Case 1 - Chest Pain - Progress Test Revision Flashcards
What areas of the heart are supplied by the RCA?
Right atrium
Right ventircle
Inferior left ventricle
Posterior septum
What areas of the heart are supplied by the circumflex artery?
Left atrium
Posterior left ventricle
What areas of the heart are supplied by the LAD?
Anterior left ventricle
Anterior septum
What is a stunned myocardium?
Acute myocardial ischaemia results in a prolonged heart wall motion abnormality which eventually resolves
What is somatic pain?
Pain in the skin, muscles, bones or joints
What is visceral pain?
Pain in the organs in the thoracic or abdominal cavities
Risk factors for ischaemic heart disease
Unmodifiable:
- Age
- Male gender
- Family history
Modifiable:
- Smoking
- Hypertension
- Hypercholesterolaemia
- Obesity
- DM
Pathophysiology of ischaemic heart disease
- Endothelial dysfunction triggered by smoking, hypertension and hyperglycaemia.
- Causes pro-inflammatory, pro-oxidant, proliferative and reduced nitric oxide bioavailability.
- Fatty infiltration of the subendothelial space by LDL particles.
- Monocytes migrate from the blood and differentiate into macrophages.
- Macrophages phagocytose oxidised LDL, forming large foam cells.
- Macrophages die and propagate the inflammatory process.
- Smooth muscle proliferation and migration from the tunica media into the intima forms a fibrous capsule covering the fatty plaque.
Who may not experience pain in an MI?
Elderly, diabetics
Where are ECG changes seen for MIs in different parts of the heart?
Anterior = V1-V4 (LAD) Inferior = II,III, aVF (RCA) Lateral = I, V5-V6 (circumflex) Posteroir = Tall R waves in V1-V2 (usually left circumflex)
Acute management of an MI:
Morphine
Oxygen (if O2 sats < 94%)
Nitrates (use in caution if hypotensive)
Aspirin 300mg
How is risk in an NSTEMI classified determining requirements for PCI?
GRACE score
Secondary prevention medications for ACS
Aspirin A second antiplatelet (eg. clopidogrel / ticagrelor) A beta blocker An ACE-i A statin
What score is used to stratify risk post myocardial infarction?
Killip class I-IV (classifies 30 day mortality based on signs of HF)
When should PCI be considered?
Presentation within 12 hours of start of symptoms + PCI can be delivered within 120 minutes of the time when fibrinolysis could be given
What medication should you give before PCI
Aspirin + another antiplatelet.
If patient is not on an oral anticoagulant = prasugrel.
If patient is on an oral anticoagulant = clopidogrel
What medication should you give during PCI via radial access?
Unfractionated heparin + bailout glycoprotein IIb/IIIa inhibitor (GPI)
What medication should you give during PCI via femoral access?
Bivalirudin + bailout GPI
Medications to give with fibrinolysis
Give an antithrombin at the same time.
Give ticargrelor after procedurue.
If ongoing MI consider PCI.
How long after fibrinolysis should an ECG be repeated?
60-90 minutes
How is NSTEMI managed medically?
If no immediate PCI planned = give fondaparinux.
If managing without PIC = give ticagrelor
If patient is at a high bleeding risk should you use ticagrelor / clopidogrel?
Clopidogrel
Which calcium channel blocker should be used in AF?
Diltiazem
What score is used to quantify stroke risk in AF?
CHA2DS2 VAS2
What score is used to determine the risk / benefit of starting warfarin?
HASBLED
What anticoagulation is used in AF?
Warfarin / NOAC
What does a soft S1 indicate?
Mitral regurgitation
Long PR
What does a loud S1 indicate
Mitral stenosis
What does a soft S2 indicate?
Aortic stenosis
What does S3 indicate?
Normal in < 30.
Left venticular failure (eg. dilated cardiomyopathy), constricive pericarditis (pericardial knock), mitral regurgitation
What does S4 indicate?
Aortic stenosis, HOCM, hypertension
What type of murmur is aoritc stenosis?
Ejection systolic murmur heard in the aortic area, with radiations to the carotids
What signs are assoicated with aortic stenosis?
Slow rising pulse Narrow pulse pressure Soft / absent S2 S4 Thrill
Can have left ventricular hypertrophy or failure
What are the most common causes of aortic stenosis?
Over 65s:
Degenerative calcification
Under 65s:
Bicuspid aortic valve
How is aortic stenosis managed?
Asymptomatic:
- observe
Symptomatic / valvular gradient > 40:
- valve replacement
What type of murmur is tricuspid regurgitation?
Pansystolic murmur which becomes louder on inspiration
What type of murmur is aortic regurgitation?
Early diastolic
What type of murmur is mitral stenosis?
Mid-diastolci
What type of murmur is pulmonary stenosis?
Ejection systolic heard loudest on inspiration
What type of murmur is mitral regurgitation?
Pansystolic murmur
What are the signs associated with mitral regurgitation?
Quiet S1
Widely splity S2 (in severe cases)
May be broad p waves on an ECG
May have cardiomegaly on a CXR
echo is used to diagnose
How is mitral reguritation managed?
Acute MR:
- nitrates
- diuretics
- positive ionotropes
- intra-aortic balloon pump to increase CO
In HF:
- ACE-i
- beta blockers
- spironolactone
In acute severe cases:
- surgery (repair of valve preferable)
