Cardiovascular Flashcards
What are the three main types of acute coronary syndrome?
- Unstable angina.
- STEMI.
- NSTEMI.
How are acute coronary syndromes classified?
- ST elevated? STEMI.
- ST not elevated? NSTEMI or unstable angina.
If non-ST elevated:
Troponin raised? NSTEMI.
Troponin normal? unstable angina.
What is the clinical presentation of acute coronary syndromes?
- Acute onset, crushing chest pain radiating to arm/shoulder.
- Nausea/vomiting.
- Sweating.
- Breathlessness.
What is the difference between stable and unstable angina?
- Unstable angina occurs at rest/ during extremely light exercise.
- Stable angina occurs under exertion, and resolve with rest.
What is are the risk factors for acute coronary syndrome?
- Hypertension.
- Diabetes.
- Obesity.
- Old age.
- Smoking.
- Hyperlipidemia (high cholesterol/LDL).
- Raised GFR (kidney disease).
What is the pathophysiology of acute coronary syndrome? (Thrombosis)
ACS involves formation of a thrombus within the coronary vessels:
1) Injury to endothelial wall of vessel.
2) Exposes collagen, triggering the intrinsic pathway.
3) Clotting factors released (coagulation cascade) and platelets aggregate at the site of injury.
4) Thrombus forms, containing: RBC’s, platelets, neutrophils and is surrounded by a fibrin mesh.
If the thrombus is fully occlusive, this will cause an MI.
If the thrombus is partially occlusive, this will cause unstable angina.
What are the investigations used for ACS?
12 lead ECG as soon as suspected ACS:
- ST elevation suggests STEMI.
Troponin testing:
- Raised troponin suggests MI (with ST elevation = STEMI, without ST elevation = NSTEMI).
- Normal troponin + normal ECG suggestive of unstable angina.
What is the initial treatment as soon as ACS suspected?
- Initial loading dose of aspirin.
- GTN to relieve symptoms (morphine if required).
- O2 if O2 sats are <90%.
What is the treatment immediately after ACS confirmed?
- PCI/CABG.
(In the case of STEMI, PCI should be urgently carried out within 2 hours). - If PCI/CABG not possible, use altepase (a thrombolytic).
- Commence dual antiplatelet therapy (clopidogrel/prasugrel + aspirin).
DON’T ADMINISTER P2Y12 INHIBITOR IF IMMEDIATELY HAVING PCI/CABG - THIS WILL BE DONE IN THEATRE.
What is the long term management of ACS?
FOR ALL ACS:
- B blocker (bisoprolol).
- Dual antiplatelet therapy (aspirin + clopidogrel).
- Statin (atorvastatin).
FOR MI (STEMI OR NSTEMI): - ACEI (ramapril) or ARB 2nd line (losartan).
FOR UNSTABLE ANGINA:
- GTN for any future episodes of angina.
- ACEI (ramapril) ONLY IF: DIABETIC, CKD OR HEART FAILURE PRESENT.
What is stable angina?
- A form of ischaemic heart disease.
- Angina that occurs on exertion, and is relieved by rest.
What is the clinical presentation of STABLE angina?
- Substernal pain (in some cases can radiate to the jaw/neck).
- PROVOKED BY EXERCISE/EMOTIONAL STRESS.
- RELIEVED BY REST/GTN.
What are the risk factors for stable angina?
- Old age.
- Smoking.
- Obesity.
- Diabetes.
- Hypertension.
- Male.
- Raised LDL.
What is the pathophysiology of stable angina?
- Development of lipid-dense plaques in the arterial wall.
- The plaques cause stenosis.
When 70-80% stenosis is achieved, stable angina may occur.
What are the investigations used for stable angina?
- Ensure the condition is stable.
Then:
- ECG is 1st line. Usually normal (>50%) but sometimes will be abnormal and give clues to pathological cause.
- EchoCG is GS, but not always used.
- Lipid profile (check for hyperlipidemia).
- Haemoglobin (check for anaemia which can cause angina symptoms).
What is the treatment for stable angina?
- Low dose aspirin.
- GTN to relieve symptoms.
- Statin (atorvastatin) to lower LDL.
- B blocker (bisoprolol) /ACEI (ramapril) to control BP.
What is the major complication of angina?
- MI.
What is the definition of heart failure?
The heart is unable to pump enough blood around the body to meet demands for blood and oxygen.
What is the definition of congestive heart failure?
- Heart failure with breathlessness and oedema (due to increased sodium and water levels).
What is the clinical presentation of congestive heart failure?
- Dyspnoea.
- Tachycardia.
- S3 gallop.
- Cardiomegaly.
- Rales (“rattling heart”).
- Ankle oedema.
What are the risk factors for congestive heart failure?
- Hypertension.
- Male.
- Diabetes mellitus.
- Dyslipidemia.
- Old age.
- Obesity.
- LV dysfunction/hypertrophy.
- AF.
What is the pathophysiology of congestive heart failure?
A chronic condition. Usually associated with LV remodelling due to conditions such as: - MI - Cardiomyopathy (e.g. hypertrophic). - Pulmonary hypertension. - Valvular heart disease.
What are the investigations used for congestive heart failure?
ECG - Signs may be suggestive of underlying pathology (e.g. left axis deviation suggests LVH).
EchoCG. Can detect things like LVH (Diastolic heart failure) or Left ventricular dilation (systolic heart failure). Can also detect valvular heart diseases.
CXR - “ABCDE”. Alveolar oedema (Bat wings), Kerley B lines, Cardiomegaly, Dilated upper lobe vessels, Pleural effusion.
BNP - Increases in heart failure.
What is the treatment for congestive heart failure?
- Lifestyle changes (increased exercise, better diet, weight loss etc.).
- Loop diuretics (e.g. furosemide).
- ACEI (ramapril) + B-blocker (bisoprolol).
If ACE not tolerated, ARB (losartan).
What are the main complications of congestive heart failure?
- Pleural effusion.
- AKI (contributed to by the use of loop diuretics/ACEI).
What is the mnemonic to remember the ECG changes seen in hyperkalaemia?
“Go, go wide, go tall, go long”
- Small/absent P wave
- Wide QRS complex
- Tall tented T waves
- Long PR interval
What is acute heart failure?
- Rapid onset/worsening of heart failure symptoms requiring urgent evaluation and treatment.
What is the presentation of acute heart failure?
- Dyspnoea.
- Ankle oedema.
- Raised JVP.
- Fatigue.
- Heart gallop (S3).
- Cold extremities.
What are the risk factors for acute heart failure?
- Hypertension.
- Old age.
- Diabetes mellitus.
- Smoking.
- Arrhythmia (most commonly AF).
What are the investigations used in acute heart failure?
ECG. Usually abnormal (e.g. arrhythmia shown).
CXR. “ABCDE”
BNP. Raised.
EchoCG. Will show underlying pathology, and allow measurement of the LVEF (key for management).