cardiovascular Flashcards
MI/ACS:
- most common cause?
- non-modifiable risk factors? 3
- modifiable risk factors? 8
rupture/erosion of the fibrous cap of atheromatous plaque in coronary artery -> platelet-rich clot + vasoconstriction produced by platelet release of serotonin + thromboxane
nb can rarely be dt vasospasms or vasculitis
- older age
- male
- FH (1st degree relative had IHD <50)
- hyperlipidaemia
- hypertension
- metabolic conditions (diabetes)
- poor diet
- lack of exercise
- stress/depression
- smoking
- cocaine use
MI/ACS:
- symptoms? 8
- what is a silent MI?
- who is most likely to get a silent MI? 2
- acute central chest pain (>20 mins)
- pain in L arm, jaw or back
- anxiety (impending doom)
- fatigue
- nausea
- sweatiness
- palpatations
- SOB
MI presents without chest pain
- elderly
- diabetics
MI/ACS:
- signs? 3
nb history often more important!
- pale/grey
- sweaty (can’t fake!)
- high pulse
nb may be signs of heart failure (^JVP, , 3rd heart sound, basal crepitus)
nb may also hear pericardial rub
MI/ACS:
- bloods? 5
- other investigations? 1
- troponin
nb creatinine Kinase -MB rarely used now - FBC
- U+Es
- glucose
- lipids
- ECG (ST elevation or new LBBB)
nb in 20% of ACS, ECG is normal initially!
can do CXR to exclude differentials but don’t delay treatment to do!
MI/ACS:
- initial pharm treatment? 7 (acronym)
- treatment for STEMI? 2
BROMANCE
- beta-blockers
- reassurance
- oxygen
- morphine (IV)
- aspirin
- nitrates (GTN)
- clopidogrel
- antiEmetics (eg metoclopramide)
(nb sometimes give a NOAC as well for VTE prophylaxis)
nb don’t give B blockers if:
- bradycardiac
- hypotensive
- heart failure
- asthmatic
- fibrinolytics (rTPA)
- PCI surgery
MI/ACS
- long-term pharm treatments? 5
- long-term non-pharm treatments? 4
- aspirin
- clopidogrel
- statin
- B blocker (norm metoprolol)
- ACE inhibitor
- more exercise
- control diabetes (if relevant)
- better diet
- stop smoking
differential diagnosies for MI/ACS:
- cardiovascular? 5
- resp? 2
- GI? 3
- other? 1
- angina
- pericarditis
- myocarditis
- aortic dissection
- PE
- pneumonia
- pneumothorax
- oesophageal spasm
- GORD
- acute pancreatitis
- MSK pain
Angina pectoris:
- three types?
- pathophysiology?
- stable angina
- unstable angina
- prinzmetal (variant) angina
normally atheroma -> reduced O2 supply to heart muscle -> pain
(other rarer causes)
variant angina = spasms in coronary artery
Angina pectoris:
- modifiable risk factors? 4
- unmodifiable risk factors? 6
- high fat diet
- smoking
- lack of exercise
- psychological stress
- age
- male
- FH (IHD <50yrs)
- diabetes
- hypertension
- elevated CRP
Angina pectoris:
- three features of stable angina (according to NICE)?
- triggers for stable angina, bar physical exertion? 3
- associated symptoms? 4
- constricting discomfort in:
- – front of chest
- – neck
- – shoulders
- – jaw
- – arms
- precipitated by physical exertion
- relieved by rest or GTN within about 5 mins
- emotion
- cold weather
- heavy meals
- dyspnoea
- nausea
- sweating
- light-headedness
Angina pectoris:
- symptoms that make diagnosis of stable angina unlikely? 5
- continuous or very prolonged pain
- pain unrelated to exertion/other triggers
- pain brought on by breathing
- pain associated with dizziness
- pain associated with palpitations, tingling or difficulty swallowing
Angina pectoris:
- ECG changes? 3
- pathological Q waves (in particular)
- LBBB
- ST- segment + T-wave abnormalities (eg ST-segment depression, T-wave flattening or inversion)
a normal ECG does not confirm or exclude angine!
Angina pectoris:
- non-pharm management? 3
- pharm management? 4
- stop smoking
- loose weight
- more exercise
- GTN spray (contraindicated w Viagra)
(- consider long-acting nitrate) - Beta-blocker (or Ca channel blocker)
- Aspirin
- Statin (if high chol)
nb can give K+ channel activator (eg nicorandil) if unresponsive
nb get diabetes and HTN under control too
nb consider surgery if bad
Angina pectoris differentials:
- CVS? 7
- Resp? 3
- GI? 4
- MSK? 4
- psych? 1
CVS
- MI
- unstable angina
- prinzmetal angina
- dissecting thoracic aneurysm
- pericarditis
- acute HF
- arrhythmias
Resp
- PE
- pneumothorax
- pneumonia
GI
- peptic ulcer
- ruptured oesophagus (boerhaves*)
- GORD
- pancreatitis
MSK
- costochondritis
- rib fracture
- arthritis
- pulled muscle
Psych
- anxiety/panic attack
AF
- commonest causes? 4
- other causes?
- what percentage are idiopathic (‘lone AF’)?
common:
- IHD (+/ MI or heart failure)
- HTN
- valvar heart disease
- hyperthyroidism
other:
- congenital heart disease
- caffeine/alcohol/stimulants
- sick sinus syndrome
- wolf-parkinson white
- acute infection (e.g. pneumonia)
- PE
- low K or Mg
10% are idiopathic
AF:
- risk factors? 3
- excessive alcohol + caffeine intake
- obesity
- age
AF:
- symptoms? 4
- signs? 1
- palpitations
- chest pain/dyscomfort
- dyspnoea
- faintness
nb often asymptomatic
- irregularly irregular pulse
nb if caused by valve disease then will hear a murmur (nb often mitral valve disease)
AF:
- bloods? 3
- other test needed? 1
- findings on other test? 2
- U&E
- troponin
- thyroid function test
- ECG
- absent P waves
- irregular QRS complexes
nb consider echo to look for structural abnormalities
AF:
- three TYPES of treatment?
- outline above treatment and which patients each would be suitable for
1) treat underlying cause
- suitable for:
- – acute precipitating event (alcohol toxicity, infection, hyperthyroidism)
2) Rhythm control
- suitable for:
- – younger patients (<65)
- – highly symptomatic
- – concurrent CCF
- – recent onset AF (<48hrs)
- how:
- – echo (TOE) to check for thrombus, treat with lmwh or warfarin prior to cardioversion (4 wks if thrombus found or >48hrs after start of AF)
- – pharmacological or electrical cardioversion
Rate control: - suitable for: --- older patients (>65) --- previous cardio version failure - how: --- Warfarin (or dabigitran) --- Beta blocker (or rate-limiting Ca channel blocker) (--- if fails, add amiodarone or digoxin)
AF:
- differential diagnoses? 6
- atrial flutter* (sawtooth pattern)
- atrial extra systoles
- ventricular ectopic beats
- sinus tachycardia
- supra ventricular tachycardia
- wolf-parkinson white
Essential Hypertension:
- systolic/diastolic definition of high BP?
- % prevalence in 45-54 yo?
- % prevalence in over 75s?
- % that is actually secondary to another condition (e.g. conn’s syndrome)
over 140/90mmHg
- 30% of 45-54 yo
- 70% of over 75s
5% is secondary
Essential Hypertension:
- non-modifiable risk factors? 3
- modifiable risk factors? 4
- afrocarribean ethnicity
- increased age
- FH
- diabetes
- obesity
- high salt intake
- high alcohol intake
- smoking
Essential HTN:
- bedside tests/investigations? 3
- blood tests? 3
- BP (incl 24-hr BP monitor)
- fundoscopy (hypertensive retinopathy)
- urine dipstick (protein)
nb can also do an ECG (looking for LVH or myocardial ischaemia) or possibly even an echo
nb on cardio exam may find LV heave or artery bruits
- blood cholesterol
- fasting glucose
- U&E (see kidney damage)
Essential HTN:
- non-pharm management? 6
- pharm control for all? 1
- 1st line drug for <55 yo?
- 1st line drug for >55 yo + black ethnicity of any age?
- weight loss
- exercise
- low fat diet
- reduce salt intake
- reduce alcohol intake
- stop smoking
- statin (also diabetes control if relevant)
<55 yo
- ACE inhibitor (or ARB if hate cough)
> 55 yo or black
- Ca channel blocker (or thiazide diuretic)
DVT:
- Risk factors? 10
- increased age
- obesity
- past DVT
- pregnancy
- synthetic oestrogen
- trauma
- surgery (esp pelvic or orthopaedic)
- immobility
- cancer
- thrombophilia
DVT:
- symptoms + signs
- scoring system used?
- blood test?
- imaging?
- red
- painful
- swollen
- hot
must be UNILATERAL
- WELLS
- D-dimer (very sensitive, not specific)
(- nb could do specific bloods if suspect thrombophilia) - ultrasound of leg
DVT:
- treatment?
- prevention? 3
- high dose LMWH
- or high dose LMWH with warfarin then take LMWH off
(nb warfarin is pro-thrombotic for first 48hrs)
- low dose LMWH
- TED stockings
- stay mobile
DVT:
- infectious differential diagnoses? 3
- other DD? 4
- cellulitis
- superficial thrombophlebitis
- insect bite
- ruptured baker’s cyst
- sprain/rupture achilles tendon
- physical trauma (imvl haematoma)
- peripheral (stasis) oedema (or lymphedema)
nb other rarer causes (e.g. compartment syndrome)
Common causes of heart failure:
- Right-sided? 4
- Left-sided? 4
Right-sided
- LVF
- pulmonary stenosis
- Right ventricular MI
- lung disease (cor pulmonate)
Left-sided
- Left-ventricular MI
- hypertension
- aortic stenosis
- mitral or aortic regurg
nb CCF = right AND left failure
nb rare causes include steroids, come chemo, cocaine and other stuff
Signs + symptoms of heart failure:
- Right-sided? 6
- Lef-sided? 10
Right-sided
- peripheral oedema
- ascites
- nausea
- anorexia
- pulsation in neck + face (RHF -> tricuspid regurg)
- murmur (+/or 3rd ‘gallop’ heart sound)
Left-sided
- fatigue
- wheeze (cardiac ‘asthma’)
- SOB
- poor exercise tolerance
- displaced apex beat
- cold peripheries
- nocturnal cough (+/- pink frothy sputum)
- orthopnoea
- paroxysmal nocturnal dyspnoea (PND)
- nocturia
nb think logically about the back-up of fluid when each side of the heart has failed
Heart failure:
- blood tests?
- other investigations? (and what they show)
- BNP
- FBC
- U&E
(- LFT, may cause hepatic-congestion) - ECG (indicate cause)
- CXR (ABCDE)
- – Alveolar oedema (bat wing shadow)
- Kerley B lines (interstitial oedema)
- – Cardiomegaly (heart width >50%)
- – Dilated prominent upper lobe vessels
- – pleural Effusion (blunting of angles)
- Echocardiogram
- – valvular defects, previous MI, ejection fraction, hypertrophy etc
Heart failure differential diagnoses:
- conditions causing dyspnoea? 5
- conditions causing peripheral oedema? 6
dyspnoea DD:
- COPD
- asthma
- PE
- lung cancer
- anxiety
peripheral oedema DD:
- prolonged inactivity
- venous insufficiency
- nephrotic syndrome
- hypoalbuminaemia
- some drugs (some Ca channel blockers, NSAIDs)
- obesity
