Cardiovascular

Question 1

ACS - Early Management

Answer 1

A-E assessment - baseline bloods including: clotting, troponins and cross match.

MONA: Morphine, Oxygen (if sats are low, think about giving anyway), Nitrates sublingual (3 x 5min intervals) (IV if no response) - check if hypotensive first. Aspirin - 300mg chewed.

STEMI - refer to cardiology for PCI
NSTEMI - calculate GRACE score if over 3% in 6m, raised trops or persistent pain, ST depression or diabetes then - semi-elective PCI w/in 48hrs

Clopidogrel 300mg and LMWH e.g. Enoxaparin 1mg/kg

Question 2

ACS - Long Term

Answer 2

Admit under cardiology
Daily U+Es and cardiac markers (2-3 days)
Asprin (for life) and Clopidogrel (for 1 year) 75mg od
Fondiparinoux 2.5mg SC od/Enoxaparin 1mg/kg SC daily
B-blocker, titrated so HR around 60bpm
Statin and ACE inhibitor started 48 hours after event
Address all modifiable RF
Start nitrates if angina
Discharge after 5-7 days.

Question 3

Stable Angina

Answer 3

Treat underlying problems and co-morbidities - manage risk factors w/ lifestyle advice.
GTN spray and B-blocker/CCB
Aspirin and Statin
ACEi if diabetes

Question 4

Risks of PTCA

Answer 4

Local dissection of the coronary artery
Acute coronary occlusion 
1% mortality risk 
2% AMI risk
Improves Sx but does not have prognostic benefit.

Question 5

Complications of CABG

Answer 5

MI
Bleeding 
Stroke 
Arrhythmia's 
Tamponade 
Aortic Dissection 
Respiratory/Systemic complications

Question 6

Pericarditis

Answer 6

High dose NSAIDS

Question 7

Constrictive Pericarditis

Answer 7

Excision of the whole pericardium

Question 8

Acute Pulmonary Oedema

Answer 8

Sit the patient upright and administer 100% oxygen
Administer 2.5mg of diamorphine
Sublingual nitrates if SBP above 90
IV furosemide 40-80mg
Consider IV nitrates if SBP over 100
If SBP under 100 treat as cardiogenic shock and alert ICU
- may need invasive ventilation

Question 9

ARDS

Answer 9

Sit patient up and administer 100% oxygen
NIPPV usually CPAP, most require mechanical ventilation.
IV nitrates titrated upwards until clinical improvement seen
IV furosemide
Morphine 10-20mg
Metoclopramide 10mg/IV
Aminophylline if bronchospasm present

Question 10

CCF

Answer 10

Lifestyle advice: Education, obesity control, diet modification, smoking cessation. Bed rest important after acute exacerbation. In all patients with compensated for CCF then low level endurance activity is recommended.

ACEi is first line with B-blocker introduced when stable.
Diuretic if symptomatic oedema
Spironolactone plus nitrates is second line
Digoxin third - used in refractory CCF = Sx at rest or if optimal triple therapy has not worked.

Question 11

Mitral Stenosis

Answer 11

Treat AF appropriately
Diuretics: reduce pre-load and pulmonary congestion
Surgery: Balloon valvuloplasty or open valvotomy if valve not viable.

Question 12

Mitral Stenosis Sx and signs

Answer 12

Sx - fatigue (due to reduced CO), orthopnoea, dyspnoea, haemoptysis, palpitations.

Signs - AF, malar flush, rumbling diastolic murmur with opening snap in left lateral position , displaced apex beat. Small volume pulse.

Question 13

Mitral regurgitation

Answer 13

Treat AF appropriately
Treat HF appropriately
Surgery if Sx are deteriorating to prevent irreversible LV damage.
- consider at NYHA grade 2

Question 14

Mitral Regurgitation Sx and Signs

Answer 14

Sx - fatigue (due to reduced CO), dyspnoea, orthopnoea, palpitations (AF and increased stroke volume).

Signs - AF, displaced apex beat due to LVH, pan-systolic murmur which radiates to the axilla.

Question 15

Tricuspid Regurgitation Sx and Signs

Answer 15

Sx - Fatigue, ascites/oedema.

Signs - grossly raised JVP, hepatomegaly, pan-systolic murmur best hear on inspiration

Question 16

Aortic Stenosis

Answer 16

Prompt valve replacement

Question 17

Aortic Stenosis Sx and Signs

Answer 17

Sx - syncope on exertion, SOB and angina

Signs - slow rising pulse and narrow pulse pressure, heaving apex beat and LVF. Ejection systolic murmur best heard at upper RSE, radiating to the carotids.

Question 18

Aortic Regurgitation

Answer 18

Prompt valve replacement before there is significant lV dysfunction.

Question 19

Aortic Regurgitation Sx and Signs

Answer 19

Sx - fatigue, SOB and palpitations - more likely to get LVF than any other murmur

Signs - collapsing pulse, wide pulse pressure, displaced apex beat. Early diastolic murmur, best head leaning forward at left LSE.
De Musset’s sign - head nodding
Quinke’s - capillary pulsation in nail bed
Pistol shot femorals - sharp bang heard in time with heart beat if femorals are auscultated.

Question 20

Infective Endocarditis

Answer 20

Consult microbiology early if suspected
Valvular incompetence and CCF
Glomerulonephritis

Question 21

Bradycardias

Answer 21

A-E and treat reversible cause
Assess for adverse features and risk of asystole
- adverse features: shock, syncope, HF, myocardial ischaemia
- Risk of asystole: recent asystole, mobitz type 2 or complete heart block.
if any of these are present, initiate treatment and seek senior advise.
- atropine 500mcg IV repeated up to a maximum of 3mg

Ventricular pacing will more often than not be required in the near future.

Question 22

Regular Narrow complex tachycardia

Acute and further prevention.

Answer 22

Vagal manoeuvres: e.g. Valsalva manoeuvre.
IV adenosine 6mg → 12mg → 12mg
Beta blocker

Prevention of episodes:
beta-blockers
radio-frequency ablation

Question 23

Broad complex Tachycardias
VT
AF w/ bundle branch block
Polymorphic VT

Answer 23

If regular then assume VT
Amiodarone 300mg IV over 20mins and then 900mg 24hr infusion
aF

AF with bundle branch block - treat as narrow complex

Polymorphic VT is treated with Magnesium Sulphate over 10mins, 2g.

If previously diagnosed SVT with bundle branch block then treat as per narrow complex.

People who are prone to VT/VF are often fitted with internal cardiac defibrillators.