Cardiovascular Conditions Flashcards
55 y/o bus driver is found to have a sustained BP of 174/106mmHg after several readings. He is asymptomatic. 10 years ago he suffered an attack of gout.
BMI of 29. Drinks 21 units of alcohol/wk. Smokes 20 cigarettes a day, does not exercise. Takes regular ibuprofen 3x daily for arthritic hip pain.
Investigations are unremarkable, except high plasma urate & raised ALT.
What is your management & why?
Advise: weight loss, smoking cessation, reduce high purine foods, stop aspiring & replace with paracetamol.
Consider secondary causes, e.g. Cushings/Conns/Phaeochromocytoma.
Do not use diuretics due to gout risk.
Possibly try Losartan + calcium channel blocker.
23 y/o recently married female secretary found to have high BP when attending GP complaining of headaches.
Non-smoker, not on contraceptive pill. No FHx of cardiovascular disease or diabetes. Eats takeaway meals & crisps with her husband, daily salt intake >9g/day. BMI = 32.
Serial BP readings: 148/96mmHg.
Management & why?
ABPM to confirm.
Check fundus, investigate for secondary causes including fibromuscular dysplasia.
Dietary changes are required, e.g. salt. Advise weight loss & review in 3-6 months. If still hypertensive, consider treatment.
Avoid ACEI/ARB due to teratogenicity. Start with labetalol, nifedipine later. If reliable contraception & made aware of teratogenicity, document & option to initiate ACEI/ARB. Pregnancy requires close monitoring.
74 y/o asthmatic male found to have systolic hypertension when he visits GP complaining of swollen ankles.
Previous MI at 64. MAP: 210/78mmHg. No medications, stopped smoking after MI & drinks minimal alcohol.
Total plasma cholesterol concentration = 6.4mmol/l, LDL = 3.4mmol/L & Triglyceride = 2.8mmol/L.
Management & why?
ECHO & 24hr ABPM. Start secondary prevention meds: aspirin/statin/ACEI +/- loop diuretic.
Avoid beta-blockers in asthma.
45 y/o male found to have BP of 172/102mmHg during medical for private pilot’s licence. GP repeats, falls to mean of 154/98mmHg.
ECG shows LV hypertrophy. Urine contains raised microalbumin. Blood glucose is high, & further tests confirm diabetes mellitus.
Management & why?
Confirm diagnosis by ABPM.
LVH and raised microalbuminuria = end-organ damage, so requires aggressive treatment. Calculate ASSIGN score.
Start with lifestyle advice, ACEI, statin & metformin.
You are called to the house of Mr Paton a 56 y/o with severe chest discomfort for 1hr. The pain radiates down his left arm, he feels nauseated, breathless, and is pale and clammy.
ECG shows ST elevation in the antero–septal chest leads. You diagnose an acute antero–septal myocardial infarction.
1a. What drug treatment would you administer at this time and how would you give it?
Aspirin 300mg chewed or soluble.
IV opiate + anti-emetic: morphine/diamorphine + metoclopramide/cyclizine.
Oxygen only if SpO2 <94%.
Glyceryl trinitrate.
Clopidogrel 600mg or ticagrelor/prasugrel.
You are called to the house of Mr Paton a 56 y/o with severe chest discomfort for 1hr. The pain radiates down his left arm, he feels nauseated, breathless, and is pale and clammy.
ECG shows ST elevation in the antero–septal chest leads. You diagnose an acute antero–septal myocardial infarction.
You have administered the necessary medication, what other immediate action would you then take?
Order ambulance if not already done, & let hospital know of his impending arrival.
If available, attach a cardiac monitor to watch for pulseless VF/VT.
Wait till ambulance arrives & consider accompanying him to hospital.
Ambulance will often relay ECG findings electronically back to tertiary hospital.
You are called to the house of Mr Paton a 56 y/o with severe chest discomfort for 1hr. The pain radiates down his left arm, he feels nauseated, breathless, and is pale and clammy.
ECG shows ST elevation in the antero–septal chest leads. You diagnose an acute antero–septal myocardial infarction.
1c. Following immediate prompt transfer to a major hospital, what treatment is indicated? Consider the conditions in which this condition is indicated.
PCI - primary percutaneous coronary intervention if symptom onset is within 12 hours & procedure can be performed within 90-120 mins of diagnosis.
Anti-coagulant therapy e.g. fondaparinux or unfractionated heparin should also be administered to prevent re-occlusion of coronary vessel.
You are called to the house of Mr Paton a 56 y/o with severe chest discomfort for 1hr. The pain radiates down his left arm, he feels nauseated, breathless, and is pale and clammy.
ECG shows ST elevation in the antero–septal chest leads. You diagnose an acute antero–septal myocardial infarction.
If Mr. Paton lived more than 2 hours from a hospital and is unable to receive pPCI within 120 mins of diagnosis, what other treatments might be appropriate? What are the indications, contraindications and cautions of such treatments?
Thrombolytic therapy is indicated if PCI is not possible. Can be given at home.
Fibrin specific agents, e.g. streptokinase or tenecteplase, can be given as a single injection.
Indication: acute MI - significant ST elevation in 2 contiguous leads or new left bundle branch block on ECG with typical chest pain.
Contraindications: recent stroke/surgery/trauma/head injury, active peptic ulcer, allergy to streptokinase (use alternative), severe hypertension.
You are the senior HO on call when a 56y/o male is admitted as an emergency.
His wife dialled 999 as her husband had experienced 1hr of severe chest pain. Mr Paton is clearly in pain and unwell. An ECG shows ST depression in the anterolateral leads.
PMHx: peptic ulcer 10 years ago. He has not yet been given any drugs except oxygen.
Q2a. What is the likely diagnosis and what tests are needed?
Non ST elevation MI (NSTEMI).
Serial cardiac troponins, specifically troponin I and T which are highly specific for acute MI. Request at presentation & at 12 hours after symptom onset.
FBC, serial ECGs and a CXR.
You are the senior HO on call when a 56y/o male is admitted as an emergency.
His wife dialled 999 as her husband had experienced 1hr of severe chest pain. Mr Paton is clearly in pain and unwell. An ECG shows ST depression in the anterolateral leads.
PMHx: peptic ulcer 10 years ago. He has not yet been given any drugs except oxygen.
What immediate drug treatments would you administer/consider?
Aspirin 300mg soluble or chewed.
IV morphine/diamorphine + anti-emetic e.g. metoclopramide or cyclizine.
Oxygen ONLY if SpO2<94%.
Glyceryl trinitrate.
Clopidogrel 300mg or ticagrelor/prasugrel.
Anti-coagulation: fondaparinux/heparin.
Beta-blocker.
Statins.
You are the senior HO on call when a 56y/o male is admitted as an emergency.
His wife dialled 999 as her husband had experienced 1hr of severe chest pain. Mr Paton is clearly in pain and unwell. An ECG shows ST depression in the anterolateral leads.
PMHx: peptic ulcer 10 years ago. He has not yet been given any drugs except oxygen.
Where in the hospital should Mr Paton be managed?
Mr. Paton should be managed in the coronary care unit.
You are the senior HO on call when a 56y/o male is admitted as an emergency.
His wife dialled 999 as her husband had experienced 1hr of severe chest pain. Mr Paton is clearly in pain and unwell. An ECG shows ST depression in the anterolateral leads.
PMHx: peptic ulcer 10 years ago. He has not yet been given any drugs except oxygen.
What treatment options should be considered after drug administration?
Coronary angiography +/- PCI is indicated.
However, a conservative approach can be considered if he is at a low risk or if coronary angiography is contraindicated.
Your cardiac arrest bleep goes off and you are called to see Mr Paton, a 56 year old electrician who had been admitted with an anterior myocardial infarction a few hours earlier.
Cardiopulmonary resuscitation is in progress. The cardiac monitor shows ventricular fibrillation.
What action do you take?
DEFIBRILLATE.
Correct electrolyte abnormalities.
If further rhythm disturbances occur, anti-arrhythmic drugs may also be needed.
Your cardiac arrest bleep goes off and you are called to see Mr Paton, a 56 year old electrician who had been admitted with an anterior myocardial infarction a few hours earlier.
Cardiopulmonary resuscitation is in progress. The cardiac monitor shows ventricular fibrillation.
You administer defibrillation and Mr. Paton returns to sinus rhythm. His BP drops to 70mmHg systolic & CXR shows infiltrates compatible with pulmonary oedema.
What drug treatment may be useful & how is it administered?
He is probably in cardiogenic shock (poor prognosis).
Ask advice from senior.
Repeat ECG - consider re-infarction.
Order echocardiogram.
Possibly requires IV inotrope e.g. dobutamine or high dose dopamine.
CPAP may help to offload some pulmonary oedema.
Despite low BP, IV furosemide might also be required.
Intra-aortic balloon pump may be beneficial.
Mr Paton, a 56 y/o is sent to your ward for further management after being in the coronary care unit for a NSTEMI & cardiogenic shock.
He is now reasonably well. His blood pressure is 110/60 mmHg. His pulse rate is 94 beats per minute. He is known to have impaired ventricular function, with an estimated ejection fraction of 36%. You look for his drug kardex but find that this has gone missing.
What drugs do you think that he could or should be taking at this stage of his hospitalisation?
Mr. Paton, at this point should be taking:
Low-molecular-weight-heparin SC until mobile.
Aspirin 75mg.
Clopidogrel/ticagrelor/prasugrel.
Anti-coagulant.
ACEI.
Statin.
Aldosterone antagonist e.g. spironolactone (indicated for MI complicated by HF).
Possibly furosemide, beta-blocker.
