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CP3 Medicine > CARDIOLOGY - ACS and Angina > Flashcards

CARDIOLOGY - ACS and Angina Flashcards

1
Q

Broad catergories - chest pain (5)

A 
Cardiac 
Pulmonary 
GORD
MSK 
Other
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2
Q

Myocardial ischaemia - SOCRATES

A 
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
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3
Q

RF Myocardial ischaemia (10)

A 
Hyperlipidaemia 
DM 
Smoking 
FHx 
HTN 
Obesity 
Race
Male 
Age 
Renal disease
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4
Q

Ix Myocardial ischaemia (5)

A 
ECG
Trops 
CK
CXR
Ddimers
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5
Q

Type A Aortic Dissection

A

Involves aortic arch and valve proximal to LSCA

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6
Q

Sx from type A Aortic dissection

A

Limb ischaemia
Cerebral ischaemia
Aortic regurg
Cardiac tamponade

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7
Q

Type B Aortic dissection

A

Involves descending thoracic aorta distal to LSCA

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8
Q

Sx from type B Aortic dissection

A

Paraplegia
Ischaemic bowel
Renal aa failure
Lower limb ischaemia

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9
Q

Who gets aortic dissection classically

A

Middle aged HTN males

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10
Q

Other RF Aortic dissection (5)

A 
Bicuspid aortic valve disease 
Atherosclerosis 
Marfan's 
Ehlers Danlos 
During pregnancy
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11
Q

Which gene defect is related to aortic dissection?

A

Fibulin-5 –> fibrillin

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12
Q

SOCRATES Aortic dissection

A 
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
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13
Q

Ix Aortic dissection

A

CXR/AXR

CT - definitive diagnosis

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14
Q

What is pericarditis

A

Inflammation of the pericardium

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15
Q

Causes pericarditis

A

Idiopathic
Viruses - fl,EBV,mumps, HIV
Bacteria - pneumonia, FR, fever, TB, staph, strep,
Fungi
MI, Dresslers
Dx
RA/SLE, surgery, malig, radioT, sarcoidosis

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16
Q

SOCRATES - Pericarditis

A 
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
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17
Q

ECG changes pericarditis

A

Saddle shaped ST elevation

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18
Q

What is pain in shoulder tip suggestive of?

A

Diaphragmatic pleural irritation

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19
Q

SOCRATES PE

A 
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
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20
Q

GORD and GTN spray

A

Relieves after 20 mins

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21
Q

Definition of ACS

A

Acute central chest pain, lasting > 20 minutes, not relieved by 3x GTN sprays at 5 min intervals

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22
Q

How gets ACS without chest pain aka silent infarction

A

Elderly

Diabetics

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23
Q

Sympathetic activation Sx ACS

A

Tachycardia
HTN
Pallor
sweatiness

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24
Q

Vagal stimulation Sx ACS

A

Bradycardia

Vomiting

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25
Q

STEMI vs NSTEMI

A 
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
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26
Q

Def unstable angina

A

Occuring at rest or sudden incr f/severity of existing angina

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27
Q

Blood results UA

A

Plasma Trops and CK = norm

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28
Q

ECG UA

A

Normal

Or ST depression +/- T wave inversion

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29
Q

MI time course - 0-12hrs

A

Infarct not visible

Loss of oxidative enzymes

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30
Q

MI time course - 12-24hrs

A

Infarct pale/blotchy, w/ intracellular oedema

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31
Q

MI time course - 24-72hrs

A

Infarcted area excites acute inflamm response, w/ dead area soft + yellow w/ neutrophilic involvement

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32
Q

MI time course - 3-10days

A

Organisation of infarcted area by vascular granulation tissue

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33
Q

MI time course - 10days to several m

A

Collagen deposition

Infarct replaced by scar

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34
Q

Normal troponin levels

A

<10

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35
Q

How long can troponin stay elevated for?

A

Up to 2 w

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36
Q

What areas of the heart does the R coronary aa supply?

A 
RA
RV
Posterior septum 
SAN (60%)
AVN (80%)
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37
Q

What type of MI does a RCA give?

A

Post/inferior MI

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38
Q

Which leads does a posterior/inf MI show up in

A

II, III aVF

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39
Q

What 2 aa does the L coronary aa split into?

A

LAD

Circumflex

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40
Q

What areas of the heart does the circumflex artery supply?

A

LA

LV

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41
Q

What type of MI does circumflex aa give?

A

Lateral MI

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42
Q

What ECG leads does a lateral MI show up in

A

I
aVL
V5-6

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43
Q

What areas of the heart dose the LAD aa supply?

A

LV

Anterior septum

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44
Q

What type of MI does LAD aa give?

A

Antero-sepatal MI

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45
Q

What ECG leads does an antero-septal MI show up in?

A

V1-4

46
Q

MI ECG changes at: 5 mins

A

Tall, pointed T-waves

47
Q

MI ECG changes at: 30 mins

A

ST elevation

48
Q

MI ECG changes at: 2+hrs

A

T wave inversion + Q waves develop

49
Q

MI ECG changes at: days after

A

ST segment returns to normal

50
Q

MI ECG changes at: weeks after

A

Q wave remains

51
Q

Which investigation is contraindicated in unstable angina?

A

Stress tests

52
Q

When does troponin levels peak after an MI?

A

24hrs

53
Q

What marker is useful for rapid diagnosis of MI?

A

Myoglobin

54
Q

Why take FBC + U+E for MI Ix

A

Glucose is lowered

Lipids are raised

55
Q

CXR features MI (2)

A

Cardiomegaly
Pulmonary oedema
Widened mediastinum

56
Q

Which test definitively defines presence, extent and severity of CAD?

A

Coronary angiography

57
Q

What is the earliest sign of acute MI on ECG?

A

Hyperacute T waves

58
Q

What leads are hyperacute T waves most evident in?

A

Anterior chest leads

59
Q

What ECG change is often the earliest recognised sign of an acute MI

A

ST elevation

60
Q

What ECG change is DIAGNOSTIC of a STEMI

A

1mm of ST elevation in 2 contingous leads

61
Q

What ECG change is the only firm evidence of myocardial necrosis?

A

Q waves

62
Q

How long may T wave inversion take to resolve?

A

2 weeks

63
Q

Which type of MIs does T wave inversion tend to persist in?

A

Anterior MI

64
Q

Mx STEMI (MOANA)

A 
morphine IV 10mg 
O2
Antiplaetlets - aspirin (300mg) or clopidogrel (600mg)
Nitrates/GTN
Anti-emetics (10mg metocloperamide)
65
Q

When do you not use GTN spray in STEMI Mx

A

if pt = hypotensive

66
Q

What meds to give post PCI

A

Clopidogrel + abciximab (reduce complication rates)

67
Q

C/I Thrombolysis (6)

A 
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
68
Q

What is the GRACE score

A

Determines mortality risk in ACS

69
Q

Highest GRACE score risk features in NSTEMI/UA

A

> 6m raised trops
Persistent pain
ST depression
Diabetes

70
Q

Factors taken into account GRACE score

A 
Age
HR < BP 
class of CHF
Renal fct
ST segment changes 
Troponin 
Whether there was an arrest at admission
71
Q

Lterm Mx ACS

A 
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
Discharge 5-7 days
72
Q

Immediate complications MI

A

Arrhythmias

73
Q

S term complications MI (6)

A 
Pulmonary oedema 
Cardiogenic shock 
Thromboembolism 
Venticulo-septal defect 
Ruptured chordae tendinae 
Rupture of ventricular wall
74
Q

When does rupture of ventricular wall happen after MI?

A

2-10 days after

75
Q

Why does rupture of ventricular wall post MI happen?

A

B/C reorganisation + softening of wall

–> haemopericardium, cardiac tamponade + rapid death

76
Q

L term complications MI (3)

A

Heart failure
Dressler’s syndrome
Ventricular aneurysm formation

77
Q

What is Dressler’s syndrome

A

Immune mediated pericarditis post MI

78
Q

Sx Dressler’s syndrome

A

Sharp chest pain
Exaccerbated by movement + lying down
Relieved by sitting forward

79
Q

Tx Dresslers’ syndome

A

High dose aspirin / NSAIDs

80
Q

Define angina

A

Chest pain precipitated by exercise and relieved by rest.
Usually fades within mins
Caused by heart not getting enough O2

81
Q

Causes angina (11)

A 
Coronary aa disease 
Aortic stenosis 
LVH
Anaemia/carboxyhaemoglobinaemia 
Atheroma 
Embolus 
Thrombosis 
Spasm
Inflammation coronary aa 
Generalised HoTN
Tachyarrhythmia
Hyperthyroidism
82
Q

What is atherosclerosis

A

Non-specific thickening of walls of aa –> loss of contractility + elasticity decreased blood flow

83
Q

What is an atheroma

A

Specific degenerative disease affecting large/med size aa

84
Q

Pathology of Angina

A

LDLs into intima
LDLs taken up by macrophages –> fatty streak
Macrophages stimulate cytokines –> collagen deposition –> plaque becomes fibrotic
–> pressure atrophy
Endothelium is fragile, ulcerates

85
Q

RF Angina (9)

A 
Age
Male 
FH
Smoking 
Diet 
Obesity 
HTN 
Hyperlipidaemia 
DM
86
Q

What is decubitus angina

A

Angina precipitated by lying down as there is increased venous return to heart

87
Q

Prinzmetal’s angina

A

Occurs without provocation at rest as result of coronary aa spasm

88
Q

Ix that show Prinzmetal’s angina

A

ST elevation

But no trops rise

89
Q

PS Angina (socrates)

A 
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
90
Q

Ix Angina

A 
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
91
Q

NICE tool - likelihoodness of CAD

A

 >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

92
Q

FFR value that is significant in Angina

A

<0.75

93
Q

FFI value that is significant in Angina

A

<0.89

94
Q

Mx angina

A

Mx risk factors

1st line = GTN + B blocker or CCB

95
Q

Mx - angina (refractory disease)

A

Combination therapy
Or
Nicorandil

96
Q

2’ prevention angina

A

Statin

Low dose aspirin

97
Q

SE aspirin

A

GI ulcer

Bleeding

98
Q

effect nitrates

A

Decrease pre-load and afterload - decr O2 req of myocardium

  • -> VD
  • -> Incr O2 delivery
99
Q

SE nitrates (2)

A

Headache

HoTN

100
Q

effect B blockers

A

Negative inotroic and chronotropic effects
Slow HR
Reduces contractility
Reduce aa pressure

101
Q

SE b blockers (5)

A 
GI problems 
Fatigue 
Poor perfusion 
Bronchoconstriction 
Hypoglycaemia
102
Q

Effect CCB

A

Inhibit excitability of cardiac mm

Prevents SM contraction, reduce afterload and –> coronary VD

103
Q

What do rate limiting blockers (CCBs) do

A

Inhibit conduction through AVN and cause bradycardia

104
Q

What does dihydropyrmidine blockers do

A

Reduce contractility but may –> reflex tachy C

105
Q

Which Dx is 1st line in prinzmetal angina

A

CCB

106
Q

SE CCB

A

Dizziness
Flushing
Headache
Peripheral oedema

107
Q

effect nicorandil

A

Combined NO donor + activator ATP sensitive K channels on vascular SM –> hypoerpolarisation + marked VD

108
Q

What is PCTA

A

Dilate coronary atheromatous obstructions

Inflate catheter-mounted balloon w/ obstruction using fluoroscopy

109
Q

Risks PCTA (2)

A

Local dissection

Acute coronary occlusion

110
Q

When is CABG indicated

A

For sx control in patients unsuitable for PCI

111
Q

How long after ACS should you avoid air travel

A

2 months

112
Q

How long after ACS should you avoid intercourse

A

1 month

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