Cardiology Flashcards
Early Management of ?ACS
MONCA
Morphine, 5mg IV up to 10mg Oxygen - only if desaturated Nitrates - GTN spray/buccal nitrates (c/o if hypotensive) Clopidogrel - or prasugrel/ticagrelor Aspirin - 300mg
what score should be used to assess a patient with ?ACS
GRACE score
what is the management of unstable angina and a STEMI
BROMAANCE
Beta-blocker - secondary prevention Reassurance Oxygen - if <92% Morphine - 5mg up to 10mg Aspirin - 300mg, 75mg secondary prevention Ace-Inhibitor - secondary prevention Nitrates/GTN spray Clopidigrel - 300mg then 75mg secondary prevention Fonduparinox Statins
Initial Management of a STEMI
MONA + PCI if within 90 mins ideally but may be up to 12 hours
if PCI not indicated thombolysis via alteplase/streptoskinase indicated if there are no other contraindications
Long term medications post ACS
Aspirin 75mg OD
Clopidogrel 75mg OD for at least a year
Beta Blocker Bisoprolol – dose titrated to get HR around 60bpm
Statin - 80mg atorvostatin O.N
Ace-inhibitor - 2.5mg ramipril B.D
Management of Stable angina
- GTN + BB
- GTN + BB + CCB or + Isorbide Nitrate if CIs are present
- GTN + BB + CCB + Nicorandil
Secondary prevention:
Statin
Low dose aspirin
ACE inhibitor of co-morbid diabetes
what is the advice for travel/work/driving post MI
May return to the office after 2 months
Drivers/pilots should not
Heavy manual labourers should seek lighter work
Travel - Avoid air travel for 2 months
Sex - Avoid intercourse for 1 month
Driving DVLA do not need to be notified
If successful treatment with PCI, driving can continue for 1 week
Otherwise driving can continue after 4 weeks
what is the advice for travel/work/driving in angina
DVLA do not need to be notified
Driving can continue unless it occurs at rest, whilst driving or on emotion
Recommence when adequete symptom control is achieved
what is the advice for travel/work/driving in AAA
Driving – notify DVLA if >6cm
Annual review to permit licensing
what are the rules for driving for HGV drivers with a new diagnosed cardiovascular condition
In general al CV diagnoses lead to revocation of licenses for 6 weeks
3 months after CABG
Relicensing can occur if exercise/other functional requirements are met
surgical management of angina
PCI or CABG Symptom control for patients unsuitable for PCI Must be on full medical therapy
what are the main incisions for cardiac surgery
Median sternotomy
Most common
Gives best view of heart
Anterolateral thoracotomy
Access to right of heart
Posterolateral thoracotomy
Access to distal arch and descending thoracic aorta
Bilateral transverse thoracotomy
Popular for double lung transplants, or heart and lung transplants
what is the main treatment for chronic coronary artery disease
CABG > PCI but both may be done
what are the options and their features for heart valve disorders
Prostetic valves are classified into man made or tissue valves
Man-made
Ball in cage or bileaflet valves
Durable but thrombogenic requiring anticoagulation with warfarin/NOAC
Gives an audible click that can be heard without a stethoscope if you stand close to the patient
Tissue valves
Homographs (humans) or Xenographs (pigs)
Anticoagulation not required but more prone to degenerative failure
Homographs are more resistant to degeneration so are preferred in younger patients to avoid long term anticoagulation
Valve infection is devastating, but fortunately rare, with the lowest risk being in homograft valves
Tx for constrictive pericarditis
excision of the whole pericardium
whats the management for acute pulmonary oedema
Sit upright
100% oxygen
IV diamorphine 1.25mg-5mg
IV furosemide 40mg-80mg
GTN spray 2 puffs sublingual (unless SBP <90)
Continue necessary investigations
SBP >100 = start IV nitrate infusion
Consider non invasive ventilation (CPAP) if not improving
SPB <100 = treat as cardiogenic shock
May require invasive ventilation
Treatment of ARDS
ICU admission
Sit up
100% oxygen
CPAP used initially
Most progress to mechanical ventilation
IV nitrates titrated up until clinical improvement is seen
Or a drop in SBP
IV furosemide
40-80mg
Morphine
10-20mg + 10mg metclopramide
aminophylline if bronchospasm present
Treatment algorithm for CCF
- Lifestyle advice + Ace-is + BBs, add diuretic if symptomatic with oedema
- Second line = spironolactone/ ATRA /hydralazine + nitrate second line
- digoxin 3rd line (unless there is bradycardia/heart block)
what vaccinations are reccomended for CCF patient s
pneumococcal + seasonal flu
how is aortic stenosis managed
Symptomatic = prompt valve replacement
Percutaneous valvuloplasty if unfit for surgery
asymptomatic = leave
how do you manage an aortic regurgitation
Treat AF
Treat heart failure
Surgery if symptoms are deteriorating to prevent irreversible LV impairment (new york HF association 2 and above)
how do you manage aortic regurgitation
Aim to replace valve before there is significant LV dysfunction so indicated If there are increasing symptoms, cardiomegaly or ECG deterioratio
how do you manage mitral stenosis
Diuretics: reduce pre-load and pulmonary venous congestion
Surgical management if still activity-limiting
Balloon valvuloplasty if valve pliable/non-calcified
Open valvotomy otherwise
Tx for bacterial endocarditis
if suspect consult a microbiologist early
Empirical therapy – IV for 4 weeks
Benzylpenicillin (or any beta lactam)
Gentamicin
+Fluclox if acute
Subsequent therapy dependent on sensitivies/organisms
management of arrythmia
A-E treat reversible cause
Assess for adverse features Shock Syncope pulmonary oedema chest pain
Risk of asystole Recent asystole Mobitz type 2 Complete heart block If none of the above are present, continue to monitor
If any of these features are present, treat
Atropine 500mcg IV repeated up to 3mg
Cardiology may do transcutaneous pacing
management of supraventricular tachycardias
A-E resus
DC cardioversion if there is abnormal features
if irregular rhythm treat as AF
Regular = attempt vagal manouvres first
Carotid sinus massage
Dunk head in water
Unsuccessful vagal manouvres = IV adenosine
6mg initially, then 12 if no effect, then another 12
Contraindicated in asthmatics, use IV verapamil instead
If adenosine unsuccessful, DC cardioversion
Secondary prevention is done using beta blockers
Tx of ventricular tachycardias
Immediate electrocardioversion if SBP <90 Chest pain HR >150 Pulmonary Oedema Syncope
absence of these signs = amiodarone
300mg loading dose over 30 mins
Tx of VFib
Treat as cardiac arrest (CPR and critical care team immediately)
management of acute atrial fibrillation
if <48 hours - immediate cardioversion if haemodynamically unstable + heparin if possible
if >48 hours they should be anticoagulated for at least 3 weeks before DC cardioverted
If there is a high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to have at least 4 weeks amiodarone or sotalol prior to electrical cardioversion
Following electrical cardioversion patients should be anticoagulated for at least 4 weeks.
chronic management of atrial fibrillation
Rhythm control - flecainide or amiodarone (if Younger than 65 years, Symptomatic, First presentation, Lone AF or AF secondary to a corrected precipitant (e.g. Alcohol))
Cardiac ablation used as rate control for cases that dont respond to chemical antiarrhythmics
otherwise rate control - beta blockers/CCBs/Digoxin
use CHADSVASC and HASBLED for antocoagulation on either a DOAC or warfarin
Tx of atrial flutter
AF
Tx of eisenmengers
only curative treatment is a complete heart and lung replacement
Tx of heart blocks
1st degree/2:1 nothing required
2:2 and 3rd = pacing
