Chapter 2: Cardiovascular Flashcards
What are the 6 life-threatening causes of Chest Pain?
1) AMI/Unstable Angina
2) Aortic Dissection
3) Pulmonary Embolism
4) Tension Pneumothorax
5) Esophageal Rupture
6) Ruptured PUD
What other important but not life-threatening causes of Chest Pain are there?
1) Respiratory-Pneumonia with pleurisy
2) Cardiac-Pericarditis/myocarditis
3) GI- GERD, Esophageal Spasm
4) Others/Referred-Biliary Dz, Subphrenic abscess, MSK, Herpes Zoster
What are some features of the chest pain history suggestive of AMI?
- Radiation to both arms
- Pain lasting>30mins
- Crescendo pattern, maximal intensity after several minutes
- Substernal location of CP
- Similar to previous angina pain
Chest pain unlikely to be cardiac ischemia when:
- CP is sharp/stabbing in nature
- No history of angina or AMI
- Tenderness on palpation of chest wall/pleuritic in nature
What is the single best historical predictor of ACS?
Known history of AMI/Known CAD
What do you think of when there is CP+neurological symptoms?
Aortic Dissection
Risk factors of Painless AMI?
- Prior CCF
- Prior Stroke
- Age>75
- DM
- Women
Apart from the standard RF of CAD, what are the other newly emerging RFs?
- SLE
- RA
- HIV
What are the necessary investigations in a typical patient with CP?
- ABC
- Oxygen Supplementation, Pulse oximetry, Continous ECG monitoring, BP monitoring, Set IV Plug and cardiac enzymes and CXR
What is the utility of doing an ECG in the acute setting of CP?
-Rule out AMI, PE, Ischemia
What is the utility of doing a CXR in the acute setting of CP?
- Cx of AMI
- Aortic dissection
- Respiratory Causes
- Peripheral PE
- Pneumomediastinum
What is the cardiac marker that rises earliest and when does it peak?
Myoglobin, 6-9 hours
What is the serologic gold standard of AMI?
CK-MB
What is the diagnostic accuracy of the new high sens Trop T and I?
92% at 3 hours
What are the risk factors of Aortic Dissection(AD)?
- HTN
- Smoking
- Atherosclerosis
- Pregnancy
- Pts with collagen disorders/vasculitis(eg.GCA/Marfan’s)
What is the DeBakey Classification System?
Type 1: AA,DA,arch
Type 2: AA before L subclavian
Type 3: DA at/beyond L subclavian
What is the Stanford Class?
Type A: Involves AA(+-DA)
Type B: Only DA
Features in CP History classic of AD?
Sudden, severe tearing CP, radiating to the back, maximal at onset;
what other a/w signs and symptoms in AD?
syncope, TIA, stroke, paraplegia, numbness, neuro symptoms, new onset AR murmur, pulse deficit, widened mediastinum
Can MI occur with AD?
Yes, usually due to the dissection down to the right coronary sinus causing inferior MI secondary to RCA infarct
If AD is suspected in a CP patient what drugs are contra-indicated?
Anti-platelet and thrombolytic therapy
What is the aim of medical therapy in AD?
Lower the RISE of BP and to lower mean BP (to reduce systolic BP to 100-120 mmHg provided Urine output is 30ml/hr) and HR.
(Med Rx reduces the velocity of LV contrac and reduces shear stress and minimizes tendency for propagation of the dissection)
How would you initially manage this patient with AD?
1) ABC and Monitor Vital signs in critical area
2) High flow O2
3) 2 large bore IV lines and
4) Request the following bloods: FBC, Renal panel, PT/PTT, GXM 4-6 units PCT, Cardiac enzymes
5) 12 lead ECG and CXR
6) Urinary Catheter(look for anuria and renal involvement)
7) Call CTVS
What are the imaging possibilities to order in AD?
Bedside TEE
CT aortogram
What are the medications to administer in AD?
1) Analgesia(IV Morphine)
2) IV Labetalol
3) IV Nitroprusside infusion plus IV Propranolol
Indications of surgical repair in AD?
All Stanford A
Type B with Cx
Uncontrolled HTN
Progression of dissection
what is AAA?
localized dilatation of the an artery >50% of the normal diameter.
When do patients with suspected AAA have an U/S done?
Pulsatile mass>3cm
What are the RF having a AAA?
Smoking
HTN
Dyslipidemia and hyperhomocysteinemia
What are RF of AAA rupture?
COPD, HTN
What mgmnt tips are recommended for AAA rupture?
- Do not over resuscitate patient
- Plain AXR to identify calcified aorta(egg-shell appearance)
- Bedside U/S to detect aneurysm
- If pt is stable, CT scan
What is the proposed pathophysio of AHF?
Increased preload, afterload and reduced CO or combination of all
What is the aim of Rx in AHF?
Redistribution of volume status in the body
what is one diagnosis to exclude before attributing the S&S as due to AHF?
Renal Failure as a cause of fluid overload
What S&S and diagnostic findings are classical of AHF?
PND, Orthopnea, Prev hx of ACS/CAD/CCF, S3 Heart sound, pulmonary venous congestion, interstitial edema
What values of BNP/ NT-proBNP values are used to diagnose ADHF?
BNP>500 or NT-proBNP>1000
what are some important precipitants of ADHF?
- Myocardial ischemia
- Non-compliance to fluid intake restriction
- Superimposed infection eg. pneumonia
- Dysrhythmias
Which co-existing dz increases mort rate of ADHF?
DM
What are the aims of pharmaco rx?
- to decrease R side filling
- to increase L side emptying
After initial resuscitation measures what specific mx therapy is given?
1) Nitrates (Sublingual GTN)
2)ACE-I
-mild to mod: Captopril
mod to severe: Enalapril
3) Diuretics
-IV Lasix (Frusemide)
4) NIV(shown to reduce mortality)
5) Inotropes-Patients who are hypotensive from the outset
What features must you be cautious about before giving nitrates?
1) Hypotension
2) RV infarct
3) Acute MR
4) AS (Dependance of preload to maintain BP)
5) Pulmonary HTN
6) Patients taking Sildenafil
What is HTN crisis?
Homogenous group of elevated BP with HTN emergencies(target organ dysfunction rather than high BP) HTN urgencies(Clinical scenarios with high BP >180/120 without obvious end-organ dysfunction
What is the pathophysio of HTN crisis?
An abrupt elevation in vascular resistance seems to be the initiating step that triggers vicious cycle of BP rise
What are the secondary causes of HTN crisis?
1) Renal-Renal artery stenosis, Acute Glomerulonephritis, Vasculitis, HUS/TTP
2) Endocrine-Pheochromocytoma, Cushings, Renin-secreting tumours
3) Pregnancy- Eclampsia
4) Drugs- cocaine, sympathomimetics, Amphetamines
5) CNS-Head Injury, Cerebral infarction
What is an important pathophysio of HTN crisis to include in mgmnt of the condition?
The rate of rise of BP is more important than the actual BP per se. Hence overzealous correction, may be hazardous leading to reduction in CPP and hence stroke or AMI
Presentations of HTN emergencies?
1) HTN encephalopathy
2) Acute ischemic stroke
3) Intracranial hemorrhage
4) Acute LV failure
5) AD
6) AMI/ACS
7) Acute renal failure
8) Eclampsia
9) Sympathetic crisis
What investigations are indicated in HTN crises?
Bedside: ECG, Urine dipstick for proteinuria and hematuria, UPT in females
Bloods: FBC, Renal Panel, LFT(for pregnant females for HELLP) and cardiac enzymes
Radio: CXR, CT brain if AMS
What is PRES and how do you treat it?
Posterior reversible encephalopathy syndrome. It is a reversible condition causing AMS, seizures, papilledema, headache, N/V, visual disturbances.
Rx is to reduce MAP within sn hour to 20-25% below presenting level or diastolic BP to no less than 100-110 mmHg then further towards 160/100 mmHg over the next 2-6 hours
What is the recommendation for rx in stroke due to HTN crisis?
anti-HTN therapy not routinely indicated
What is the recommendation for rx in ICH/SAH due to HTN crisis?
The BP goal in reducing the MAP to limit hemorrhage must be balanced against the reductions in CPP. Nimodipine is specially indicated in SAH as it reduces cerebral arterial vasospasm.
What is the recommendation for rx in acute LV failure due to HTN crisis?
Control BP till alleviation of signs of HF. GTN IV drug of choice
How about AMI in HTN crisis?
BP of more than 180/110 is a CI to thrombolysis. Avoid vasodilators such as nitroprusside.
How do you treat AKI in HTN crisis?
Avoid ACE-I. Fenoldopam has advantage of increasing renal blood blow
What is the rx of HTN urgency?
The pt’s own meds can be given if poor compliance. Options include felopdipine, amlodipine, labetolol
What is ACS and what are the differences between the sub-categories?
Unstable Angina(UA), NSTEMI, STEMI. UA and NSTEMI are subendocardial ischemic changes vs STEMI which is a complete occlusion of a cornoary artery with transmural involvement.
How is a NSTEMI and UA diagnosed?
NSTEMI will have elevated cardiac biomarkers without evidence of ST elevation. NSTEMI does not need to have ECG changes present.
UA is dx on clinical grounds where there is no more CP after treatment and no ECG/biomarker changes
What is the relation between Trop Markers and Mort?
The higher the trop, the higher the 30 day mort
What are the Rx aims of ACS?
1) Control of symptoms and prevention of MI and death using anti-ischemic and anti-thrombotic Rx
2) Important to manage HTN and AHF in the acute setting to reduce stress on myocardium
After initial primary resus and survey, what is the specific mgmnt of ACS?
1) Dual anti-platelet rx- Aspirin 300mg PO and Ticagrelor(180mg) or if CI, Plavix(Clopidogrel) 600mg.
2) Sublingual GTN (CI in RV infarct) and IV Heparin
3) IV Morphine
4) Activate Cath Lab
5) Take Consent for PCI
6) Order Bloods: FBC, U/E/Cr, PT/PTT, GXM, Cardiac enzymes
7) Order CXR
What is the alternative to PCI and what are the indications?
Thrombolytic Rx:
1) Typical CP
2) ST segment elevation
3) CP
What are some CI for thrombolytic rx?
1) Hx of ICH
2) Hx of Stroke in past 3 months
3) Suspected AD
4) cerebral AVM/tumour
5) Bleeding diathesis
6) Sig Head Trauma
If the patient is in shock what is the mgmnt?
1) PR for GI bleed?
2) Bradycardia or Tachycardia?
3) RV infarct?
- Do right sided leads
- Fluid challenge
- Start inotropes
