Cardiology - CP, ACS + MGMT Flashcards
A 75 year old male with known colorectal carcinoma presents to A&E with chest pain and shortness of breath. The pain is worse on breathing in and coughing. What other sign/symptom would aid your diagnosis?
A. Gradual onset chest pain B. Absent peripheral pulses C. Collapsing Pulse D. Haemoptysis E. Abdominal Pain
D. Haemoptysis
You should be thinking of PE:
pleuritic chest pain + SOB + Hx of malignancy
Mr B a 52 year old male presents to his GP with central, tight chest pain. He has noticed the pain comes on when he is gardening or walking to the bus stop in a hurry, but normally goes away when he rests. What medication would the GP prescribe to treat his underlying condition?
A. GTN spray B. Propanolol (Beta Blocker) C. Ramipril (ACEi) D. Aspirin E. Atorvastatin (Statin)
B. Propanolol (Beta Blocker)
Looks like stable angina (central, tight CP, relieved by rest)
BBs are primary medical management
Definition of angina?
Angina Pectoris is chest pain arising from the heart as a result of myocardial ischaemia bought about by exertion and relieved by rest
What pathology causes angina?
Most commonly artherosclerotic processes in coronary artery disease.
Rarer causes include anaemia, tachyarrhythmia, small vessel disease and heart failure.
What types of angina are there?
Decubitus Angina
Printzmetal Angina
Unstable Angina
Syndrome X
What is Decubitus Angina?
Angina with symptoms experienced when lying down
What is Printzmetal Angina?
Symptoms caused by coronary artery vasospasm
What is Unstable Angina?
Symptoms that occur on rest or is of increasing frequency/severity
What is Syndrome X?
Symptoms of angina but with normal exercise tolerance tests and normal coronary angiograms
What is the clinical presentation of Acute Coronary Syndrome/ Angina?
(SOCRATES)
Chest Pain: S – central O – sudden C – crushing, tight, “elephant on chest” R – left arm, jaw A – sweating, nausea, collapse, SOB, pallor T – at rest (ACS specific) E – exacerbated by exercise, cold weather, emotion, relieved by GTN
What will you find on examination of a patient with ACS/ Angina?
Pallor
Sweaty
Anxiety
Signs of CV disease:
Xanthelasma
Corneal Arcus
What are the non-modifiable risk factors of ACS/Angina?
age,
male,
Fhx of IHD (MI in 1st Degree relative <55)
What are the modifiable risk factors of ACS/Angina?
obesity; cocaine, smoking; HTN, DM, hyperlipidaemia,
How would you diagnose and clinically assess angina?
Diagnosis is based on features of anginal pain:
- Constricting discomfort in the chest, or neck, shoulders, jaw, arms
- Precipitated by exercise
- Relieved by rest or GTN within 5 minutes
Clinical Assessment
3 features = typical angina
2 features = atypical angina
1 or no features = non-anginal pain
If clinical assessment is insufficient to exclude stable angina, what investigation would you perform?
12-lead ECG:
- ST flattening/inversion
- pathological Q waves
- may be normal!
How would you diagnose someone with typical angina?
3 out of 3 features of anginal pain:
- Constricting discomfort in the chest, or neck, shoulders, jaw, arms
- Precipitated by exercise
- Relieved by rest or GTN within 5 minutes
How would you diagnose someone with atypical angina?
2 out of 3 features of anginal pain:
- Constricting discomfort in the chest, or neck, shoulders, jaw, arms
- Precipitated by exercise
- Relieved by rest or GTN within 5 minutes
A patient comes in with chest pain which is unstable. What do you suspect? How do you proceed?
ACS!
Emergency admission
A patient comes in with stable chest pain but has no known CAD. What do you do?
- CT coronary angiography
- Non-invasive functional imaging
- Invasive coronary angiography
Don’t worry about knowing what 2. is.
What are the two most common presentations of Ischaemic Heart Disease?
Stable angina
ACS
What is the DDx of ACS? (3)
- Unstable angina
- nSTEMI
- STEMI
What investigations would you perform in a patient with known CAD who has atypical angina?
Exercise ECG or
Stress functional imaging or
Echo
How do you manage angina?
- Conservative Management
RF modification - smoking cessation, weight loss, exercise - Medical Treatment
Anti-anginals - Beta-blockers, CCBs
Preventative/Episodic Tx - GTN
RF management - aspirin, ACEi, BBs - Surgical Treatment
Revasculatisation: PCI or CABG (if medical treatment insufficient)
What is aortic dissection?
A tear in the tunica intima resulting in blood accumulation between the inner and outer tunica media (false lumen).
How do you classify aortic dissection? What’s the name of the classification?
Stanford Classification:
Type A - Tear in the ascending aorta
Type B - Tear in the descending aorta (after the left subclavian branch)
What are the risk factors for aortic diss.?
Hypertension
Atherosclerosis
Connective tissue disorders (SLE, Marfan’s, Ehler’s Danlos)
Iatrogenic (angiography/angioplasty)
Congenital - coarctation of aorta
Cocaine
Aortic diss. presentation?
S – central O – sudden C – tearing R – back A – depends on position of tear: Carotid - blackouts, hemiparesis Coronary - MI, angina Renal - AKI, renal failure Coeliac trunk - abdo pain
Aortic diss. examination findings?
Tachycardia,
BP >20mmHg discrepancy between arms,
Wide pulse pressure,
Murmur on back below scapulae
Signs of Aortic Insufficiency:
Collapsing pulse
EDM
Aortic dissection investigations?
Bloods - FBC, U&Es (renal damage), X Match 10 units of blood
CXR - Widened mediastinum and aortic notch visible
CT Thorax - Visualisation of dissection
Echo - TOE (very sensitive)
ECG - often normal, maybe some LV Hypertrophy
CT aortogram – gold standard showing intimal flap
(TOE - Transesophageal Echocardiography)
What is pericarditis?
Inflammation of the pericardial sac
Can be acute, subacute or chronic
What are the causes of pericarditis?
- Idiopathic
- Infection:
- Viral (coxsackie, flu, EBV, mumps)
- Bacterial (pneumonia, strep, staph, TB, rheumatic fever) - Post-MI:
- Early (24-72hrs)
- Dressler Syndrome (2-10 weeks) – pleuritic chest pain, low grade fever, pericarditis
What is dressler syndrome?
Secondary form of pericarditis occurring after injury to heart or pericardium.
Occurs 2-12 weeks post MI due to antibodies forming against circulating myocardial antigens.
Consists of fever, pleuritic pain, pericarditis and/or pericardial effusion.
Presentation of pericarditis?
S – central/retrosternal C – sharp and pleurtic R – neck and shoulders (may mimic MI) A – fever, dyspnoea E – worse lying down/inspiration/coughing relieved by leaning forward
Examination finding in pericarditis?
Pericardial friction rub
“walking on snow”
Soft S1
S4 gallop
Complications of pericarditis?
Cardiac tamponade
pericardial effusion
What is a PE?
Pulmonary embolism (PE) is the sudden occlusion of the pulmonary or one of its branches. In a PE, the lung is ventilated but not perfused - leading to impaired gas exchange.
Where do PE’s originate from?
Emboli commonly arise from iliofemoral veins (less commonly from right heart) and lodge in the pulmonary circulation.
PE risk factors?
Smoking
Obesity
Immobility >1 weeks
Long distance travel
Recent surgery
Malignancy
Previous DVT/PE
FHx of DVT/PE
Pregnancy
OCP
Management of PE?
Dependent of Well’s score:
High probability of PE – immediately start LMWH until INR >2 for 24hrs or 5 days
Warfarin loading – 24hrs post diagnosis and continued for 3 months
Haemodynamically unstable – thrombolysis or embolectomy
What is GORD?
Reflux of gastric contents into the oesophagus often as a result of reduced lower oesophageal sphincter (LOS) tone or hiatus hernia
Presentation of GORD?
Presentation: S – central O – gradual C – burning R – stomach, neck A – acidic taste, waterbrash, sore throat, cough T – after meals, worse at night E - leaning back (lying down), alcohol
GORD investigations?
ECG -may need to exclude cardiac causes
OGD, barium swallow, oesophageal manometry
GORD risk factors
obesity
pregnancy
What is chostochondritis?
Temporary inflammation of the costal cartilage.
Chostochondritis causes?
Idiopathic, strenuous lifting (physical trauma), infectious causes
Features of chostochondritis?
Pleuritic chest pain with tenderness on the sides of the sternum. Typically affects 3rd, 4th and 5th costosternal joints
What is Tietze’s syndrome?
Inflammation of costal cartilage, same features as chostochondritis plus palpable swelling. Typically affects 2nd or 3rd costosternal joint.
What differentiates Tietze’s syndrome from chostochondritis?
Tietze’s has palpable swelling of sternum/costal cartilages
Tietze’s/ chostochondritis treatment?
Rest
NSAIDs
Corticosteroid injections if severe
Generally self limiting
A 70 year old gentleman with known hypertension presents to A&E with tearing chest pain, radiating to the back. His CXR shows a widened mediastinum. What is the most likely diagnosis?
A. Aortic Dissection B. STEMI C. Teitze’s Syndrome D. Costochondritis E. Pulmonary Embolism
A. Aortic Dissection
Hypertension is a risk factor
Tearing chest pain radiating to the back
Widened mediastinum on CXR
A 54 year old gentleman with a BMI of 27kg/m2 presents with burning chest pain. He finds that it is often worse in the evening and has noted a strange taste in his mouth. What is the most likely diagnosis?
A. Angina B. Teitze’s Syndrome C. Aortic Dissection D. GORD E. Pericarditis
D. GORD
Obese, burning CP, strange taste
What is ACS?
Umbrella term for different forms of unstable coronary disease with the same underlying pathology
What is a STEMI?
Complete occlusion of coronary artery resulting in full thickness myocardial muscle ischaemia
ST elevation on ECG (or new onset LBBB)
What is an NSTEMI?
Permanent myocardial damage causing an increase in creatine kinase and troponin. Involves less than full thickness myocardial muscle ischaemia and damage.
No ST elevation on ECG – may have ST depression, T wave inversion or normal ECG
What is unstable angina?
Unstable Angina – Ischaemia but no significant permanent damage. Symptoms at rest/minimal activity OR at a lesser degree than the individual’s previous angina (crescendo angina)
Negative troponin/CK
What are the types of complications of ACS? (5)
Ischaemic complications Mechanical complications Arrhythmic complications Cardiac Arrest Pericarditis
What are the ischaemic complications of ACS?
- Repeat MI – if this is suspected, measure CK-MB rather than troponins
- Post-infarction Angina – occurs from a few hours to 30 days post MI. More commonly seen in NSTEMIs
What are the mechanical complications of ACS?
- Heart Failure – result of damaged cardiac tissue. Can range from mild signs of HF to cardiogenic shock
- Papilliary Muscle Rupture – Mitral Regurgitation post MI is found in between 15-30% of patients but is usually transient and asymptomatic.
PMR is life-threatening – new and loud pan-systolic murmur at apex, radiating to the axilla. - Ventricular Aneurysm – aneurysm arising from weakened ventricular wall which can block the outflow of blood from the heart
What are the arrhythmic complications of ACS?
VT, VF
Complete Heart Block
Reentry circuits
What is the difference between an MI and Cardiac Arrest?
Cardiac Arrest = electrical problem
MI = circulatory problem – damaged heart muscle can result in cardiac arrest
MI can cause a CA
How quickly after an MI does pericarditis develop?
Early - 24-96 hours post MI –> inflammatory response to necrotic tissue
Dressler’s Syndrome – 2-12 weeks post MI due to antibodies forming against circulating myocardial antigens
A 60 year old patient presents to A&E with central crushing chest pain, radiating to the jaw. His ECG is normal. What is the next step?
Creatine Kinase Repeat ECG Discharge Exercise ECG Troponin
Troponin
A 46 year old diabetic man presents to A&E following collapse. The patient is very distressed and is sweating. On the way to the hospital, his wife had to stop the car to allow him to vomit. His ECG is normal but his 12 hour troponins are positive. What is the most likely diagnosis?
Inferior STEMI Anterior STEMI NSTEMI Unstable Angina Ventricular Wall Aneurysm
NSTEMI
A 68 year old patient presents to A&E with sharp central chest pain. She was discharged 4 weeks ago following an MI. Her ECG shows saddle-shaped ST segments diffusely. What is the most likely diagnosis?
Repeat MI Dressler’s Syndrome Pericarditis Ventricular Wall Aneurysm Heart Failure
Dressler’s Syndrome
A 56 year old overweight man with a history of high cholesterol comes in complaining of central crushing chest pain that came on at rest. He has had a similar pain before but only when playing tennis. His ECG shows ST depression and a 12 hour troponin is negative.
Inferior STEMI Anterior STEMI NSTEMI Unstable Angina Ventricular Wall Aneurysm
Unstable Angina
What is the general management plan in a patient with ACS?
(ABC Approach) Oxygen (only if sats <90%) Antiplatelet - 300mg Aspirin - 300mg Clopidogrel Analgesic - Morphine (+ metaclopramide) Anti-Ischaemic - Sublingual GTN
STEMI management primary aim?
Coronary reperfusion therapy - PCI or fibrinolysis
STEMI management in patient with <12h onset of symptoms?
PCI is preferential if it can happen within 120 minutes of the time that fibrinolysis could be given
(If a patient presents within 1 hour of onset of symptoms, better to give fibrinolysis than to be transferred to a centre for PCI than delay by 120 minutes)
STEMI management in patient with >12h onset of symptoms?
Coronary angiography with follow on PCI if indicated
NSTEMI/Unstable Angina Management?
- Immediate -> aspirin and antithrombin
2. Risk stratification - GRACE risk score
What antithrombin medication do you give in NSTEMI/Unstable Angina Management?
Fondaparinux - for patients with a low bleeding risk UNLESS coronary angiography planned within 24hrs of admission
LMWH as an alternative if pts. undergoing angiography
What is the GRACE Risk Score?
The GRACE risk model is a web-based tool that can be used to predict in-hospital and post-discharge mortality or MI in patients following an initial ACS.
What is the management of GRACE high risk patients?
IV Glycoprotein IIb/IIIa inhibitors - Tirofiban/Eptifibatide
Coronary angiography (+ follow on PCI if indicated) within 96 hours of admission
What is the management of GRACE low risk patients?
Conservative management without angiography
-> Unless ischaemia demonstrated by persistent symptoms or ischaemia testing
What are the 3 main forms of post-ACS management? V. generally
Conservative
Medical
Surgical
Conservative post-ACS management (ongoing management)?
Diet – DASH diet (Mediterranean), smoking cessation, increased physical activity (20-30 minutes per day)
Medical post-ACS management?
- ACEi
- Dual antiplatelet therapy - aspirin (lifelong after STEMI) + Clopidogrel - up to 12 months)
- Statin
- Beta Blocker
Surgical post-ACS management?
CABG
-> may be indicated for triple vessel disease or left main stem disease >50%
A 50 year old man presents to his GP with central chest pain. The ECG shows a STEMI. His sats are 96%. What medication should the GP give whilst waiting for an ambulance?
Fondaparinux 2.5mg Oxygen Propanolol Aspirin/Clopidogrel 300mg Ramipril
Aspirin/Clopidogrel 300mg
STEMI MGMT: Oxygen (only if sats <90%) Antiplatelet - 300mg Aspirin - 300mg Clopidogrel Morphine (+ metaclopramide) Sublingual GTN
A 70 year old female with known hypertension and hypercholesterolaemia presents with central crushing chest pain, which radiates to the left arm. The pain started 2 hours ago. Her ECG shows LBBB. What is the most appropriate management.
Thrombolysis Angiography Fibrinolysis PCI CABG Fondaprinux
PCI
LBBB suggests STEMI. Symptom onset is less than 12h
A 78 year old woman is bought to A&E following chest pain. Her ECG shows ST depression and T-wave inversion. 12 hour troponins are positive. What is the most appropriate management?
PCI Fibrinolysis Fondaparinux CABG Thrombolysis Andgiography
Fondaparinux
NSTEMI management - immediate aspirin and antithrombin. Then GRACE.
A man is being discharged following an MI. Which of the following drugs should not make up a part of his post MI management?
ACEi Aspirin Clopidogrel Heparin Statin B-Blocker
Heparin
Medical ongoing management (psot-ACS):
- ACEi
- Dual antiplatelet therapy - Aspirin + Clopidogrel
- Statin
- Beta Blocker
