Case 1- Chest Pain Flashcards
What is the TIMI score used for?
Calculates risk of further cardiac event in UA/ NSTEMI patients
Score above 3- coronary angiography recommended
Investigations required in suspected ACS
Physical examination
ECG- can be normal
Bloods- troponin I+T, FBC (anaemia), UE (ACE-I), glucose and HbA1C, LFT (statin), lipid profile, TF
CXR- exclude other causes/ pulmonary oedema
Echocardiogram- used after event to assess functional damage
CT Coronary angiography- gold standard
NB- GP wouldn’t do troponin. This could also be investigation ladder for stable angina
Investigations required for stable angina
ECG- stress ECG to look for ischaemia
FBC- Hb (anaemia)
Fasting lipid profile- metabolic syndrome
Fasting blood glucose/ HbA1c- metabolic syndrome
TFT’s- hyperthyroidism
CT angiography- gold standard for measuring CAD
NB- anaemia and hyperthyroid are causes of angina chest pain
Ivabradine
Patient must be in sinus rhythm
Ranolazine
Caution in heart failure, elderly, decreased BMI, prolonged QT
Nicorandil
Contraindicated in pulmonary oedema, hypotension, hypovolaemia, LVF, diverticulitis (see below);
NB- can ulcers that can occur anywhere along the gastrointestinal tract. They are refractory to treatment and most only respond to withdrawal of treatment.
Post-PCI procedure
Requires dual anti platelet therapy for 12 months
ECG changes and stable angina
May show ST segment changes when symptomatic or during a stress ECG
Differences between myocarditis and pericarditis
P- pleuritic pain, improves on leaning forward, pericardial rub
M- flu-like prodrome, signs of heart failure eg. bibasal crackles, ST changes in specific terrorties (akin to ACS), not widespread like pericarditis
ECG changes with myocarditis
Non specific ST segment and T wave abnormalities but ST segment elevation and depression can occur
Risk factors for aortic dissection
HTN
Marfan’s
Elders-Danlos
Smoking
Bicuspid aortic valve
Coarctation of the aorta
FHx aortic dissection
Management of an aortic dissection
Beta blocker, if rupture- vasodilator (after BB)
Stanford A- surgery (aortic root replacement if originating at valve)
Stanford B- conservative management
ACS differentials
Aortic dissection, pericarditis, stable angina pectoris, PE, pneumothorax, pleurisy, oesophageal spasm, costochondritis, rib fracture
ECG changes pericarditis
Inwards concave ST segment elevation globally with PR depressions
Investigations for suspected pericarditis
ECG- ST segment elevation globally with PR depressions
Bloods- FBC, UE, troponin (I&T- can be raised), CRP and ESR (raised)
CXR- normal (unless pericardial effusion)
TTE (all patients should have one)
NB- can arise secondary to malignancy (ie. may have lung cancer with a pleural effusion and pericarditis)
Investigations for suspected myocarditis
ECG- non specific T wave and ST segment abnormalities
Bloods- FBC UE troponin (I&T- raised) ERS CRP
CXR
LV aneurysm
Persistent ST elevation 4 weeks after sustaining an MI
Bibasal crackles
3 and 4 heart sounds
ACS Poor prognostic factors
Age
Heart failure
PVD
Reduced systolic BP
Killip class
Initial serum creatinine concentration
Elevated initial cardiac markers
Cardiac arrest on admission
ST segment deviation
KILLIP
1- no signs of heart failure
2- lung crackles, S3
3- frank pulmonary oedema
4- cardiogenic shock
GTN side effects
Hypotension
Tachycardia
Headache
Where to avoid statins
Pregnancy
Initial ACS management
MONA
Morphine (if required)
Oxygen (if sats below 94%)
Nitrates (careful in hypotension)
Aspirin (300mg)
Additional STEMI management if patient is undergoing PCI
Give praugrel if not on an anticoagulant (clopidogrel if they are)
Give heparin + glycoprotein IIb/IIIa inhibitors (abciximab)
Additional STEMI management if someone is receiving fibrinolysis/thrombolysis
Give an antithrombin (heparin)
Give ticagrelor
If ongoing, repeat ECG at 60-90 minutes and consider PCI
STEMI Criteria
Wait for lecture
NSTEMI/UA management
Aspirin 300mg
Heparin (fondaparinux) if no immediate PCI
GRACE <3%: + ticagrelor
GRACE >3%: PCI (+ticagrelor/heparin)
Conservative management of NSTEMI/UA
GRACE score less than 3%
Aspirin + Ticagrelor (not at a high bleeding risk) or clopidogrel (if at high bleeding risk)
Coronary angiography for NSTEMI/UA
Within 72 hours if GRACE score more than 3%, or immediately if clinically unstable (with PCI)
Give prasugrel/ ticagrelor if not taking an anticoagulant, clopidogrel if they are
Give heparin
Miscellaneous angina management
1) GTN spray, lifestyle modification, aspirin, statin
2) BB, CCB
NB- calcium channel blocker as monotherapy-verapamil or diltiazem, if used in combination with a beta-blocker, use nifedipine or amlodipine (never give BB and verapamil)
3) If a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine
NB- If the patient’s symptoms continue after the use of drug management then the patient can then be referred for PCI or bypass graft assessment.
Isosorbide mononitrate
Asymmetric dosing regimes should be used for standard-release ISMN to prevent nitrate tolerance (ie. in morning and afternoon)
DVLA requirements following PCI
For a private vehicle (group 1), patients do not need to notify the DVLA following PCI and may resume driving after 1 weeks providing they don’t have any other disqualifying condition.
For a Group 2 vehicle (bus or lorry), patients must notify the DVLA, and may not drive for at least 6 weeks. After 6 weeks the DVLA will assess to determine if the requirements for exercise or other functional tests are met and to ensure there is no disqualifying condition
Investigation of choice for suspected aortic dissection
CT angiography- stable
TOE- unstable
What is pyrexia defined as
Temperature above 38 degrees C
Causes of pericarditis
viral infections (Coxsackie)
tuberculosis
uraemia (causes ‘fibrinous’ pericarditis)
trauma
post-myocardial infarction, Dressler’s syndrome
connective tissue disease
hypothyroidism
malignancy
Management of pericarditis
all patients with suspected acute pericarditis should have transthoracic echocardiography
Most common cause of death post-MI
V fib
What MI can pre-dispose to a bradyarrhythmia (AV block)
Inferior MI
Dressler’s syndrome
Fever and pleuritic chest pain 4 weeks post-MI
Raised ESR
Give NSAIDs
Ventricular aneurysm
Persistent ST elevation (may get thrombus in the aneurysm- anticoagulate)
Left ventricular free wall rupture
Acute heart failure secondary to cardiac tamponade- raised JVP, pulsus parodoxus, diminished heart sounds
Ventricular septal defect post-MI
Acute heart failure and pan-systolic murmur
Acute mitral regurgitation post-MI
Typically due to inferior/posterior MI’s causing papillary muscle rupture
Acute hypotension, pulmonary oedema, systolic murmur
Re-infarction blood test
Creatine kinase (CK-MB) remains elevated for 3 to 4 days following infarction. Troponin remains elevated for 10 days. This makes CK-MB useful for detecting re-infarction in the window of 4 to 10 days after the initial insult
Statin’s and liver function
Treatment with statins should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.
Primary prevention CVD
When QRISK3 is greater than 10%
atorvastatin 20mg OD
Secondary prevention CVD
After someone has angina/MI
4A’s;
A – Aspirin (plus a second antiplatelet such as clopidogrel for 12 months)
A – Atorvastatin 80mg
A – Atenolol (or other beta-blocker – commonly bisoprolol) titrated to maximum tolerated dose
A – ACE inhibitor (commonly ramipril) titrated to maximum tolerated dose
Additional ACS management if due to cocaine
Patients with MI secondary to cocaine use should be given IV benzodiazepines as part of acute (ACS) treatment
Basic ACS management
MONA
2nd AP and AC eg. fondaparinux (NSTEMI)/heparin (STEMI)
Reperfusion therapy (STEMI- if within 12 hours onset and can be delivered in 120 mins, NSTEMI- depends on GRACE score- if more than 3% PCI within 72 hours, if unstable, immediately)
Long-term management (4A’s)
NB- fibrinolysis if PCI not administered for STEMI (failure to stop infarction- PCI)
2nd AP choice
if the patient is not taking an oral anticoagulant: prasugrel
if taking an oral anticoagulant: clopidogrel
Wellen’s syndrome
Resolved chest pain in a patient with deeply inverted T waves in V2-3 → ?Wellen’s pattern, suggestive of critical stenosis of the left anterior descending artery (LAD)
Synchronised vs unsynchronised DC cardioversion
Synchronised- when patient still has a pulse ie. tachycardia with signs of shock/myocardial ischaemia
Unsynchronised- pVT/VF (shockable rhythms)
Diabetes control after MI whilst in CCU
type 2 diabetics are converted to intravenous insulin in the immediate period following a myocardial infarction.
Classification of ACS
If there is ST elevation or new left bundle branch block the diagnosis is STEMI.
If there is no ST elevation then perform troponin blood tests:
If there are raised troponin levels and other ECG changes (ST depression or T wave inversion or pathological Q waves) the diagnosis is NSTEMI
If troponin levels are normal and the ECG does not show pathological changes the diagnosis is either unstable angina or another cause such as musculoskeletal chest pain
