Cardiovasc Flashcards
Chest pain - probability diagnosis?
- Psychogenic
- Musculoskeletal
- Angina
AMI - management
Management
o Oxygen – now only indicated if Sa02 <95%
o Aspirin
o GTN 300mcg SL or spray (every 5/60 as necessary up to 3 doses) – be aware of Viagra
o IV access
o IV morphine 2-5mg bolum; 1mg/min until pain relief up to 15mg
o ECG – key is to classify ACS into STEMI or non-STEMI
Key management of STEMI will be to get a patient to a Cath lab for PTCA ideally within an 1 hour of chest pain (if not possible e.g. rural locations thrombolysis is indicated if no CI’s exist)
Post AMI complications to be weary of are: CCF; pericarditis; LV aneurysm; Ventricular septal and mitral valve papillary rupture
Pericarditis - Presenting symptoms
- Can cause 3 types of pain – pleuritic (commonest) – often worse with lying flat, pain mimicking AMI, pain synchronous with heart beat and radiating to left shoulder
- O/E – fever, Signs of tamponade
Pericarditis - Investigations and Mx
- ECG – PR depression, diffuse saddle shaped STE
- Echo – can detect effusions, tamponate
- Cardiac CT – can show pericardial thickness
- Bloods including inflammatory markers are useful
Management – treat underlying cause, NSAIDS, rest
Aortic Dissection - Presenting picture
- Sudden severe midline chest pain – tearing in nature; may be interscapula
- Associated PMhx: Aortic valve disease, Hypertension, Pregnancy, Genetics – Marfans, Ehlers-Danlos
Examination Findings:
- BP (may be high, low or normal)
- Asymmetric pulses
- Signs of tamponade – hypotension, quiet HS, raised JVP, pulsus paradoxus; pericardial friction rub
- Systolic murmur – AR (incompetence)
- Ischaemic neurological deficits – hemiplegia, hemiparesis
Aortic Dissection - Ix and Management
Investigations
- CXR – screening test
- TTE or helical CT for diagnosis
- ECG findings – may mimic AMI findings
Management - Surgery
Respiratory causes of Chest Pain
- PE
- Lung Cancer
- Pneumonia
- Pleuritis – can be due to infection, pulmonary infarction, tumour, connective tissue disorders
Spontaneous Pneumothorax - when to suspect? Hx/Ex/Ix/Mx?
- Suspect in those with history of – Asthma or COPD and young slender males
- O/E – tachycardia, Decreased breath sounds
- Diagnosis is made on CXR – expiratory films
- Management - <25%, no symptoms – can observe, if symptoms drain, >25%. drain
CP caused by cox-sackie virus (faecal oral route)
Epidemic Pleuordynia
- Occurs in epidemics and mainly affects children and young adults
- Causes chest/upper abdominal pain – often pleuritic in nature, as well as myalgia elsewhere
- Diagnosis of exclusion
- Management is analgesia
What are features of Chostocondritis?
- Often precedes an URTI
Often one sided, sharp and made worse with breathing, physical activity and palpation
Unilateral sharp pleuritic chest pain with a tender, fusiform swelling at the chndrosternal junction?
Tietze Syndrome
Cause is not well understood – may relate to physical strain or minor injury
Seven masquerades for Chest pain?
- Depression
- Drugs
- Diabetes x
- Anaemia - indirectly
- Thyroid dysfunction x
- Spinal dysfunction - referred pain from facet joints rather than nerve root pain
- UTI x
Chest pain in Children? Most common causes?
Most common cause – idiopathic followed by musculoskeletal, cough related, costochondritis and psychogenic
– low chest pain lasting 30s-3mins after exercise – relieved by standing up right and taking slow deep breaths
Precordial Catch aka Texidor twinge or stitch
AF - epidemiology?
AF affects 1% of the Australian Population >50% are over 75
RR of stroke is increased by 5x and 3x increased risk of CCF
AF - Risk factors?
- Structural e.g. valvular abnormalities, cardiomyopathy
- Conduction e.g sick sinus syndrome, WPW
- Functional e.g AMI, pericarditis
- Stress on the heart e.g. IHD, hypertension, PE
- Physiologic/Hyperadrenergic states – medications and drugs, stress, fever, hyperthyroidism
AF - Categories?
- Paroxysmal (usually <48 hours) - 90% have recurrent episodes
- Persistent >7 days
- Permanent >1 year
- Lone (without evidence of structural disease)
AF - History?
- Palpitations
- SOB
- Lightheadedness/syncopal episodes
- Focal neurological deficit
- PMhx
- Meds and drugs – e.g. alcohol, caffeine, illicit drugs
AF - Examination findings
- Vitals- Pulse irregularly irregular, BP to check for decompensation, fever as potential cause
- HS – listen for murmurs – valvular abnormalitites
- Chest – if CCF bibasal crackles, peripheral oedema, JVP raised
AF - Investigations
• ECG
- Absence of p-waves
- Irregular RR intervals
• Echo
- TOE or TTE
- TOE used to exclude left atrial appendage thrombus
Bloods • FBE • UEC • LFT • TSH • Ca/Mg • Fasting glucose • Fasting lipid profile
• CXR – check for CCF
Acute management AF
In patients without CCF and without pre-excitation:
- Metoprolol 2.5-5mg IV over 2/60, up to 3 doses OR
- Verapamil 0.075-0.15 mg/kg IV over 2/60
In patients with CCF and without pre-excitation – IV digoxin or IV amiodarone
In patients with pre-excitation – IV amiodarone
AF - Rate control
- Beta blocker – e.g. metoprolol 50-200mg/day OR
- Non-dihydropyridine calcium channel blocker – e.g. diltiazem or verapamil
- Digoxin – indicated for rate control in patients with CCF, LV dysfunction or sedentary individuals
- Oral amiodarone – may be indicated when other medical therapies fail
- Ablation of AV node or accessory pathways – may be indicated if medical therapies fail
AF - Rhythm control?
Rate control preferred – only do if the above measures fail
DC Cardioversion
Recommended if rapid ventricular rate unresponsive to medications and myocardial ischaemia or hypotension or heart failure
If <48 hours of known duration of AF can do without delay for anticoagulation
If >48 hours or of unknown duration – either 3/52 anti-coagulation INR 2-3 OR initial anticoagulation, TOE to confirm no atrial thrombus, then cardioversion within 24 hours
Pharmacologic Cardioversion options include flecainide, amiodarone
How do you decide anti-coagualtion for AF?
Determined by the CHA2DS2-VA Condition and Points C Congestive heart failure (or Left ventricular systolic dysfunction) 1 H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) 1 A2 Age ≥75 years 2 D Diabetes Mellitus 1 S2 Prior Stroke or TIA or thromboembolism 2 V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque) 1 A Age 65–74 years 1
0 - low risk - no therapy or low dose aspirin
1 - moderate risk – benefit from warfarin/anticoagulation
>/= 2 points - high risk and long term oral anticoagulant therapy is strongly recommended
CHADS 2 score Annual stroke rate 0 1.9 % 2 4% 4 8.5% 6 18%
Other relevant factors
Echo findings - systolic dysfunction and left atrial enlargement
Vascular factors - previous MI, PVD, complex aortic plaque
Risk Mitigation for AF Anticoagulation
Looks at risk of major bleeding whilst on oral anticoagulant treatment
Risk of major bleeding is at least 1-1.5% annually
HAS-BLED
• Helps identify correctable RF’s for bleeding and identify patients at high risk
• It should not be used to exclude patients from anticoagulant treatment but rather serve to indicate increased monitoring
• Correctable RF’s should be managed
Hypertension (Sytolic BP >160mmHg) Abnormal renal or liver function Stroke (history of) Bleeding (Hx of or diathesis) Labile INRS (<6/10 in therapeutic range) Elderly (>65) Drugs (antiplatelet agents, NSAIDS, alcohol >/= 8 SD per week)
Anticoagulation in AF
Warfarin or novel anticoagulants (target thrombin directly)
Warfarin in AF
Its used in valvular AF - mod/sev mitral STENOSIS or mechanical heart valve. Otherwise use a NOAC
Reduces the incidence of AF related stroke by about 2/3rds
Which novel anticogulants are available? When are they used? What dosage?
Rivaroxaban
Dose is 20mg daily – reduce to 15mg OD if CrCl 30-49
PBS approved for:
• Preventions of stroke and systemic embolism in non-valvular AF and at least one additional risk factor as defined by the CHADS2 score
• Prevention of venous thromboembolism after THR or TKR surgery
• Treatment of acute PE; DVT or prevention of venous thromboembolism recurrence in people with a history of VTE
- Bleeding risk less than or equal to that of warfarin
- No antidote - unlike warfarin
- Not to be used in patients with hepatic disease, increased INR, severe renal impairment
Pradaxa (Dabigatran)
150mg BD; Dose reduction to 110mg BD for age >/=75, CrCl 30-50, higher risk of bleeding
PBS approved for:
• Preventions of stroke and systemic embolism in non-valvular AF and at least one additional risk factor as defined by the CHADS2 score
• Prevention of venous thromboembolism after THR or TKR surgery
• Treatment of acute PE; DVT or prevention of venous thromboembolism recurrence in people with a history of VTE
Eliquis (Apixaban)
• Requires BD dosing – either 2.5mg BD or 5mg BD
• Dose reduction for Age >/= 80; bodyweight = 60kg; Serum Cr >/= 133
• CI – Severe hepatic disease (Child-Pugh C); severe renal impairment CrCl <25; strong clinical risk of bleeding
PBS approved for:
• Preventions of stroke and systemic embolism in non-valvular AF and at least one additional risk factor as defined by the CHADS2 score
• Prevention of venous thromboembolism after THR or TKR surgery
*In comparative trials only apixaban was found to have a lower incidence of major bleeds c.f. warfarin
Switching anticoagulants in AF?
Stop Warfarin
Commence new anticoagulant once INR <2
