Cardiology + stroke Flashcards
how do you manage a STEMI?
- MONA
- If PCI can be delivered within 120 mins = PCI + unfractionated heparin + clopidogrel/praseguel
- If PCI cannot be delivered within 120 mins = fibrinolysis (streptokinase) + antithrombin + ticegralor
how do you manage a NSTEMI/unstable angina?
- MONA
- If immediate PCI is planned = PCI + unfractionated heparin
- If PCI not planned = fondaparinux
How do you manage a stroke?
300mg aspirin as soon as haemorrhagic stroke has been ruled out + thrombolysis (within 4.5hrs of onset of symptoms) +/- thrombectomy (within 6hrs - if large vessel stroke)
what is included for secondary prevention of stroke?
- if atherosclerosis is primary cause then continue aspirin for 2 weeks then lifelong clopidogrel + statin + hypertensive mx
- if cardioembolic is primary cause then NOAC (rivaroxaban etc) +/- hypertensive mx
How do you decide if someone with AF requires anticoagulation?
CHA2DS2VAS score.
- men = 1 or more point then anticoagulate
- women = 2 or more then anticoagulate
C = congestive heart failure (1) H = hypertension (1) A2 = Age 75 or more (2) D = diabetes (1) S2 = stroke/TIA (2) V = vascular disease (1) A = age 65-75 (1) S = sex - female (1)
what is Beck’s triad?
signs of tamponade
- raised JVP
- Hypotension
- muffled heart sounds
What are the types of aortic dissection and what is the managment of each?
Type A = ascending aorta and arch of aorta. Mx is aortic graft
Type B = descending aorta. Mx is conservative - BP control is key
pulsus paradoxicus
tamponade
drop in systolic BP with inspiration
what murmur is associated with dilated cardiomyopathy
mitral regurgitation
what murmur is strongly associated with rheumatic fever
mitral stenosis
describe the inheritance of hypertrophic cardiomyopathy
AD but 50% are sporadic
what is the investigation of choice for cardiomyopathy
echo
what is rheumatic fever and how does it present
illness that presents 2-4 weeks post group A beta haemolytic strep infection (usually pharyngitis)
Symptoms include arthritis, pericarditis, chorea, erythmea marginatum, subcutanous nodules
how do you manage rheumatic fever
- IV benzylpenicillin then 10 days of phenoxymethylpenicillin
- Manage presentation ie NSAIDs for arthritis, steroids for heart failure
what organisms cause endocarditis?
- staph aureus most common. If acute presentation or IVDU think staph aureus
- staph epidermidis. Prosthetic valve less than 2 months ago
- strep viridans. Post dental procedure
what antibiotics should be used in endocarditis?
Native valve = amoxicillin and gentamicin
Prosthetic valve = vancomycin and gentamicin
IVDU/staph = flucloxicillin
what investigations should be done for endocarditis
3x blood cultures, echo
what investigations should be done for heart failure?
- ECG
- BNP (if not raised then unlikely to be heart failure)
- echo
- CXR
what is the management for heart failure (non acute)
- ACEi + B-blocker
- spironolactone
- loop diuretic ie furosemide, ivabridine
what is an important differential in a young patient with chest pain
myocarditis
what is the most common cause of myocarditis
viral infection - often coxsackie
what is the gold standard investigation for myocarditis
endomyocardial biopsy via cardiac catheterisation is gold standard but comes with risks
also can do cardiac MI, ECG and troponins (will be high)
chest pain relieved on sitting forward
pericarditis
saddle shaped global ST elevation
pericarditis
what effect does hypocalcaemia have on the ECG
prolongs QT
what effect does hypercalcaemia have on the ECG
shortens QT
what effect does hypokalaemia have on the ECG
flattens T wave, U wave
what effect does hyperkalaemia have on the ECG
tall tented T wave
risk of treating hypernatraemia
to fast from high to low - the brain will blow (cerebral oedema)
risk of treating hyponatraemia
to fast from low to high the pontine will die (cerebral pontine demyelination)
what is the cause of congenital long QT sydrome
genetics -
AD - romano ward syndrome
AR - jervel and lang neilsen syndrome (associated with deafness
how does congenital long QT present
feinting, seizures, hearing loss (AR), sudden death, QT >480ms
how is congenital long QT managed
- avoidance of triggers, avoid QT prolonging drugs, b-blocker, ICD
what is a risk of congenital long QT
torsades de pointes
what are the types of congenital long QT
type 1 - triggers include strenuous exercise
type 2 - triggers include loud noises
how does Brugada syndrome present?
ST elevation and RBBB
VF
what are triggers for Brugada syndrome
fever, alcohol, large meals but can also be at rest
How do you diagnose Brugada syndrome
provocation test with flecainide
how do you manage Brugada syndrome
trigger avoidance
how does catecholaminergic polymorphic VT present?
bidirectional VT in children triggered by emotional stress or physical activity
how do you manage CPVT
ICD, flecainide, b blockers
what causes congenital short QT syndrome
mutation in cardiac K channels
how does congenital short QT present
AF in newborns, QT <300
how do you manage congenital short QT
ICD, quinine
what is the investigation of choice for aortic stenosis
echo
how do you manage aortic stenosis?
- symptomatic = valve replacement
- asymptomatic with valvular gradient >40 = valve replacement
- asymptomatic = monitor
what are the options for aortic valve replacement
- surgical = young fit adults
- transcatheter = high risk patients
- balloon valvoplasty = children or adults not fit for valve replacement
what is the investigation of choice for aortic dissection
trans oesophageal echo
which conditions are associated with heart failure with a preserved ejection fraction
hypertrophic cardiomyopathy and restrictive cardiomyopathy
which condition is associated with heart failure with a reduced ejection fraction
dilated cardiomyopathy
where are inhaled foreign bodies most likely to be found?
right main bronchus
at what size would a AAA warrant surgical repair?
5.5cm or growing more than 1cm per year
what is the management order for heart failure?
B - b/blockers A - Acei S - spironolactone H - hydralazine + nitrates e D - digoxin
symptoms of heart attack + markedly raised DDimers + normal troponin? what is the diagnosis and what is the key investigation for this condition>
Aortic dissection - CT aortic angio
