CPL CVS Flashcards
what are symptoms of a STEMI?
- acute central/left chest pain for over 20 minutes
- radiating pain to the left jaw or arm
- nausea
- sweating
- palpitations
- change in HR or BP
- 4th heart sound
- signs of LVF
what lead ECG changes for an inferior MI?
II,IIIAvF
what is the vessel responsible in inferior MI?
right coronary artery
what ECG leads change in anterior MI?
V1-V4
what vessel is responsible for MI anterior?
left anterior descending
what ECG leads are for the lateral aspect?
V5-V6
What vessel is responsible for lateral MI?
Left circumflex
what investigations can be done for STEMI?
- ECG
- troponin
- BNP
- CXR
what is the treatment for STEMI regardless of the reperfusion therapy?
Aspirin- 300mg
Ticagrelor 180mg
morphine with metoclopramide
what are the options for reperfusion therapy in STEMI?
- primary PCI
- angiography
what STEMI patients can be offered PCI?
all patients presenting within 12 hours of onset of symptoms who can get PCI within 2 hours
what is the management of STEMI if they cant have PCI within 2 hours of admission?
fibrinolysis followed by rescue PCI or angiography
what is fibrinolytic treatment for STEMI?
often uses alteplase or reteplace and used when PCI can’t be given within 2 hours of admission
In STEMI if they present in 12 hours and can have PCI in the next 2 what are the PCI options?
angiography and stenting
What are causes of cardiogenic shock?
- MI
- hyperkalaemia
- endocarditis
- aortic dissection
- rhythm disturbance
- tamponade
what are clinical features of cardiogenic shock?
pale, sweaty, clammy, tachycardia, increased resp rate, P.oedema, raised JVP
what is the management of cardiogenic shock?
- give oxygen with a target of 94-98%
- IV access and ECG
- noradrenaline is first choice vasopressor
- dopamine can increase cardiac contractility
- dobutamine and GTN can reduce after load
what are clinical signs of anaphylactic shocks?
- general signs of shock
- clinical history
- wheezing
- urticaria
- angiodema
what is the management of anaphylaxis?
- ensure the airway is clear
- oxygen
- adrenaline IM 0.5mg
- chlorphernamine 100mg IV
- hydrocortisone 200mg IV
- IV saline 500ml over 15 minutes
how do you manage haemmorhagic shock?
- when restoring CO consider blood tranfusion
- coagulopathy: fresh frozen plasma and platelet concentrates
- consider tranexamic acid
what is the management of septic shock?
- broad spectrum antibiotics started within 1 hour
- 500ml crystalloid within 15 minutes
- oxygen if hypoxic
what is the septis six??
Six things to do within 1 hour: 1 Oxygen administeration 2. Blood cultures 3. IV antibiotics 4. IV fluids not exceeding 30ml/kg 5. check lactate levels 6. Measure UO
what is the diagnostic value for hypertension?
- 135/85
what is malignant/ accelerated hypertension?
A rapid rise in blood pressure leading to vascular damage with the hallmark of fibrinoid necrosis.
what are symptoms of hypertension?
- headache
- visual disturbance
what are renal causes of hypertension?
- glomerulonephritis
- chronic pyelonephritis
- polycystic kidney disease
- renal artery stenosis
what are endocrine causes of hypertension?
- cushiings disease
- conns disease
- phaeochromocytoma
- fibromuscular dysplasia
what are investigations in a patient presenting with hypertension?
- home monitoring to get an average
- fasting glucose and cholesterol levels
- ECG/ Urine
- HbA1c
- lipids
- fundoscopy
what is the treatment goal for a normal hypertensive patient?
under 140/90
what is the treatment goal for a diabetic hypertensive?
below 130/80
what is the treatment goal in over 80’s?
below 150/90
what are lifestyle changes for BP?
- stop smoking
- low fat diet
- reduce alcohol
- reduce salt
- weight lose
- increase activity
what is the first line monotherapy for hypertension management?
Under 55 years and non-black: ACE inhibitors/ angiotensin OR beta blocker
Over 55 and black: calcium channel blocker OR thiazide diuretic
what is the second line management after monotherapy for people with hypertension?
- ACE inhibitor and a calcium channel blocker
or
- ACE inhibitor and thiazide type diuretics
what is step three therapy for hypertension?
ACE inhibitor and calcium channel blocker and thiazide diuretics
what is the stage 4 treatment for resistant hyper tension?
if potassium is below 4.5 add spironolactone
If potassium is above 4.5 use a higher doze thiazide diuretic.
what is the first line anti hypertensive if all diabetic patients?
ACE inhibitor
what anti hypertensive medication should be avoided in people with diabetes?
beta blockers
why should beta blockers not be used in hypertensive treatment of diabetic patients?
- cause insulin resistance
- impair insulin secretion
- affect the hypoglycaemic response
what are side effects of calcium channel blockers? (used for hypertension)
flushes
fatigue
gum hyperplasia
ankle oedema
when should you not give thiazide diuretics for hypertension?
in patients with gout
what are side effects of thiazide diertics?
hypokalaemia
hyponatraemia
impotence
what is an example of a thiazide diuretic for hypertension?
chlortalidone 25-50mg
what is an example of a calcium channel blocker used for hypertension?
Nifedipine 30-60mg
what are side effects of ACE inhibitors?
- cough
- hyperkalaemia
- renal failure
- angiodema
what are contraindications for ACE inhibitors?
bilateral renal artery stenosis
aortic stenosis
what environmental factors can provoke angina?
- exposure to the cold
- eating a large meal
- exertion
- emotional stress
what are risk factors for angina?
- hypertension
- hyperlipiaedmia
- D.M
- sedentary lifestyle
- obesity
- smoking
- family history
what is class I angina?
- no anina with ordinary activity, angina with streneous activity
what is class II angina?
- angina during normal activites with mild limitation of activities
what is class III angina?
- angina with low levels of activity such as walking 50-100 metres on flat land. marked restriction
what is class IV angina?
angina at rest or with any level of exercise
what is unstable angina?
angina or recent onset or worsening with symptoms at rest
what is refractory angina?
Patients with severe coronary disease where revascularisation isn’t possible and not controlled by medical therapy
what are the suitable investigations in people with angina?
- FBC,LFT, Glucose, hBa1C, lipids, GFR, troponin
- ECG
- echocardiography
- CXR
what patients after basic investigation can just be managed for stable angina without further investigations?
Those with typical angina and risk of disease >90%
what is the first line treatment for stable angina?
A beta blocker or calcium channel blocker (can use dual therapy)
If a patient with stable angina can’t use first line (beta blocker/ calcium channel blocker) what can then be used?
- long acting nitrate
- ivabradine
- nicorandil
- ranolazine
what is the treatment for a current episode of angina?
- A short acting nitrate
- aspirin 75mg
also offer statins
In second line therapy for angina you can use long acting nitrates, when is isosorbide mononitrate CI?
patients taking phosphodiesterase type 5 inhibitors
Beta blockers are first line for stable angina, why is this?
They inhibit beta adrenoreceptors to reduce heart rate and myocardial oxygen consumption.
what are SE of beta blcokers>
fatigue, peripheral vasoconstriction, bronchospasm, sexual dysfunction
Calcium channel blockers can be first line for treating stable angina what are the CI?
severe bradycardia, LVF
what are causes of heart failure?
- ischaemic heart disease
- cardiomyopathy
- hypertension
valvular heart disease, congenital heart disease, alcohol, drugs, cor pulmonale, infections
what pathophysiology occurs in heart failure?
- ventricular dilation
- myocyte hypertrophy
- increased collagen synthesis
- altered myosin gene expression
- salt and water retention
- peripheral vasoconstriction
how does afterload change with heart failure?
- Increases causing a decrease in cardiac output
This increase in afterload causes dilatation in the ventricular wall which can affect LaPlaces law
How does myocardial contractility change with heart failure?
- decreases due to down regulation of beta receptors
what is the neurohormonal changes in heart failure?
There is salt and water retention and decreased CO meaning decreased renal perfusion. This causes RAAS activation and worsening of salt and water retention
what are causes of right sided heart failure?
- left ventricular failure
- cor pulmonale
- triscupid and pulmonary valve disease
what are signs of right sided heart failure?
- weight loss
- nausea
- increased JVP
- tender smooth hepatomegaly
- pitting oedema
- ascites
what are some causes of left sided heart failure?
Cardiomyopathy
hypertension
mitral and aortic valve disease
what are signs of left sided heart failure?
- fatigue
- orthopneoa
- exertional dyspnoea
- nocturnal cough
- muscle wasting
- AF
- gallop rhythm
- pulmonary oedema
what are the chest X ray finding in heart failure?
A- alveolour oedema B- kerley B lines C- Cardiomegaly D- dilated prominent upper lobe vessels E- pleural effusion
what tests are helpful for heart failure?
CXR
BNP
ECG
echocardiography
what is class I in the new york classification of heart failure?
heart disease present but no undue dyspneoa from ordinary activity
what is class II in the new york classification of heart failure?
comfortable at rest, dyspnoea during ordinary activity
what is class III in the new york classification of heart failure?
Less than ordinary activity causes dyspnoea which is limiting
what is class IV in the new york classification of heart failure?
dyspnoea present at rest all activity causes discomfort
what is framingham criteria?
A criteria for the diagnosis of heart failure
You need 2 major criteria or 1 major with 2 minors
What are the major criteria of framingham for diagnosing heart failure?
PND, abdominojugular reflex, neck vein distension, S3, basal creps, cardiomegaly, acute pulmonary oedema, increased CVP, weight loss
what are the minor critera of framingham for the diagnosis of heart failure?
bilateral ankle oedema, SOBOE, tachycardia, nocturnal cough, hepatomegaly, pleural effusion, decrease 30% vital capacity
what lifestyle advice can be given to manage chronic heart failure?
- smoking cessation
- alcohol cessation
- diet changes
- salt reduction
what medications can be used in a patient with chronic heart failure?
- loop diuretics such as furosemide to relieve symptoms
- ACE inhibitors for symptoms and mortality
- Beta blockers to improve mortality
- mineralocorticoid receptor antagonists improve mortality
what is a side effect and alternative of furosemide for heart failure?
hypokalaaemia. swap with spiroloactone
what is the emergency management of acute heart failure?
- sit the patient upright
- high flow oxygen
- diamorphiine 1.25-5mg IV
- furosemide 40-80mg IV
- GTN spray
what are causes of acute pulmonary oedema?
- left ventricular failure
- arrhythmia
- malignant hypertension
- acute respiratory distress syndrome
- fluid overload
- heart failure
- neurogenic
what are symptoms of acute pulmonary oedema?
dyspnoea orthopnea pink frothy sputum distressed pale sweaty tachycardia increased JVP lung crackles gallop rhythm wheeze often sits up/sleeps with pillows
what is seen on a CXR of someone with pulmonary oedema?
- cardiomegaly
bilateral shadowing
effusions at the costophrenic angles
kerley B lines
what is the management of acute pulmonary oedema
- treat the underlying causes
- sit the patient upright
- nitrates
- morphine
- IV frusemode
- dobutamine is hypotension or reduced perfusion
what are indications for incubation in acute pulmonary oedema?
- hypercapnia, hypoxia, acidosis despite CPAP
- physical exhausion
- decreased consciousness
- cardiogenic shock
