Cardiology Flashcards
Causes of angina
atheroma anaemia Aortic Stenosis tachyarrhythmias hypertrophic cardiomyopathy arteritis/small vessel disease (microvascular angina/cadiac syndrome X)
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
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
ECG in angina
usually normal
may show ST depression
exclude precipitating factors - anaemia, DM, hyperlipidaemia, thyrotoxicosis, temporal arteritis
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
Definitions of ACS
unstable and evolving MI
ACS with ST segment elevation or new onset LBBB
ACS without ST segment elevation
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
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
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
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
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
CXR in ACS
cardiomegaly
pulmonary oedema
widened mediastinum (aortic rupture)
Differential diagnosis in ACS
Angina Pericarditis Myocarditis Aortic dissection Pulmonary embolism Oesophageal reflux/ spasm
Pre-hospital managment of ACS
300mg aspirin chewed
GTN sublingual
analgesia- 5-10mg morphine iV + metoclopramide 10mg IV
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
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
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
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&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
