Cardiology medicine block Flashcards
What is the triad of presenting signs in ACS?
- ECG changes
- Raised troponin
- Cardiac chest pain
Define these terms in relation to the triad of ACS presenting symptoms:
- STEMI
- NSTEMI
- Unstable angina
STEMI - ST elevation, raised troponin, cardiac chest pain
NSTEMI - ST depression, T wave inversion or normal ECG, raised troponin, cardiac chest pain
Unstable angina - ST depression, T wave inversion or normal ECG, cardiac chest pain, normal troponin
How is troponin used in diagnosis of ACS?
hs-Tnl = high sensitivity troponin test. Also measure CK in STEMI pt.
Male >34 ng/L
Female >16 ng/L
These indicate a high likelihood of myocardial necrosis.
When else can troponin be increased?
- Advanced renal failure
- Large PE
- Aortic dissection/stenosis
- HCM
- Stroke
- Sepsis
- Malignancy
Draw the different ECG changes in ACS and label
Answers on iPad
What is the initial and medical management of a STEMI?
- IV access, high flow O2, pain relief - morphine + antiemetic
- Prasugrel = 300mg load and then 75mg OD rest of life - this is for pt going to have PCI, <75, >60 kg
- If pt doesn’t fit ^ criteria = clopidogrel 600mg load, 75 OD 12 months or ticagrelor 180mg load, 90mg BD 12 months
What is the interventional management of STEMI?
PCI - percutaneous coronary intervention. Is a non surgical way of opening and stenting obstructed coronary arteries.
What is the preventative management of STEMI?
Will need to reduce CVS RF:
- Medication = statin to reduce cholesterol, bisoprolol, ACEi/ARB to prevent further muscle damage
- Control BP and DM
- Stop smoking
- Need a CVS RF screen - FBC, HbA1c, lipids, random glucose
What is the management of NSTEMI/unstable angina?
- Pain relief - morphine + antiemetic
- Aspirin 300mg load, 75mg OD
- LMWH - enoxaparin if no immediate PCI planned
- Repeat ECG and risk assessment
- Grace >3% = PCI w/i 72 hours and ticagrelor
- Grace <3% = fibrinolysis eg. ticagrelor
What are the clinical features of stable angina?
Chest discomfort on exercise that is relieved by rest. Can get radiating symptoms such as tight throat and arm heaviness. Sometimes hard to distinguish it between GORD and pulm/MSK disease.
What are some specific qs to ask in stable angina hx? What are you looking for on examination?
Hx - T+R, RF, exercise tolerance
Exam - BMI, BP, evidence of PVD, hyperlipidaemia, carotid bruits, murmurs esp aortic stenosis
What are the Ix into stable angina?
- ECG
- FBC
- Full lipid profile
- Glucose and HbA1c
What drug treatments are all pt w stable angina given?
- Aspiring 75mg OD or clopidogrel if can’t tolerate
- GTN
- Statin and ACEi
What are some additional drug treatments that are offered to treat stable angina?
- B blockers for symptomatic relief and rate limitation
- Non dihydropyridine CCB eg. diltiazem also for rate limitation
- Ivabradine also for rate limitation
What are some non cardiac causes of chest pain?
- Costochondritis
- PE
- Pneumonia
- Pneumothorax
- Gastro oesophageal
- Psychosomatic
What are the stages of hypertension?
Stage 1 - 140/90 mmHg, ABPM 135/85 mmHg
Stage 2 - 160/100 mmHg, ABPM 150/95 mmHg
Severe hypertension - 180 mmHg or 110 mmHg
What are some specific qs to ask in a hypertension hx?
Sx - headaches, visual changes
RF - PMH TIA, stroke, DM, angina, syncope, FH HTN, coronary artery disease, renal disease
What are some sx associated w hypertension that may suggest of specific cause of hypertension?
Sweat, palpitations, anxiety = pheochromocytoma
Muscle weakness and tetany, increased Na+ and reduced K+ = hyperaldosteronism
What signs are you looking for on exam of someone w hypertension?
- Signs of Cushing’s and PVD
- Radio femoral delay
- Renal bruits
What are the Ix into hypertension?
- Urine dip for albumin and haematuria
- Bloods - glucose, U&Es, eGFR, lipid profile
- Fundoscopy - hypertension related retinopathy
When should treatment for hypertension be offered?
- Stage 1 HTN if target organ damage, CVS disease, DM or renal impairment
- Stage 2 HTN for anyone else
What are the target BPs?
- Low/mod risk <140 mmHg
- Stroke, DM, IHD, CKD = <130/80 mmHg
- All pt diastolic <90 mmHg but <85 if DM
- CKD and overt proteinuria <130 mmHg
What is the conservative treatment of HTN?
- Weight loss and increase exercise
- Mod salt intake
- Stop smoking
What is the pharmacological treatment of HTN?
Under 55s = ACEi/ARB or above 55 or black = CCB.
Additionally:
+CCB then +thiazide like diuretic
How do you treat resistant HTN?
ACEi/ARB +CCB +thiazide like diuretic +a/b blocker +another diuretic
What are the hypertensive emergencies and their presentations?
= increase in BP that if sustained will cause end organ damage.
Presentation - high BP + pulm oedema, AKI, MI, encephalopathy
What are the signs of end organ damage?
- Encephalopathy
- LV failure
- Aortic dissection
- Unstable angina
- Renal failure
What is the treatment of hypertensive emergencies?
Reduce diastolic BP to 100mmHg in 5-12 hours.
- Sodium nitroprusside
- Labetalol
- GTN
- Esmolol - acts in 1 min and lasts 10-20 mins, give loading dose then start infusion
What is hypertensive urgency and how does it present?
Severe increase in BP that will cause damage in days.
Present - increase BP w/o critical illness but often retinal changes, diastolic >130 mmHg
What is the treatment of hypertensive urgency?
Reduce BP to 100 mmHg diastolic over 48-72 hours:
nifedipine and amlodipine for 3 days then amlodipine forever.
Pt normally tolerate ACEi and CCB combination.
What are the symptoms of phaechromocytoma?
Most common sign - hypertension. Triad:
- Sweating
- Tachycardia
- Headaches
What are the Ix into phaechromocytoma?
- CT/MRI for adrenal tumour
- Urine levels of metanephrines and catecholamines
What is the treatment of phaechromocytoma?
- Resection of tmour
- a blocker before op to control HTN then add on B blocker
What is primary aldosteronism and how is it diagnosed?
Increased aldosterone = high Na+ low K+.
Aldosterone:renin ratio, renin low and aldosterone high.
What are the clinical features of Cushing’s disease?
- Abdo obesity and thin legs and arms
- Purple striae and easy bruising
- Muscle weakness
- High cortisol
What are the Ix for a diagnosis of Cushing’s?
- 24 hour urine cortisol excretion (is increased)
- Low dexamethosone suppression test
- Hyperglycaemic
What are the causes of heart failure?
- IHD, cardiomyopathy
- Hypertension
- Afib
- Valvular heart disease
- Chronic lung disease
- Previous cancer and chemo drugs
- HIV
What are the presentations of heart failure?
- ~ 50% have HFrEF
- Can have clinical features of HF w HFNEF
- Fluid overload, renal impairment
- Increased NHproBNP
What are the Ix into HF?
- Bloods - eGFR, FBC, LFTs, TFTs, BNP, ferritin/transferrin
- CXR
- MRI heart
- Echocardiography, most important Ix
What are the signs of heart failure on CXR?
- Cardiomegaly
- Pleural effusion + alveolar oedema
- Perihilar shadowing = batwing distribution
- Air bronchograms
- Increased width vascular pedicle
What are the signs of heart failure on an echo?
- Dilated and poorly contracting LV
- Reduced diameter, stiff LV
- Vascular heart disease
- Pericardial disease
- Atrial myxoma - tumour in atrium
What is the conservative management of heart failure?
- Stop smoking and reduce alcohol
- Salt restriction
- Fluid restriction, esp if hyponatraemia
- Weight monitoring for early identification of fluid accumulation
What is the pharmacological management of heart failure?
- Diuretics, sx management eg. furosemide, can get low K+ so spironolactone or ACEi can balance
- ACEi/ARB, if HTN, increases survival, vasodilators if can’t tolerate eg. hydralazine
- ARNI, if HFrEF
- B blockers, ivabradine if can’t tolerate
- Nitrates, reduce preload, pulm oedema and SOB
What is ARNI?
Angiotensin receptor neprilysin inhibitor = valsartan + sacubitril
What is device therapy in heart failure?
If pharmacological management fails:
- CRT - cardiac resynchronisation therapy if LBBB (broad QRS), narrows QRS
- ICD - implanted cardiac defib which reconverts VT/VF to avoid sudden cardiac death
What are the symptoms of aortic stenosis?
- Angina, HF, syncope
- Reduced exercise tolerance
- Dyspnoea on exertion
What are the causes of aortic stenosis?
- Increasing age and calcification
- Congenital bicuspid valve
- CKD
- Rheumatic fever
How do you diagnose valvular heart disease?
Echocardiography
What are the indications for surgery in valvular heart disease? What are the surgical options?
Indications - severe disease and sx, or severe disease, asymptomatic and LV dysfunc or abnormal exercise tolerance
Options - aortic valve repair or transcatheter aortic valve implant
What is the aortic stenosis murmur?
Best heard in 2nd ICS, right sternal border, is harsh and noisy here. Ejection systolic crescendo decrescendo murmur. Associated w delayed peripheral pulses. Radiates to carotid arteries in neck.
What are the sx of aortic regurgitation?
Dyspnoea on exertion and reduced exercise tolerance.
Asymptomatic for many years until LV dilation and eventual HF.
What are the causes of aortic regurgitation?
- Calcific degeneration
- Rheumatic fever
- Marfan’s
- Idiopathic dilation
- Congenital bicuspid valve
- Infective endocarditis
What is the aortic regurgitation murmur?
Early diastolic blowing murmur. Best heard left sternal border, 3rd/4th ICS. Associated w collapsing pulse and De Musset’s sign.
What is De Musset’s sign?
Head bobbing
What is the pharmacological treatment of aortic regurgitation?
ACEi reduces rate of LV dilation by reducing afterload.
What are the causes of mitral regurgitation? What is the pharmacological management?
Causes - infective endocarditis, rheumatic fever, mitral valve prolapse, IHD
Drug - diuretics by reducing afterload so reducing LV dilation
What are the RF of infective endocarditis?
- Mitral valve prolapse
- Prostheses
- Rheumatic fever,
- Valvular disease
- Congenital heart disease
- IVDU
What are the causative organisms of IE?
- Viridans group of streptococci
- Staph aureus
- Enterococci
- Fungi in immunosuppressed
When should you suspect IE? What are the sx?
Suspect - unexplained fever, bacteraemia and systemic illness, new murmur
Sx - fever, night sweats, malaise, valve insufficiency
What are the initial Ix into IE?
- ECG, CXR
- Bloods - CRP, FBC, LFTs, U&E
- Urine dip
What are the diagnostic Ix into IE?
- Echo - TOE, transoesophageal echo most sensitive
- Blood cultures - need 3-6 from diff areas, if pt stable delay abx until results come back
What are the major diagnostic criteria of IE?
- Positive cultures
- Endocardial involvement
- Positive echo = vegetation and abscess
- New valve regurg
- Dehiscence prostheses
What are the minor diagnostic criteria of IE?
- IVDU
- Anatomical abnormality
- > 38 degrees pyrexia
- Suggestive echo and cultures
- Vasculitis/embolic phenomenom
What is the management of IE?
Abx therapy:
- Streptococci - benzylpenicillin/vancomycin + low dose gentamicin
- Enterococci - amoxicillin/vancomycin + low dose gentamicin
- Staphylococci - flucloxacillin/vancomycin + gentamicin
Surgery.
How do you check the response to IE treatment?
- ECG
- Echo - assess abscess and vegetation size
- Bloods
What is considered to be bradycardia?
HR <60 BPM but can also be relative or absolute.
- Absolute - <40 BPM
- Relative - HR too slow for haemodynamic state of pt eg. BP <90 mmHg, <40 bpm, poor perfusion and urine output
What are the different classifications of bradycardia?
- Sinus node dysfunc bradycardia
- AV node block
What are the causes of bradycardia?
- Node dysfunction
- Medications
- Hypothyroidism
- Hypothermia
What are the different types of AVN dysfunction?
- First degree AVN block
- Second degree AV block, Mobitz type 1
- Second degree AV block, Mobitz type 2
- Complete AV block/third degree
Describe first degree AV block
PR interval >0.2 secs. No specific treatment indicated, if dizzy or syncope then consider cardiac monitoring..
Describe second degree AV block, Mobitz type 1
Progressive lenghtening of PR interval then failure of atrial impulse to conduct V. Often occurs after inf MI.
Describe second degree AV block, Mobitz type 2
Constant PR interval followed by sudden drop of QRS, more serious than Mobitz type 1.
Describe complete AV block
No conduction from atria to ventricles so no relationship between P waves and QRS.
What are the causes of complete AV block?
- Digoxin toxicity
- Follow after inf STEMI + resolve
- Severe hyperkalaemia
How do you treat complete AV block?
Urgent transcutaneous pacing required w/i 24 hours
- Stop digoxin and verapamil (can both cause heart block)
What complications does Afib increase the risk of?
- Cardioembolic stroke
- Cardiac instability
- Risk of death
- ACS, heart failure
How do you diagnose Afib?
- Manual pulse checks
- Assess sx - breathless, palpitations, syncope, chest pain, hx of stroke
- ECG to confirm irreg pulse caused by Afib
Describe Afib on an ECG
No visible P waves
What are the Ix into Afib?
- 24hr cardiac monitor
- Echo
What is the management of Afib?
- Anticoag to prevent stroke - informed by CHAD-VASC score, offer if score of 2+, DOACs
- Rate control
- Rhythm control
What are the rate control drugs in Afib?
Slow conduction at AVN to reduce V conduction + HR:
- B blocker
- Digoxin
- Diltiazem/verapamil if LVEF >40%
What is a reduced ejection fraction?
<40%
What are the first line treatments for supraventricular tachy?
Vagal manoeuvres - breath holding and Valsalva (pt blow hard into syringe). These slow conduction at AVN and can interrupt re entrant circuit.
Carotid massage - massage carotid sinus on non dominant side
What are the risks of carotid massage?
Auscultate for bruits before attempt due to risk of stroke from emboli.
Don’t perform on both sides.
What are bruits?
Blowing vascular sounds resembling heart murmurs over partially occluded blood vessels.
What are AVNRT and AVRT?
AVNRT - AVN re entry tachy
AVRT - atrio ventricular re entry tachycardia
Not sure how these are different
What is upper lobe diversion?
Pulm venous diversion - increased LA pressure and early sign of pulm oedema.
On CXR = dilation of upper lobe pulm veins
What is the medical management of SVT?
- Adenosine - blocks AVN conduction, if tachy due to AVNRT/AVRT, short acting and short t1/2
- CCB
- Flecainide IV but not if MI
What are the SE and risks of adenosine use?
- Chest pain, flushes and hypotension
- Avoid in pt w asthma/COPD as adenosine causes bronchoconstriction
- Administer w crash trolley next to pt = risk significant brady
Describe ventricular tachycardia
Rapid broad complex tachy shortly after a STEMI is classically VT.
What is the medical management of VT?
- B blockers
- Amiodarone
- Lidocaine
- Cardioversion if haemodynamically unstable
What are the causes of Afib?
- IHD
- Valvular heart disease, especially mitral valve disease
- Thyrotoxicosis
+ HTN, coronary artery disease, PE, pneumonia, substance misuse - Sleep apnoea is a RF
What is the mitral regurgitation murmur? Where is it best heard?
Holosystolic/pansystolic murmur, whoosh w HS1
Best heard over the apex of the heart, 5th ICS, MCL.
What is the mitral stenosis murmur?
Loud S1 and early diastolic opening snap then low pitched rumbling diastolic murmur.
What is the main cause of mitral stenosis?
Rheumatic fever
What are the clinical signs of mitral stenosis?
- Mitral facies - pink/purple cheeks
- Jugular vein distension
What are the clinical signs of mitral regurgitation?
- Peripheral oedema
- Haemopytsis
What are the differentials for chest pain?
Cardiac - STEMI/NSTEMI, angina, pericarditis, aortic dissection
Resp - pneumonia, PE, pneumothorax
Other - GORD, gallstones, neuropathy, cellulitis, MSK pain
What are the differentials for SOB?
Cardiac - HF, SVC obstruction, valvular heart disease, anaemia
Resp - pneumothorax, PE, pneumonia, COVID, asthma/COPD
Other - anaphylaxis, anxiety attack, nephrotic syndrome (swell and SOB), DKA causes hyperventilation if met acidosis
What are the top 3 causes of heart failure?
- IHD
- HTN
- Valvular heart disease, aortic stenosis most common
What are the differentials for palpitations?
Arrhythmia - tachycardia, Afib, ectopics, Aflutter
Hyperthyroidism
Anxiety
Drug use - SSRIs, MDMA, cocaine
Narrow complex tachycardia vs wide complex tachycardia
Narrow - V depolarised by His Purkinje system so tachy originates in A
Wide - V not depolarised normally, tachy originates in V
What are the differentials for syncope?
Cardiac syncope - no warning and complete recovery immediately
Vasovagal syncope - get nausea, vagal stim of GI = vom
Epileptic shock
Addisons - postural hypotension
Hypoglycaemia
What is palpitation that wakes a pt up at night and then they have to wee classic of?
Arrhythmia - Afib caused by parasympathetics (active at night) causes palpitation at night.
Then arrhythmia causes release of ANP which makes pt wee = ANP suppresses Na+ reabsorption at collecting duct = naturesis and diuresis.
What is decompensated vs compensated HF?
Decompensated - structural/func change to heart reducing ejection of blood, symptomatic = wheeze, cough, oedema, reduced exercise tolerance, fatigue
Compensated - asymptomatic
How do you assess fluid status?
- Dry mucous membranes
- Reduced urine output
- Hypotension
- Reduced cap refil time
- Tachycardia
What are some findings on fundoscopy?
- Cotton wool spots - pre proliferative diabetic retinopathy
- Neovasculisation - proliferative diabetic retinopathy
- Retinal haemorrhages - hypertension
- Optic disc swelling - hypertension
- Papilloedema - raised ICP
- Optic nerve atrophy - pale optic disc
- Cherry red spot - due to central artery occlusion
- Roth spot - IE
What can affect BNP levels?
Being on Ramipril can give a falsely low result
