CARDIOLOGY - ACS and Angina Flashcards
Broad catergories - chest pain (5)
Cardiac
Pulmonary
GORD
MSK
Other
Myocardial ischaemia - SOCRATES
S - Retrosternal, central chest pain
O - builds over mins
C - crushing, gripping
R - Neck, shoulder, jaw (C5)
A - paraesthesia arms, sweating, nausea, breathlessness, collapse
T - mins –> hrs
E - Exertion, cold, stress, heavy meal.
S - severe
RF Myocardial ischaemia (10)
Hyperlipidaemia
DM
Smoking
FHx
HTN
Obesity
Race
Male
Age
Renal disease
Ix Myocardial ischaemia (5)
ECG
Trops
CK
CXR
Ddimers
Type A Aortic Dissection
Involves aortic arch and valve proximal to LSCA
Sx from type A Aortic dissection
Limb ischaemia
Cerebral ischaemia
Aortic regurg
Cardiac tamponade
Type B Aortic dissection
Involves descending thoracic aorta distal to LSCA
Sx from type B Aortic dissection
Paraplegia
Ischaemic bowel
Renal aa failure
Lower limb ischaemia
Who gets aortic dissection classically
Middle aged HTN males
Other RF Aortic dissection (5)
Bicuspid aortic valve disease
Atherosclerosis
Marfan’s
Ehlers Danlos
During pregnancy
Which gene defect is related to aortic dissection?
Fibulin-5 –> fibrillin
SOCRATES Aortic dissection
S - Central CHx/back/betw shoulder blades
O - V sudden
C - tearing, ripping, searing pain
R - back, shoulders, neck, abdo
A - collapse, sweating, HoTN , ischaemic pain, neuro. Peripheral pulses +/-
T - constant
E - none
S - severe
Ix Aortic dissection
CXR/AXR
CT - definitive diagnosis
What is pericarditis
Inflammation of the pericardium
Causes pericarditis
Idiopathic
Viruses - fl,EBV,mumps, HIV
Bacteria - pneumonia, FR, fever, TB, staph, strep,
Fungi
MI, Dresslers
Dx
RA/SLE, surgery, malig, radioT, sarcoidosis
SOCRATES - Pericarditis
S - retrosternal
O - gradual
C - sharp/sore
R - tip L shoulder, back, neck
A - fever, viral Sx, breathless
T - constant + can last days
E/R - worse on insp/lying flat, Relieved by sitting forward + analgesia
S - varies
ECG changes pericarditis
Saddle shaped ST elevation
What is pain in shoulder tip suggestive of?
Diaphragmatic pleural irritation
SOCRATES PE
S - localised to chest wall
O - sudden
C - sharp, pleuritic
R - shoulders/back
A - Dyspnoea, haemoptysis, dizzy, syncope, cough, fever
T - constant
E/R - worse on insp, coughing, moving. R - shallow breaths analgesia
S -varies
GORD and GTN spray
Relieves after 20 mins
Definition of ACS
Acute central chest pain, lasting > 20 minutes, not relieved by 3x GTN sprays at 5 min intervals
Who gets ACS without chest pain aka silent infarction
Elderly
Diabetics
Sympathetic activation Sx ACS
Tachycardia
HTN
Pallor
sweatiness
Vagal stimulation Sx ACS
Bradycardia
Vomiting
STEMI vs NSTEMI
STEMI - ST elevation on ECG + LBBB
= Complete occlusion of coronary aa
+ full thickness MI
NSTEM = elevated troponin but no ST elevation or LBBB
- subtotal occlusion occurs
Def unstable angina
Occuring at rest or sudden incr f/severity of existing angina
Blood results UA
Plasma Trops and CK = norm
ECG UA
Normal
Or ST depression +/- T wave inversion
MI time course - 0-12hrs
Infarct not visible
Loss of oxidative enzymes
MI time course - 12-24hrs
Infarct pale/blotchy, w/ intracellular oedema
MI time course - 24-72hrs
Infarcted area excites acute inflamm response, w/ dead area soft + yellow w/ neutrophilic involvement
MI time course - 3-10days
Organisation of infarcted area by vascular granulation tissue
MI time course - 10days to several m
Collagen deposition
Infarct replaced by scar
Normal troponin levels
<10
How long can troponin stay elevated for?
Up to 2 w
What areas of the heart does the R coronary aa supply?
RA
RV
Posterior septum
SAN (60%)
AVN (80%)
What type of MI does a RCA give?
Post/inferior MI
Which leads does a posterior/inf MI show up in
II, III aVF
What 2 aa does the L coronary aa split into?
LAD
Circumflex
What areas of the heart does the circumflex artery supply?
LA
LV
What type of MI does circumflex aa give?
Lateral MI
What ECG leads does a lateral MI show up in
I
aVL
V5-6
What areas of the heart dose the LAD aa supply?
LV
Anterior septum
What type of MI does LAD aa give?
Antero-sepatal MI
What ECG leads does an antero-septal MI show up in?
V1-4
MI ECG changes at: 5 mins
Tall, pointed T-waves
MI ECG changes at: 30 mins
ST elevation
MI ECG changes at: 2+hrs
T wave inversion + Q waves develop
MI ECG changes at: days after
ST segment returns to normal
MI ECG changes at: weeks after
Q wave remains
Which investigation is contraindicated in unstable angina?
Stress tests
When does troponin levels peak after an MI?
24hrs
What marker is useful for rapid diagnosis of MI?
Myoglobin
Why take FBC + U+E for MI Ix
Glucose is lowered
Lipids are raised
CXR features MI (2)
Cardiomegaly
Pulmonary oedema
Widened mediastinum
Which test definitively defines presence, extent and severity of CAD?
Coronary angiography
What is the earliest sign of acute MI on ECG?
Hyperacute T waves
What leads are hyperacute T waves most evident in?
Anterior chest leads
What ECG change is often the earliest recognised sign of an acute MI
ST elevation
What ECG change is DIAGNOSTIC of a STEMI
1mm of ST elevation in 2 contingous leads
What ECG change is the only firm evidence of myocardial necrosis?
Q waves
How long may T wave inversion take to resolve?
2 weeks
Which type of MIs does T wave inversion tend to persist in?
Anterior MI
Mx STEMI (MOANA)
morphine IV 10mg
O2
Antiplaetlets - aspirin (300mg) or clopidogrel (600mg)
Nitrates/GTN
Anti-emetics (10mg metocloperamide)
When do you not use GTN spray in STEMI Mx
if pt = hypotensive
What meds to give post PCI
Clopidogrel + abciximab (reduce complication rates)
C/I Thrombolysis (6)
Haemorrhagic stroke at any time
Ischaemic stroke in last 6 months
CNS damage/neoplasm
Recent trauma (3 weeks)
GI bleed within last month
Bleeding disorder/aortic dissection
What is the GRACE score
Determines mortality risk in ACS
Highest GRACE score risk features in NSTEMI/UA
> 6m raised trops
Persistent pain
ST depression
Diabetes
Factors taken into account GRACE score
Age
HR < BP
class of CHF
Renal fct
ST segment changes
Troponin
Whether there was an arrest at admission
Lterm Mx ACS
48hr bed rest w/ ECG
U+E’s + cardiac enzymes 3 days
Thromboprophylaxis
Aspirin 75mg OD for life
Clopidogrel 75mg OD 1 yr
Bisoprolol (life)
Start ACEi + statin after 24-48hr
Address RF
Immediate complications MI
Arrhythmias
S term complications MI (6)
Pulmonary oedema
Cardiogenic shock
Thromboembolism
Venticulo-septal defect
Ruptured chordae tendinae
Rupture of ventricular wall
When does rupture of ventricular wall happen after MI?
2-10 days after
Why does rupture of ventricular wall post MI happen?
B/C reorganisation + softening of wall
–> haemopericardium, cardiac tamponade + rapid death
L term complications MI (3)
Heart failure
Dressler’s syndrome
Ventricular aneurysm formation
What is Dressler’s syndrome
Immune mediated pericarditis post MI
Sx Dressler’s syndrome
Sharp chest pain
Exaccerbated by movement + lying down
Relieved by sitting forward
Tx Dresslers’ syndome
High dose aspirin / NSAIDs
Define angina
Chest pain precipitated by exercise and relieved by rest.
Usually fades within mins
Caused by heart not getting enough O2
Causes angina (11)
Coronary aa disease
Aortic stenosis
LVH
Anaemia/carboxyhaemoglobinaemia
Atheroma
Embolus
Thrombosis
Spasm
Inflammation coronary aa
Generalised HoTN
Tachyarrhythmia
Hyperthyroidism
What is atherosclerosis
Non-specific thickening of walls of aa –> loss of contractility + elasticity decreased blood flow
What is an atheroma
Specific degenerative disease affecting large/med size aa
Pathology of Angina
LDLs into intima
LDLs taken up by macrophages –> fatty streak
Macrophages stimulate cytokines –> collagen deposition –> plaque becomes fibrotic
–> pressure atrophy
Endothelium is fragile, ulcerates
RF Angina (9)
Age
Male
FH
Smoking
Diet
Obesity
HTN
Hyperlipidaemia
DM
What is decubitus angina
Angina precipitated by lying down as there is increased venous return to heart
Prinzmetal’s angina
Occurs without provocation at rest as result of coronary aa spasm
Ix that show Prinzmetal’s angina
ST elevation
But no trops rise
PS Angina (socrates)
S- retrosternal
O - builds over mins
C- dull ache constriction, heavy
R - l arm, shoulders, neck, jaw
A - usually none
T - mins
E - exertion, stress, cold, food
(R - rest, nitrates)
S - mild
Ix Angina
Clinical assessment
FBC,gluc, lipids, TFTs
Resting 12 lead ECG lead
Stress-12 lead ECG (if resting is normal)
Nuclear medical testing
CT angiography
Coronary angiography
scintigraphy
Stress echo
Stress perfusion MRI
FFR
FFI
NICE tool - likelihoodness of CAD
>90%: treat as stable angina
61-90%: coronary angiography = indicated
31-60%: functional imaging = indicated – SPECT myocardial perfusion scan, exercise echo, stress MRI
10-30%: CT Ca scoring = used
<10%: investigate for another cause
FFR value that is significant in Angina
<0.75
FFI value that is significant in Angina
<0.89
Mx angina
Mx risk factors
1st line = GTN + B blocker or CCB
Mx - angina (refractory disease)
Combination therapy
Or
Nicorandil
2’ prevention angina
Statin
Low dose aspirin
SE aspirin
GI ulcer
Bleeding
effect nitrates
Decrease pre-load and afterload - decr O2 req of myocardium
–> VD
–> Incr O2 delivery
SE nitrates (2)
Headache
HoTN
effect B blockers
Negative inotroic and chronotropic effects
Slow HR
Reduces contractility
Reduce aa pressure
SE b blockers (5)
GI problems
Fatigue
Poor perfusion
Bronchoconstriction
Hypoglycaemia
Effect CCB
Inhibit excitability of cardiac mm
Prevents SM contraction, reduce afterload and –> coronary VD
What do rate limiting blockers (CCBs) do
Inhibit conduction through AVN and cause bradycardia
What does dihydropyrmidine blockers do
Reduce contractility but may –> reflex tachy C
Which Dx is 1st line in prinzmetal angina
CCB
SE CCB
Dizziness
Flushing
Headache
Peripheral oedema
effect nicorandil
Combined NO donor + activator ATP sensitive K channels on vascular SM –> hypoerpolarisation + marked VD
What is PCTA
Dilate coronary atheromatous obstructions
Inflate catheter-mounted balloon w/ obstruction using fluoroscopy
Risks PCTA (2)
Local dissection
Acute coronary occlusion
When is CABG indicated
For sx control in patients unsuitable for PCI
How long after ACS should you avoid air travel
2 months
How long after ACS should you avoid intercourse
1 month
