

inability of ventricle to relax and fill normally causes increased filling pressures EF >50% Causes- constrictive pericarditis, tamponade, restrictive cardiomyopathy, hypertension

Left ventricular failure symptoms

``` Dyspnoea poor exercise tolerance fatigue orthopnoea paroxysmal nocturnal dyspnoea nocturnal cough + pink frothy sputum wheeze (cardiac asthma) nocturia cold peripheries weight loss muscle wasting ```

Right ventricular failure | causes

Left ventricular failure pulmonary stenosis lung disease

Symptoms of right ventricular failure

``` peripheral oedema ascites nausea anorexia facial engorgement pulsation in the neck and face (tricuspid regurgitation) epistaxis ```

Acute heart failure

new onset or decompensated of chronic heart failure characterised by pulmonary/peripheral oedema ±signs of peripheral hypoperfusion

Chronic heart failure

develops or progresses slowly | venous congestion is common but arterial pressure is maintained until very late

low out put heart failure

cardiac output is low and fails to normally increase with exertion - causes- pump failure, excessive preload, chronic excessive afterload

high output heart failure

rare output is normal or increased in the face of very high need Causes: anaemia, pregnancy, hyperthyroidism, Paget's disease, AVM, beri-beri

Signs of heart failure Major criteria (2 major/ 1 major + 2 minor = HF)

``` paroxysmal nocturnal dyspnoea crepitations S3 gallop Cardiomegaly INcreased central venous pressure weight loss >4.5kg in 5days in response to treatment Neck vein distention acute pulmonary oedema hepatojugular reflux ```

Signs of heart failure Minor criteria (1 major + 2 minor = HF)

``` Bilateral ankle oedema Dyspnoea on ordinary exertion Tachycardia Decrease in vital capacity by 1/3 from maximum recorded Nocturnal cough Hepatomegaly Pleural effusion ```

Investigations in HF

ECHO FBC, U&E, LFT, BNP CXR- prominent upper lobe veins, peribronchial cuffing, diffuse interstitial or alveolar shadowing