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Year 4 General Medicine > Chest pain and management of arrhythmia > Flashcards

Chest pain and management of arrhythmia Flashcards

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1
Q

what do you do for a man who has developed chest pain

A

Take a full history and examination

NEWS

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2
Q

what do you want to rule out for a patient with chest pain

A

MI - ACS

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3
Q

investigations for chest pain

A 
12 lead ECG - compare it with old ECGs 
IV access 
CXR 
bloods - FBC, U+E, 12hr troponins, d-dimers, amylase
ABG 
ECHO 
CT chest
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4
Q

list high risk ECG changes

A

transient or persistent ST elevation
>1mm ST depression
Deep T wave inversion

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5
Q

curveball in CXR

A

pneumothorax

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6
Q

big 3 differential diagnoses of chest pain

A
  1. ACS - STEMI, NSTEMI, unstable angina, coronary spasm
  2. Acute aortic syndrome - rupture, dissection, penetrating ulcer
  3. PE
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7
Q

what are the ‘smaller’ causes of chest pain

A 
pericarditis 
pneumonia 
pneumothorax 
oesophageal spasm/reflux/rupture 
GB/pancreas 
MSK/mechanical/costochondritis/rib #/fibromyalgia 
Neuro - shingles HZV, nerve root pain 
psychosocial - panic attack 
drugs - cocaine, triptans, 5FU
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8
Q

initial treatment of ACS

A 
MONA 
Morphine + antiemetic 
Oxygen if hypoxic 
Nitrate - SL/buccal/PO/topical/IV
Aspirin - 300mg chewed
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9
Q

further treatment for ACS

A 
heparin/LMWH/Clopidogrel/ticagrelor 
B blocker 
CCU 
angiography +- angioplasty 
IV GTN
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10
Q

stable angina

A

significant artery narrowing but predictable limiting symptoms

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11
Q

plaque rupture

A

unpredictable
rapid onset
sudden occlusion of arteries –> MI

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12
Q

stable angina approach

A 
outpatient no rush situation 
medical therapy 
RF modification 
aspirin 
statins 
B blockers 
GTN
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13
Q

NSTEMI

A

ruptured atherosclerotic plaque
unstable symptoms
pain at rest
artery still open but severe and critical narrowing
threatening situation and significant mortality

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14
Q

STEMI pathophysiology

A

ruptured plaque
completely blocked artery and dying muscle
severe pain at rest
autonomic upset
emergency: time = muscle
immediate opening of artery required either PCI or thrombolysis
immediate rush

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15
Q

management of suspected ACS

A 
hospital by ambulance 
300mg aspirin unless contraindicated 
12 lead ECG within 10 min arrival 
admitted to CCU/HDU or telemetry bed 
managed by specialist CVS services for drugs/PCI/CABG
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16
Q

why should patients be taken by ambulance with MI

ie why do people die from MI

A

VF

need access to defibrillator

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17
Q

ECG interpretation structure

A 
rate 
rhythm 
ST T wave 
QRS 
PR, QT other funny stuff
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18
Q

territories in ECG
lateral
inferior
anteroseptal

A

lateral V5-6
high lateral I and aVL
inferior II, III and aVF
anteroseptal V1-4

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19
Q

what are reciprocal changes

A

ST depression in leads that dont have ST elevation

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20
Q

LBBB

A

wide QRS and goes down in V1

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21
Q

LBBB can mask ischaemia, true or false

A

true

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22
Q

RBBB

A

more subtle than LBBB

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23
Q

you can interpret RBBB ECG changes, true or false

A

true

cannot interpret LBBB underlying ECG changes

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24
Q

tall big QRS with T wave inversion

A

LVH and strain

think HOCM

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25
Q

broad QRS and up/down in V1

A

up - RBBB

down - LBBB

26
Q

deep T wave inversion

A

stress induced MI

27
Q

where should you look for P waves

A

V1 and lead II

28
Q

sinus rhythm with atrial ectopics

A

seen in healthy people

29
Q

long QT interval

A

need to measure it

30
Q

broad and narrow complete heart block - which is worse

A

broad QRS complete heart block is more malignant

could drop dead at any moment

31
Q

fusion beats

A

atria and ventricles collide at same time

seen in VT

32
Q

pericarditis ECG changes

A

widespread ST elevation across territories with no reciprocal changes
PR depression

33
Q

how can a patient with AF have a regular rhythm

A

pacemaker causing

broad QRS and very sharp spikes

34
Q

aVR is a reference strip

A

if the ECG has been done properly the aVR lead should go down

35
Q

what is the most likely cause of a student collapsing halfway through a teaching session

A

vasovagal

manage by elevating feet

36
Q

what is syncope

A

transient loss of consciousness due to cerebral hypoperfusion characterised by a rapid onset, short duration and spontaneous complete recovery
‘not enough blood to the brain’

37
Q

what is TLOC

A

transient loss of consciousness
group of things which syncope is one of them LOC with loss of awareness, amnesia, abnormal motor control, loss of responsiveness and a short duration

38
Q

classification of syncope

A

reflex syncope
orthostatic hypotension
cardiac syncope

39
Q

causes of reflex syncope

A 
triggered by an event 
can be: 
vasovagal 
situational 
carotid sinus syncope 
atypical 
it is so common
40
Q

causes of orthostatic hypotension

A 
problem with autonomics 
can be: 
PD, MSA
DM, amyloid, uraemia 
drug induced 
volume depletion
41
Q

causes of cardiac syncope

A

pathology in the heart causing you to black out
can be:
bradycardia
tachycardia
tachy brady disease
structural disease - Ao stenosis, HOCM, MI, tamponade, rupture
other - PE, dissection

42
Q

what is vasovagal syncope

A

trigger results in reflex activation and decreased cerebral blood flow and pooling of blood in peripheral arterial circulation

43
Q

what are the 3 Ps of vasovagal syncope

A

no features suggesting other disease AND
Posture - prolonged standing or prevent by sitting
Provoking factors - pain, procedure
Prodromal features - sweats, feeling hot, blacking of vision

44
Q

what is situational syncope

A

type of reflex syncope

clearly and consistently provoked by trigger e.g. straining, coughing, swallowing, post exertion syncope

45
Q

define orthostatic hypotension

A

fall in SBP >20 or DBP >10 after standing 3 min

46
Q

history taking for syncope

A 
circumstances 
posture prior to event 
prodromal symptoms 
appearance - eyes open, pallor 
tongue biting (tip vs side - seizure)
injuries 
duration of onset to return of consciousness 
post event confusion?
47
Q

features suggestive of epilepsy

A 
biting side of tongue 
head turning 
no memory of abnormal behaviour prior, during or after 
post ictal confusion 
unusual posturing 
prodromal deja/jamais vu
48
Q

people who are syncopal may jerk?

A

yes

but doesnt look like a TC seizure

49
Q

red flags for syncope

A 
abnormal ECG 
heart failure 
TLOC on exertion 
FH of sudden cardiac death <40y 
new/unexplained breathlessness 
heart murmur
50
Q

where can syncopal patients be referred to

A

TLoC clinic

after routine investigations

51
Q

what investigation must everyone who has had syncope must have

A

ECG

52
Q

what should you screen for in an ECG for syncope

A

conduction abnormalities - QT prolongation, pre-excitation, Brugada
structural abnormalities - hypertrophy, T wave changes

53
Q

what is an r test

A

ECG monitoring for long periods of time

54
Q

Implantable loop recorders are commonly used

A

not commonly as they are expensive but are very useful when they are used
machine inserted under skin

55
Q

Indications for ECHO

A

structural disease concern
previously known heart disease
abnormal ECG
presence of murmur

56
Q

DVLA at a glance

A

updated DVLA and driving guidance for medical professionals

57
Q

advanced treatments for arrhythmias

A

implantable defibrillators (ICD)
cardiac resynchronisation pacemakers
radiofrequency ablation

58
Q

radiofrequency ablation

A

common procedure
multiple venous access
catheters in the heart
diathermy or cryotherapy

59
Q

indications for radiofrequency ablation

A

SVT
atrial flutter
AF

60
Q

subcutaneous ICD

A

sits under the skin in the axilla and the tip is at the sternal notch
more cosmetically appealing
no need to enter venous circulation

61
Q

list the investigations for working up a patient with syncope palpitations

A

Everyone - 12 lead ECG
Recurrent symptoms - ECG when symptomatic
Daily / short lived - 24 hour tape / r test
Less frequent symptoms - 7 day r test
Recurrent infrequent syncope - implantable loop recorder
Exertional symptoms - exercise treadmill test
Murmur, abnormal ECG, suspected HF… - ECHO
Seizures - Neurology

Year 4 General Medicine (16 decks)

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