CVS Long Case (UKM) Flashcards

1
Q

List the possible differentials (life-threatening) for ACS

A
  • Aortic dissection
  • Pulmonary embolism
  • Pneumothorax
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2
Q

What is the immediate management of STEMI?

A

Immediate investigations:
- ECG within 10 minutes of arrival
- Set up 2 IV access
- Other urgent investigations: cardiac troponin, FBC, RP, glucose, lipid profile

  • Put on continuous cardiac monitoring
  • Assess hemodynamic status
  • Medications: Aspirin 300mg STAT, Clopidogrel 300mg STAT, Sublingual GTN if SBP >90mmHg
  • Supportive treatments:
    1. Pain relief: IV MORPHINE 2-5mg by slow bolus injection every 5-15 minutes + IV antiemetic
    2. Oxygen if SpO2 <90%
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3
Q

What is the definitive treatment of STEMI?

A

Choice of method depends on:
1. Time from symptom onset to first medical contact
2. Any CI to fibrinolytic therapy
3. Any high-risk features

Time from symptom onset to FMC:
1. Early (<3 hours): Both primary PCI and FT are equally effective (But, PCI is preferred if can be done)
2. Late (3-12 hours): PCI is preferred
3. Very late (>12 hours): not required PCI or FT if asymptomatic, PCI if symptomatic

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4
Q

What are the CI for fibrinolytic therapy?

A
  • Risk of intracranial hemorrhage
  • Risk of bleeding
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5
Q

List some high-risk feature in STEMI that requires a PCI to be done

A
  • Large infarct
  • Anterior infarct
  • Hypotension, cardiogenic shock
  • Significant arrhythmia
  • Elderly
  • Post-CABG or Post-PCI
  • Post-infarct angina
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6
Q

Answer the following questions:
Fibrinolytic therapy
1. Golden hour to administer
2. ideal door-to-needle time
3. Regime

A
  1. within hours of symptom onset
  2. 30 minutes
  3. IV tenecteplase single bolus injection
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7
Q

Answer the following questions about PCI
1. Ideal door to balloon time
2. If delay due to transfer is expected, total duration should be less than?
3. What are the pre-procedure preparation, procedure, and post-procedure steps?

A
  1. 90 minutes
  2. <120 minutes
  3. PCI
    Pre-procedure:
    - Dual antiplatelet has been given: ASPIRIN 300mg +
  4. Clopidogrel 300-600 mg loading or
  5. Prasugrel 60mg loading
  6. Ticagrelor 180mg loading
    - Anticoagulation with UFH

Procedure:
- Vascular access: radial artery
- Stenting is performed during PCI using drug-eluting stent

Post-procedure:
- Stop anticoagulation
- Continue dual-antiplatelet for 12 months

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8
Q

Describe about the subsequent management of patient in the CCU

A

Admit all patients with STEMI to CCU

Supportive treatment:
- Pain relief: IV opioids
- Stool softener -> to avoid straining
- O2 to keep SpO2 above 95% via nasal prong

Monitoring
- Continuous vital signs and cardiac monitoring
- Vigilant about early complications of MI

Medical treatment:
- Dual antiplatelet: ASPIRIN 75-100mg daily +
1. Clopidogrel 75mg daily
2. Prasugrel 10mg daily
3. Ticagrelor 90mg BD
- Anticoagulation for patient who received fibrinolytic (LMWH or UFH if patient age>75, renal impairment)
- Beta-blocker (Start ASAP and continue after discharge)
- ACE-inhibitor (Should be started within 24 hour and continue indefinitely)
- High-intensity statin
- Mineralocorticoid receptor antagonist: SPIRONOLACTONE (In patients with LVEF <40% or with heart failure)
- Nitrates: not routinely prescribed

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9
Q

What are the CI in prescribing Beta blocker?

A
  • HR <60bpm
  • SBP <100mmHg
  • Pulmonary congestion
  • Signs of peripheral hypoperfusion
  • 2nd or 3rd degree heart block
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10
Q

What are the risk stratification of patient before discharge?

A
  • Evaluate patient’s short-term risk using STEMI TIMI score
  • For long-term risk assessment: involves a series of investigations
    1. Blood test
    2. Echo to assess LVEF
    3. Stress test -> identify any residual ischemia
    4. Patient who did not undergo PCI should have coronary angiogram if TIMI score is high
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11
Q

Describe the immediate management of non-ST elevation ACS

A
  • 12-lead ECG within 10 minutes of arrival to the ED
  • Examination to look for signs of heart failure
  • Set up IV access and take urgent investigations
    1. Cardiac biomarkers: CK-MB, troponin I
    2. Others: FBC, RBS, lipid profile, BUSE
  • Urgent medications
    1. Aspirin 300mg crushed and swallowed
    2. Clopidogrel 300mg
    3. Sublingual GTN every 5 minutes for maximum 3 times in patient with continuous chest pain
  • Supportive treatment
    1. Oxygen only when SpO2<90% or evidence of respiratory distress
    2. Pain relief: IV Morphine 1-5mg, repeated 5-30 minutes is useful
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12
Q

Once diagnosis of non-STEMI is established, risk stratify the patient early

What is the purpose of risk stratification?

A
  • To categorize patient into high, intermediate or low-risk group
  • To guide subsequent treatment strategy
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13
Q

State the parameters in TIMI risk score

Mnemonic: AMERICA

A

A -> Age >65
M -> Markers (cardiac biomarker) elevated
E -> ECG shows ST segment deviation
R -> Risk factors for CAD (>3): DM, hypertension, hyperlipidemia
I -> Ischemic chest pain >2 episodes in previous 24 hours
C -> Coronary stenosis >50%
A -> Aspirin use within 7 days

Each parameter = 1 point
0-1 = low risk
3-4 = intermediate risk
>5 = high risk

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14
Q

How would you manage the patient after assessing his/her TIMI score?

A

Low to intermediate-risk patient -> ischemic guide strategy, together with further evaluation using a non-invasive test

High-risk patient -> manage with INVASIVE strategy which involves a coronary angiography followed by subsequent revascularization therapy (like PCI, CABG)

Medications:
- Dual antiplatelets: ASPIRIN + CLOPIDOGREL
- Anticoagulation
- Beta-blocker to all patient within first 24 hours
- ACE inhibitor when indicated: hypertension, DM, LVEF <40%
- High-intensity statins to all patient without CI

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15
Q

State the complications of MI
1. Immediate
2. Early
3. Late

A

Immediate
- Cardiac arrest
- Acute heart failure
- Cardiogenic shock

Early
- Papillary muscle rupture
- Pericarditis
- Interventricular septal rupture
- Left ventricular free wall rupture

Late
- Ventricular aneurysm (persistent ST elevation)
- Dressler syndrome
- Arrhythmia
- CCF
- Reinfarction

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16
Q

How would you diagnose and manage cardiogenic shock?

A

Diagnosis:
- SBP<90mmHg or MAP<65mmHg for 30 mins or requires vasopressor to achieve SBP>90mmHg
- Pulmonary congestion or elevated left ventricular filling pressure
- Evidence of impaired organ perfusion

Management:
- Inotropes: Noradrenaline to maintain MAP at least 65mmHg
- Pulmonary artery catheter insertion
- ECMO and LV assist device are last resort

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17
Q

What are the possible triggers to be asked in the current episode for a patient with stable angina?

A
  • Physical exertion
  • Anemia
  • Emotional stress
  • Extreme temperature
  • Tolerance to nitrate
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18
Q

Topic of discussion: Stable angina
If this is a recurrent episode of CAD, what are the possible complications?

Also, what are the high risk features and common conditions associated with CAD

A

Bio -> Ischemic cardiomyopathy
Psycho -> Anxiety
Social -> Limited physical tolerance

High-risk features:
- Angina refractory to medical treatment
- Low level of effort tolerance

Common associated conditions
- Peripheral vascular disease
- Cerebrovascular disease
- Impotence/sexual dysfunction

19
Q

How do you confirm the diagnosis of angina and assess its risk?

A
  • Before any investigation, clinical probability of CAD must be first assessed thoroughly
  • Patients with very low or very high clinical probability often DO NOT require any further non-invasive testing
  • Patients with INTERMEDIATE clinical probability are recommended to undergo further NON-INVASIVE TESTING
20
Q

What are the factors to consider whether revascularization therapy is necessary?

A
  • Angina symptoms that affect quality of life
  • Moderate to severe ischemia based on non-invasive testing
  • Number of coronary vessels involved
  • Anatomical complexity of the lesion
21
Q

State (2) methods of revascularization in a case of stable angina

A
  • Percutaneous coronary intervention (PCI)
  • Coronary artery bypass grafting (CABG)
22
Q

What is the common symptom of infective endocarditis?

Include also other symptoms based on the following headings:
1. Constitutional symptoms
2. Cardiac symptoms
3. Non-specific symptoms

A

Fever

Other symptoms:
Constitutional symptoms: Malaise, Weight loss, night sweats, loss of appetite

Cardiac symptoms: Chest pain, palpitation

Non-specific symptoms: Arthralgia, myalgia, back pain

23
Q

State the risk factors of infective endocarditis

A

Due to thrombus
- Previous insult to the heart
- Pre-existing cardiac disease
- Cardiac prosthesis

Due to the introduction of bacteria
- IVDU
- Conditions that require long-term catheter in situ
- Immunocompromised
- Recent dental procedures**

24
Q

Differentiate between acute IE from subacute IE

A
25
Q

State the most likely organisms for infective endocarditis

A
  • Viridans group streptococci
  • Staph aureus: IVDU, prosthetic valve
26
Q

List some early complications of infective endocarditis

A
  • Heart failure
  • Conduction defect: palpitation, syncope
  • Renal impairment: oliguria
  • Neurological complications
  • Embolic event: leg pain (lower limb), abdominal pain (spleen, mesentery)
27
Q

What are the possible findings to note while examining the hands of a patient with IE?

A
  • Clubbing
  • Splinter hemorrhage
  • Osler’s node
  • Janeway lesion
  • Petechiae
  • Arthritis
28
Q

What are the possible findings to note while examining the face of a patient with IE?

A

Eyes
- Subconjunctival hemorrhage
- Pallor
- Jaundice
- Romana sign (unilateral swelling of the eyeball or eyelid due to bite by the bug that causes Chagas disease)
- Horder spots (Pathognomonic for psittacosis)

Oral cavity -> Oral hygiene

29
Q

State the murmurs one could heard on systemic examination of IE

A
  • Mitral and aortic area
    1. Mitral regurgitation
    2. Aortic regurgitation
30
Q

What are the signs of heart failure?

A
  • Raised JVP
  • Bibasal crepitations
  • S3 gallop
  • Pitting edema
31
Q

How is the diagnosis of IE made primarily?

A

Blood C&S

Echocardiography (Transthoracic echo)
Abnormalities:
- Vegetation
- Abscess
- New dehiscence of prosthetic valve

32
Q

List other assessments required to diagnose IE

A
  • Ventricular function assessment
  • Pulmonary artery pressure
  • Quantification of valvular regurgitation
  • Any pericardial effusion?

Additional investigations to confirm the diagnosis: MODIFIED DUKE’S CRITERIA (can be used in all condition EXCEPT IN)
- Prosthetic valve endocarditis
- Pacemaker/defibrillator lead endocarditis

This is because the conventional echocardiogram might miss the vegetation in these conditions

Additional investigations to increase the sensitivity
- Cardiac CT scan
- PET-CT or radiolabelled leucocyte SPECT

33
Q

State the major and minor criteria of IE

A

Clinical criteria
- 2 major
- 1 major + 3 minor
- 5 minor

34
Q

List the investigations done to monitor IE treatment response

A
  • Repeated blood culture
  • FBC: WCC trend
  • Inflammatory markers
35
Q

What is the definitive treatment of IE?

A

Empirical antibiotic

Consider the following factors:
- Type of valve: native/prosthetic
- If prosthetic: duration since surgery (early: <12 months; late: >12 months)
- Community or healthcare-acquired
- Previous antibiotic use
- Risk factors for fastidious organisms
- Onset: acute or subacute

Generally:
- Community-acquired/late prosthetic: Ampicillin + gentamicin +/- cloxacillin
- Early prosthetic: Vancomycin + Gentamicin + Rifampicin +/- Cefepime

36
Q

What is the subsequent management if the blood culture comes back to be negative IE?

A
  • Consider IE due to atypical organism
  • Consider serological testing and PCR
37
Q

State the indications for urgent surgery in a case of IE

A
  • Severe valvular regurgitation/heart failure/hemodynamic unstable
  • Persistent infection/Perivalvular extension/uncontrolled sepsis
  • Fungal endocarditis
  • Very large vegetation (>10mm)/previous systemic embolization
38
Q

What are the things you should educate IE patients upon discharge?

A
  • Signs of relapse
  • Educate patient not to self-treat with antibiotics if fever recurs
  • Signs and symptoms of heart failure
  • Educate about good oral hygiene and prophylaxis before dental procedures
39
Q

If a patient develops renal impairment throughout the course of IE, what is the possible cause?

A
  • Immune complex or vasculitic glomerulonephritis
  • Renal infarct due to septic emboli
  • Heart failure/sepsis causing pre-renal AKI
  • Antibiotic toxicity: acute interstitial nephritis
  • Contrast-induced nephropathy
40
Q

If you are the houseman that is in charge of a patient with IE, describe how you would take a blood C&S from this patient?

A
  • Blood should only be taken directly from the peripheral vein and not from the central venous catheter
  • I will take at least 3 sets of samples, each taken at least 30 minutes apart
  • I will apply a strict aseptic technique throughout the procedure
41
Q

A patient presented with acute onset of SOB
What are the possible causes (especially life-threatening)

A
  • ACS
  • Pulmonary embolism
  • AECOPD
  • AEBA
  • Pneumothorax
42
Q

What are the causes of acute deterioration of the CCF?

Mnemonic: HEART FAILS

A

H = Hypertension crisis
E = Eat medication (non-compliance), electrolyte disturbances
A = ACS, alcohol consumption
R = Restriction of fluid not followed, renal disease worsening
T = Thyrotoxicosis
F = Fluid retention due to NSAIDs, thiazolidinediones
A = Arrhythmias
I = Infection (pneumonia)
L = Low Hb (anemia)
S = Some other (pulmonary embolism, myocarditis), Stress (emotional or physical)

43
Q

List the complications of heart failure

A
  • Arrhythmias - atrial fibrillation, ventricular arrhythmias (VT, VF), bradyarrhythmias
  • Thromboembolism - stroke, peripheral embolism, DVT, pulmonary embolism
  • MSK - muscle wasting
  • RS - pulmonary congestion, respiratory muscle weakness