Cardiovascular Flashcards
Define stable angina
Pain brought on by exercise/emotion and relieved by rest, -ve troponins and no changes on ECG.
Define unstable angina
Pain comes at rest or unpredictable intervals, -ve troponins and no changes on ECG.
NSTEMI definition
+ve troponins, no ST elevation
STEMI definition
+ve troponins, ST elevation
Key History questions (in addition to normal history SOCRATES, exploring sx etc.)
- Onset, aetiology, presentation, previous treatment, investigations, complications, progression, recovery (ORTICPR)
- Risk Factors (previous IHD, hyperlipidaemia, DM, HTN, FHx, Smocking, COPD, Obestity/inactivity)
- Previous/current treatments and ?effectiveness
Examination for Ischemic Heart Disease + findings
- Vital signs
- Signs of valvular heart disease (↑WOB/RR, arrythmias, oedema, murmur, Abdo pain, hepatomegaly)
- Signs of cardiac failure (↑WOB/RR, rapid or irregular HR, elevated JVP, murmur/lung oedema, peripheral oedema, weight gain, hair loss, hepatomegaly)
`- If diabetic/HTN: Optic fundi for retinal changes
DDx for ischemic heart disease
GORD, PE, Oesophageal spasm, MSK, Cardio/resp
Ischemic Heart Disease Ix
- ECG (compare old and current for changes)
- Troponins (note they don’t rise until ~6hr after MI and so repear troponins usually done after this to ensure MI not missed. Can remain elevated for 2 weeks)
- ETT (to stimulate ischaemia if needed)
- ECHO (to look for valvular pathology and heart function)
- Angiogram
Stable angina mangement
GTN (careful with sildenafil/viagra)
- can add beta blocker
Unstable angina mangement
Aspirin, GTN, statin, consider beta blockers or ca channel blocker. Basically all of the secondary prevention - consider angiogram +/- angioplasty
STEMI mangement
- Morphine, oxygen, GTN/IV nitroglycerin, aspirin, heparin, metoclopramide
- Consider ACEi and beta blockers
- Admit to CCU for continuous ECG
- PCI/angioplasty (<90mins)
o If not offered, transfer preferred over thrombolysis if transport time 2-3hrs
o Reduced mortality compared with thrombolysis
o Can’t do if previous bypass - Thrombolysis (converts plasminogen to plasmin, initiating fibrolysis)
o <85y/o, IV Tenecteplase
o >/=85y/o Streptokinase
NSTEMI mangement
- Morphine, oxygen, GTN/IV nitroglycerin, aspirin, heparin, metoclopramide
- Consider ACEi and beta blockers
- Admit to CCU for continuous ECG
- Early revascularisation, not as urgent (up to 24hrs after MI)
MI complications
- Arrythmias, Bradycardia, Heart failure, ventricular aneurysm, cardiogenic shock, ventricular free wall rupture, pericarditis, dressler syndrome, MR
IDH secondary prevention
Non-pharmacological – diet, physical activety, smoking cessation, cardiac rehab program
Pharmacological – BP lowering, Statins, antiplatelet, anti-anginal (beta-blocker, diltiazem, nitrates)
Surgical – CABG (pts with 3xvessel disease), not done acutely unless angioplasty/thrombolysis fail
Definition of infective endocarditis
Fever + new murmur = infective endocarditis until proven otherwise
ID notes
- Valves don’t have their own dedicated blood supply so when bacteria attach there no wcc get there to clean them away.
- IE higher risk if valve damaged (Rh heart)
- Most commonly strep viridans
- Caused by bactermia
- Prophylactic Abx for medical/dental procedures no longer recommended as bacteria enter our blood stream all the time
Infective endocarditis Hx
Presenting sx: acute heart failure, fever, fatigue and maybe sx suggesting embolic phenomena to large vessels (stroke, gangrene)
Risk factors = recent dental, endoscopic or operative procedures, valve disease, prosthetic valves, past rheumatic fever, heart disease/operations, IV drug use, immunosuppression
Infective endocarditis exam
Hands - Clubbing, splinter haemorrhages, Osler nodes (painful red), Janeway lesions (non-tender, tiny, red palms)
Eyes - Roth spots (red haemorrhage w white centre)
Neuro - Signs of peripheral embolic disease forming abcess (but embolic abscesses can form in almost any organ)
Heart - Listen for new or changed murmur. Most often vegetations cause regurgitation (commonly mitral)
Signs of cardiac failure and infection (look for source)
Infective endocarditis diagnosis
Dukes Criteria
2 major criteria OR 1 major + three minor OR 5 minor
Major criteria
1. Typical organism on 2x blood cultures
2. Evidence of endocardiac involvement on ECHO – vegetation, abscess or new regurgitation
Minor Criteria
1. Predisposing cardiac conditions on IV drug use
2. Fever >38˚
3. Vascular phenomena or stigmata
4. Positive blood culture that does not meet major criteria
5. ECHO abnormal but not meeting above criteria
Infective Endocarditis DDx
- Rheumatic fever
- Atrial myxoma (cardiac tumour)
- Other cardiac neoplasm
- SLE
infective endocarditis Ix
Bloods
- Cultures: strep veridans (penicillin) and staph aureus (flucloxacillin) predominantly
Must have 3 sets of peripheral blood cultures before antibiotic administration
- FBC (raised neutrophils) and ESR (high)
Imaging
- CXR (heart failure, cardiomagly)
- ECHO (vegetations, regurgitation or access), TOE is more sensitive
Other
- MSU: looking for haematuria (from emboli)
IE Tx
- IV empirical antibiotics = vancomycin and ceftriaxone
- IV Abx dependent on the organisms sensitivities, at least 4 weeks but 6-8 if prosthetic valves
- Consider cardiac surgery e.g. valve replacement (if severe heart failure, valvular obstruction, abscess)
- Consider antibiotic prophylaxis (high dose, short term) for future medical/dental procedures – but this is controversial
Heart failure
Heart unable to pump sufficiently to meet the bodies requirements. Not a diagnosis, but rather the clinical manifestation of many underlying, progressive forms of heart disease.
When heart not getting enough O2 to organs then compensate by increase HR, increase muscle mass, increase blood volume and work of pump.
Heart Failure Classifications
- Left vs. right
- Acute vs. chronic
- Low output (heart problem) vs high output (O2 demand to high)
- Reduced EF/systolic (EF <50%) vs preserved/EF/diastolic
