Corrections - ACS Flashcards
A new LBBB due to ischaemia is the result of the occlusion of what artery?
Proximal LAD or left main stem artery
Why is a new LBBB indicate a worse prognosis in MI?
A large amount of myocardium and conductive tissue needs to be affected to cause this ECG appearance and these patients are usually acutely unwell.
MI can cause tachycardia or bradycardia.
What type of MI would bradycardia indicate?
Inferior MI due to vagal activation
When should PCI be offered in STEMI patients?
<12 hours from symptom onset
AND
PCI can be delivered within 2h of the time when thrombolysis could have been given
Also, if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered.
Prior to PCI, a patient is given dual antiplatelet therapy (aspirin + one more).
What is the 2nd antiplatelet determined by?
Is the patient taking an anticoagulant?
If the patient is taking an anticoagulant, what is the 2nd antiplatelet given prior to PCI?
Clopidogrel
If the patient is NOT taking an anticoagulant, what is the 2nd antiplatelet given prior to PCI?
Prasugrel
What is the site of choice in PCI?
Radial artery
What drug therapy is required DURING PCI in STEMI patients?
UH + bailout glycoprotein IIb/IIIa inhibitor (GPI)
What is action of fibrinolytic drugs (e.g. atelplase, streptokinase) used in thrombolysis?
Activate plasminogen to plasmin.
Plasmin breaks down fibrin in clots.
A previous stroke in what time period is a contraindication to thrombolysis?
<3m
What are 3 indications for thrombolysis?
1) STEMI
2) Massive PE with haemodynamic instability
3) Ischaemic stroke
What ECG changes does a posterior MI cause?
A posterior MI causes ST depression not elevation on a 12-lead ECG.
Also tall R waves in V1-V2
What does the GRACE score predict?
6m mortality of death 6m following NSTEMI
Give mx pathway for STEMI
1) MONA
2) Identify STEMI
3) Decide PCI or thrombolysis
3a) PCI:
- prior give dual antiplatelet (aspirin + clopidogrel/prasugrel depending if anticoagulated0
- during give UH + GPI
3b) thrombolysis e.g. streptokinase + antithrombin e.g. fondaparinux
Describe mx pathway for NSTEMI
1) MONA
2) Identify NSTEMI
3) GRACE score to determine immediate/delayed angiography
3a) GRACE >3 –> coronary angiography + PCI within 72h
3b) GRACE ≤3 –> delayed
4) Coronary angiography –> UH
5) Delayed angiography –> fondaparinux
What does LV aneurysm post-MI increase the risks of?
Thrombus may form within the aneurysm increasing the risk of stroke.
Patients are anticoagulated.
What are the 3 categories of NSTEMIangina patients that should have coronary angiography?
1) Immediate –> unstable patients e.g. hypotension
2) Within 72h –> GRACE >3%
3) Considered for patients if ischaemia is subsequently experienced after admission
Pericarditis in the first 48 hours is common following what type of MI?
Transmural
When does LV free wall rupture typically occur post-MI?
1-2w after
How do patients with LV free wall rupture post-MI typically present?
Acute HF 2ary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds.
Management of LV free wall rupture?
Urgent pericardiocentesis and thoracotomy are required.
Following an ACS, what medications should all patients should be offered?
1) Dual antiplatelet therapy
2) Statin
3) ACEi
4) Beta blocker
What is the diagnostic test for Lyme disease?
Antibody titres for Borrelia burgdorferi
How can lyme disease affect the heart?
Can cause myocarditis (can present as ST elevation in ECG)
How can sepsis (e.g. from a CAP) result in myocardial ischaemia?
Sepsis results in inadequate perfusion of tissues –> release of lactate & troponin.
For STEMI patients receiving thrombolysis, what should they be given alongside this?
Antithrombin e.g. fondaparinux
What complication post MI causes systolic murmur, hypotension & pulmonary oedema?
Mitral regurgitation (papillary muscle rupture)
What do long straight lines preceding QRS complexes on an ECG indicate?
Pacemaker - these are pacing spikes delivered by a pacemaker to stimulate contraction of the heart.
What investigation must be repeated 60-90m after fibrinolysis in a STEMi?
ECG –> to assess for ongoing ischaemia (i.e. resolution of ST-segment elevation).
If not resolved then transfer for PCI.
What does a sinusoidal wave pattern on an ECG indicate?
Severe hyperkalaemia
What does severe hyperkalaemia in the context of an AKI require?
Immediate discussion with critical care/nephrology to consider haemofiltration/haemodialysis
Purpose of getting ECG prior to starting azithromycin?
Rule out prolonged QT interval
What diameter defines an AAA?
> 3cm
How often should patients have follow up scans if they have an AAA of 3 - 4.4cm?
Yearly
How often should patients have follow up scans if they have an AAA of 4.5 - 5.4cm?
3 monthly
Who is an elective repair for AAA considered in? (3)
1) Diameter growing >1cm a year
2) Diameter ≥5.5cm
3) Symptomatic
Driving rules for AAA?
Inform DVLA if >6cm
Stop driving if >6.5cm
What size AAA must patients inform the DVLA?
≥6cm
What is the gold standard imaging for diagnosing a ruptured AAA?
CT angiogram (only in stable patients)
What is the most common risk factor for aortic dissection?
Chronic HTN
Why are connective tissue disorders a risk factor for aortic dissection?
due to inherent weakness in the wall of the aorta.
Risk factors of aortic dissection?
1) HTN, male sex & increasing age
2) Connective tisue disorders:
- Marfan syndrome
- Ehlers-Danlos syndrome
- Turners syndrome
3) Atherosclerosis
4) Inflammatory conditions e.g. GCA
5) Trauma
6) Pregnancy
7) Bicuspid aortic valve
8) 9) Abrupt, transient, severe increase in blood pressure e.g. emotional stress, pain, cocaine/amphetamine use or heavy lifting.
Complications of aortic dissection?
1) Aortic regurg (propagation)
2) End organ ischaemia
3) Rupture of outer layer (adventitia) –> life threatening
Describe Stanford system classification of aortic dissection
Type A –> affects ascending aorta BEFORE braciocephalic artery
Type B –> affects descending aorta AFTER left subclavian artery
What is the investigation of choice in aortic dissection?
CT angiography of the chest, abdomen and pelvis
What investigation is more suitable in aortic dissection in unstable patients who are too risky to take to CT scanner?
Transoesophageal echocardiography (TOE)
What type of MI does aortic dissection typically cause?
Inferior due to RCA involvement
How soon after an MI does a VSD typically occur?
Approx 5 days
Does HTN indicate AAA rupture or aortic dissection?
Aortic dissection
What is the single most common cause of 2ary hypertension?
1ary hyperaldosteronism (including Conn’s syndrome)
Renal disease accounts for a large % of the other cases of 2ary HTN.
What are some renal conditions that may increase the BP? (4)
1) glomerulonephritis
2) pyelonephritis
3) adult polycystic kidney disease
4) renal artery stenosis
What are some endocrine disorders (other than 1ary hyperaldosteronism) may also result in increased BP? (5)
1) phaeochromocytoma
2) Cushing’s syndrome
3) Liddle’s syndrome
4) congenital adrenal hyperplasia (11-beta hydroxylase deficiency)
5) acromegaly
What are some drugs that can cause 2ary HTN? (5)
1) steroids
2) monoamine oxidase inhibitors
3) COCP
4) NSAIDs
5) leflunomide
How can renal artery stenosis be diagnosed?
Duplex US or CT angiogram
What clinic BP readings define:
1) Stage 1 HTN
2) Stage 2 HTN
3) Stage 3 HTN
1) 140/90
2) 160/100
3) 180/120
What is a QRISK score?
% chance that patient will have stroke or MI over next 10 years
Mechanism of spironolactone?
Potassium sparing diuretic:
Blocks the action of aldosterone in the kidneys, resulting in sodium excretion and potassium reabsorption.
Target clinic BP for <80 vs >80 y/o?
<80 –> <140/90
> 80 –> <150/90
What 2 eye signs may be seen in malignant HTN?
1) papilloedema
2) retinal haemorrhages
Management of malignant HTN?
1) SAME DAY referral
2) Fundoscopy exam –> to look for key findings
Which group of medications can lead to atherosclerosis?
Atypical antipsychotics
Atorvastatin 20mg is offered as 1ary prevention to which 2 groups of patients?
1) CKD
2) T1DM for >10y or are >40 y/o
How can statins affect the liver?
Can cause a transient and mild rise in ALT and AST in first few weeks.
Stop statins if rise is >3x baseline.
If a patient taking statins is prescribed clarithromycin or erythromycin, what should they be advised?
Should be advised to STOP taking their statin whilst taking these antibiotics.
Macrolides are enzyme INHIBITORS.
How is familial hypercholesterolaemia inherited?
Autosomal dominant
What is considered the gold standard for determining coronary artery disease?
Invasive coronary angiography
How many doses of GTN spray can patients take?
3 and then need to call and ambulance
1) Take 1st dose when symptoms start
2) Wait 5 mins then take 2nd dose if symptoms persist
3) Wait 5 mins then take 3rd dose if symptoms persist
4) Wait 5 mins then call ambulance if symptoms persist
What is used for the medical long term symptomatic relief in stable angina?
Either, or a combo of:
1) Beta blocker (e.g. bisoprolol)
2) CCB
If CCB is used as monotherapy, a rate limiting one should be used e.g. diltiazem or verapamil (avoid in HF with reduced EF)
If used in combination with a beta-blocker then use a long-acting dihydropyridine CCB (e.g. modified-release nifedipine).
Define impaired glucose tolerance
Fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
If new BP >= 180/120 mmHg + no worrying signs but no signs of papilloedema/retinal haemorrhages, what is next step?
Urgent investigations for end-organ damage (e.g. bloods, urine ACR, ECG)
Target BP in patients with diabetes?
<130/80
Should you offer medication right away if patient has clinic BP reading of HTN?
No - offer ABPM first to confirm diagnosis
Which antiplatelet carries a higher bleeding risk: clopidogrel or ticagrelor?
Ticagrelor
What can be seen in an ECG in Dressler’s syndrome?
global ST elevation and T wave inversion
What can be seen in an echo in Dressler’s syndrome?
pericardial effusion
