Cardiology- complete Flashcards
What are STEMI criteria?
STEMI criteria
clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or
≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
new LBBB (LBBB should be considered new unless there is evidence otherwise)
What is the initial drug therapy for all patients with ACS?
aspirin 300mg
oxygen if sats < 94%
morphine for patients with severe pain
nitratesn (SL or IV)- should be used in caution if patient hypotensive
Management of STEMI
Aspirin 300mg
Is PCI possible within 120 minutes?
Yes
for PCI
Give Prasugrel, give unfractionated heparin + bailout gylcoprotein IIb/IIIa inhibitor, and use a drug-eluting stent
No
for fibrinolysis
Give an antithrombin at the same time
Give Ticagrelor after
for onging ischemia consider PCI
Assumptions for STEMI management
Pt presented within 12 hours of symptoms AND PCI can be delivered within 120 minutes - if not then fibrinolysis
if pt high risk of bleeding then swap prasugrel for ticagrelor/ and swap ticagrelor for clopidogrel
if pt on oral anticoagulation then swap prasugrel for ticagrelor
When to consider PCI after thrombolysis?
An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered.
How do you manage NSTEMI/ unstable angina?
Aspirin 300mg
Fondaparinux if no immediate PCI planned
then-
** estimate 6 months mortality using GRACE
if low risk (3 or less)
- Ticagrelor
if high risk (more than 3)
- PCI (immediate if unstable vs 72 hrs if stable)
- Give prasugrel or ticagrelor
- give unfractionated heparin
- Drug-eluting stent
Assumptions not high bleeding risk and not on oral anticoagulations
Following an ACS, all patients should be offered?
dual antiplatelet therapy (aspirin plus a second antiplatelet agent such as an adenosine diphosphate receptor (ADP) receptor inhibitor)
ACE inhibitor
beta-blocker
statin
what are adenosine diphosphate receptor (ADP) receptor inhibitors?
clopidogrel, ticlopidine, prasugrel and ticagrelor
they impair platelet aggregation and fibrinogen-mediated platelet cross-linking
What are the ECG features of a LBBB?
QRS duration > 120ms
Dominant S wave in V1 (W shape rS in V1)
Broad monophasic R wave in lateral leads (I, aVL, V5-6)
Prolonged R wave peak time > 60ms in leads V5-6
(M shape R in V6)
Absence of Q waves in lateral leads
Associated features include:
Left axis deviation (LAD);
Poor R wave progression in precordial leads, and
Appropriate discordance (discussed below)
https://litfl.com/left-bundle-branch-block-lbbb-ecg-library/
Pulmonary embolism ECG findings?
Sinus tachycardia is most common
finding
Classical is the ‘S1Q3T3 pattern’ or the McGinn-White Sign: a large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain.
WiLLiaM vs MaRRoW
in LBBB there is a ‘W’ in V1 and a ‘M’ in V6
in RBBB there is a ‘M’ in V1 and a ‘W’ in V6
Causes of new LBBB
New LBBB is always pathological.
Causes of LBBB include:
MI
HTN
aortic stenosis
cardiomyopathy
rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
Sgarbossa Criteria
Used to help diagnose MI in patients with new LBBB
Concordant ST elevation ≥ 1 mm in ≥ 1 lead
Concordant ST depression ≥ 1 mm in ≥ 1 lead of V1-V3
Proportionally excessive discordant STE in ≥ 1 lead anywhere with ≥ 1 mm STE, as defined by ≥ 25% of the depth of the preceding S-wave
Peri-arrest Arrhythmias?
Rhythm abnormalities that occur in the peri-arrest period may be considered in two main categories:
- Arrhythmias that may lead to cardiac arrest.
- Arrhythmias that occur after initial resuscitation from cardiac arrest - these often indicate that the patient’s condition is still unstable and that there is a risk of deterioration or further cardiac arrest.
Peri- arrest arrhythmias: Tachycardia or bradycardia with life threatening features (shock/ syncope/ MI/ HF)?
Tachycardia -> synchronised DC shocks up to 3 attempts
if unsuccessful (amiodarone 300mg IV over 10-20 min/ rpt DC shock)
bradycardia -> atropine 500 mcg IV
if unsuccessful
do this as interim measures whist seeking expert help
atropine up to 3 times
isoprenaline/ adrenaline infusion titrated to response
or transcutaneous pacing
seek expert help and arrange for transvenous pacing
Potential risk of asystole in those with peri-arrest arrhythmia?
The following are risk factors for asystole. Even if there is a satisfactory response to atropine specialist help is indicated to consider the need for transvenous pacing:
complete heart block with broad complex QRS
recent asystole
Mobitz type II AV block
ventricular pause > 3 seconds
NYHA classifications?
Class I
no symptoms
no limitation
Class II
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
Class III
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
Class IV
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
MGT of massive PE with haemodynamic instability ?
thrombolysis
MGT of pt with recurrent PEs who are on recommended anticoagulation?
IVC filters
What does PESI score stand for?
the Pulmonary Embolism Severity Index (PESI) score
this can be use to determine the suitability of outpatient treatment
MGT of suspected/ confirmed PE?
- Use a DOAC (apixaban or rivaroxaban) once diagnosis is suspected
if not suitable then in order use - LMWH –> dabigatran or edoxaban
- LMWH –> warfarin
for PE in pts with severe renal impairment or antiphospholipid syndrome the use LMWH –> Warfarin
when is the Pulmonary embolism rule-out criteria (PERC) used?
When there is a low suspicion of PE
if all criteria are negative then this can be used to rule out PE
if there is a high suspicion that PE is the likely diagnosis then Wells score should be used
Wells score- what is included?
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
Clinical probability simplified scores
PE likely - more than 4 points
PE unlikely - 4 points or less
MGT of CHF
1st line - ACE-inhibitors and a beta blocker (bisoprolol, carvedilol, and nebivolol)
2nd line- Minralocorticoid receptor antagonist (MRA)
3rd line- should ne initiated by a specialist (ivabradine/ sacubitril-valsartan/ digoxin/ hydralazine/ cardiac resynchronisation therapy)
4Hs and 4Ts
Hypoxia
Hypovolaemia
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
Hypothermia
Thrombosis (coronary or pulmonary)
Tension pneumothorax
Tamponade – cardiac
Toxins
When to give adrenaline during CPR?
ASAP for non-shockable rhythms
for VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock
repeat adrenaline 1mg every 3-5 minutes whilst ALS continues
When to give amiodarone in ALS?
https://bnf.nice.org.uk/medicines-guidance/life-support-algorithm-image/
After the third shock
Does grapefruit interact with simvastatin?
Grapefruit juice is a potent inhibitor of the cytochrome P450 enzyme CYP3A4
When are statins used: primary and secondary preventions?
primary (atorvastatin 20mg)
- QRISK >10%
- T1DM
- CKD if eGFR <60
secondary (atorvastain 80mg)
- known IHD, CVD, PAD
- when uptitrated if no >40% reduction in non-HDL is achieved with 20mg
MGT of HTN if <55yrs or T2DM
Step 1: A
Step 2: A+C or A+D
Step 3: A+C+D
step 4
if K 4.5 or less low dose spironolactone
if K more than 4.5 add an alpha or beta blocker
if BP on 4 drugs then for specialist review
MGT of HTN if 55 or more and no T2DM or black African or African-carribean ethnicity
Step 1: C
Step 2: C+A or C+D
Step 3: A+C+D
if pt is black then ARB is preferred to ACE
step 4
if K 4.5 or less low dose spironolactone
if K more than 4.5 add an alpha or beta blocker
if BP on 4 drugs then for specialist review
ECG: coronary territories and their arteries
Anteroseptal
V1-V4
lt anterior descending artery
Inferior
II III aVF
Rt coronary
Anterolateral
V4-6, I, aVL
lt anterior descending or lt circmflex
Lateral
I, aVL +/- V5-6
Lt circumflex
Posterior
changes in V1-3
Reciprocal changes of STEMI are typically seen
horizontal ST depression +
tall, broad R waves+
upright T waves+
dominant R wave in V2
Posterior infarction is confirmed by ST elevation and Q waves in posterior leads (V7-9)
Lt circumflex also rt coronary
HTN medications that can worsen gout
bendroflumethiazide
what is J wave classically a feature of?
Hypothermia
A J-wave is a positive deflection at the start of the ST interval, following the QRS complex.
In patients with chronic AF - what score should be used to decide on treatment?
CHA2DS2VASc
NICE suggest using the CHA2DS2-VASc score to determine the most appropriate anticoagulation strategy.
1 CHF
1 HTN
2 Age 75 or more
1 Age 65-74
1 DM
2 Stroke/TIA/VTE
1 IHD/ PAD
1 Female
if the score is
0 no tx
1 or more if male anticoagulate
2 or more if female anticoagulant
ORBIT scoring system
2 if Hb <130 g/L for M and < 120 g/L for F, or Hct < 40% for M and < 36% for F
1 Age > 74 years
2 Bleeding history (GI, intracranial or haemorrhagic stroke)
1 Renal impairment (GFR < 60)
1 tx c antiplatelet agents
ORBIT score
0-2 Low
3 Medium
4-7 High
Tx of AF if anticoagulation is indicated?
1st line DOAC
2nd line Warfarin
Inv of choice to dx aortic dissection?
CT angiography is the investigation of choice for suspected aortic dissection (depending on stability of patient)
Transoesophageal echocardiography (TOE)
more suitable for unstable patients who are too risky to take to CT scanner
Mgt of aortic dissection
Type A (ascending aorta, 2/3 of cases)
surgical management, SBP aim of 100-120 mmHg whilst awaiting intervention
Type B (descending aorta, distal to left subclavian origin, 1/3 of cases)
conservative management
bed rest
reduce blood pressure IV labetalol to prevent progression
complications of Aortic dissection
Complications of backward tear
aortic incompetence/regurgitation
MI: inferior pattern is often seen due to right coronary involvement
Complications of a forward tear
unequal arm pulses and BP
stroke
renal failure
MGT of VT
If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure) then immediate cardioversion is indicated.
otherwise antiarrhythmics
amiodarone: ideally administered through a central line
lidocaine: use with caution in severe left ventricular impairment
procainamide
Verapamil should NOT be used in VT
If these fail, then electrical cardioversion may be needed with synchronised DC shocks
If drug therapy fails
electrophysiological study (EPS)
implant able cardioverter-defibrillator (ICD) - this is particularly indicated in patients with significantly impaired LV function
