GP - Cardio Flashcards
Describe chronic coronary syndrome
Stable angina - relieved by rest/GTN spray
Describe acute coronary syndrome
Unstable angina
Non-ST-elevation myocardial infarction = elevated troponin, CK, myoglobin
ST-elevation myocardial infarction = elevated troponin, CK, myoglobin + ST elevations on ECG
What is the management for stable angina?
- Lifestyle changes
- Medication (aspirin + statin + BB/CCB)
- Percutaneous coronary intervention
- Surgery
What is the immediate management for acute coronary syndrome?
- ECG
- Aspirin 300mg
- O2 if sats <94%
- Morphine (pain)
- Nitrate (pain/HTN)
What is the management for a STEMI?
- Aspirin 300mg
- P2Y12 receptor antagonist = ticagrelor/prasugrel
- Unfractionated heparin
- PCI within 2 hours of onset of sx
- Fibrinolysis (if delay in PCI) - ECG 60-90 minutes after
What is the management for a NSTEMI?
- Aspirin 300mg
- Fondaparinux (if no immediate PCI planned)
- Estimate 6 month mortality (GRACE)
Low risk = ticagrelor
Moderate/high risk = PCI, prasugrel/ticagrelor, unfractionated heparin, drug-eluting stents
What is the management for widespread coronary disease/recurrent MIs?
Coronary artery bypass graft (CABG)
What is Dressler’s syndrome, what are the clinical features and what is the management?
- 2-6 weeks post MI
- Fever
- Pleuritic pain
- Pericardial effusion
- Raised ESR
- NSAIDs
What are the stages of HTN?
Stage 1 = 140/90
Stage 2 = 160/90
Stage 3 = 180/120 (malignant)
What is heart failure?
Heart is unable to pump enough blood to meet the metabolic needs of the body
What is the main cause of acute heart failure?
Dressler’s syndrome - swelling/inflammation of sac around heart post MI
What is the management for acute heart failure?
OMFG:
- Oxygen
- Morphine
- Furosemide
- GTN spray
What are the main causes of chronic heart failure (diastolic)?
- Hypertrophic obstruction cardiomyopathy
- Restrictive cardiomyopathy
- Cardiac tamponade
- Constrictive pericarditis
What are the main causes of chronic heart failure (systolic)?
- Ischaemic heart disease
- Dilated cardiomyopathy
- Myocarditis
- Arrhythmias
What are the causes of left/right sided heart failure?
Left = hypertension/aortic stenosis/aortic regurgitation/etc.
Right = usually occurs after left-sided/pulmonary HTN/OSA
What are the features of left sided heart failure?
- Pulmonary oedema
- Dyspnoea/orthopnoea/paroxysmal nocturnal dyspnoea
- Bibasal fine crackles
- Cyanosis
- Reduced capillary refill
What are the features of right sided heart failure?
- Weight gain
- Peripheral oedema
- Raised JVP
- Hepatomegaly
What is the first investigation for heart failure?
NT-proBNP - released when cardiomyocytes are stretched
<400pg/ml = normal
400-2000pg/ml = moderate
>2000pg/ml = severe
What are other investigations for heart failure?
- Echo
- CXR - ABCDEF
- ECG
- Bloods
What features on a chest x-ray would indicate heart failure?
ABCDEF:
- Alveolar oedema (bat wings)
- Kerley B lines (interstitial oedema)
- Cardiomegaly
- Dilated upper lobe vessels of lung
- Effusion (pleural)
- Fluid in horizontal fissure
What is the management for chronic heart failure?
- FIRST LINE = ACE-inhibitor and beta blocker
- Aldosterone antagonist (spironolactone)
^ ACEis and spironolactone can both cause hyperkalaemia - Hydralazine
- Digoxin
- Furosemide
How can AF be classified?
- First detected episode
- Paroxysmal = terminate spontaneously
- Persistent = not self-terminating
- Permanent = continuous AF which cannot be cardioverted
What are the aims of AF management?
- Rate control = accept that the pulse will be irregular but slow the rate down to avoid negative effects on cardiac function
- Rhythm control = get the patient back into, and maintain, normal sinus rhythm (cardioversion)
What is the management for AF?
Rate control = BB or rate-limiting CCB e.g. diltiazem or digoxin
Rhythm control = electrical (DC) cardioversion or amiodarone (if structural heart disease) or flecainide
What scoring system is used in patients with AF?
CHA2DS2VASc
- CHF
- HTN
- Age >75 or 65-74
- Diabetes
- Stroke/TIA previously
- Vascular disease
- Sex female
What anticoagulants are given to patients with AF?
DOACs - apixaban, dabigatran, edoxaban, rivaroxavan
Second line = warfarin (where DOACs contraindicated or not tolerated)
What are the clinical features of pericarditis?
- Pleuritic chest pain relieved by sitting forwards
- Non-productive cough
- Dyspnoea
- Flu-like symptoms
- JVP increases on inspiration (Kussmaul’s sign)
What are the ECG changes in pericarditis?
- Saddle-shaped ST elevation
- PR depression
What is the management for pericarditis?
NSAID + colchicine +/- PPI
What is the first line management for HTN?
<55 or diabetic = ACEi e.g. ramipril
> 55 or Afro-Caribbean = CCB e.g. amlodipine
How does the presentation of MI differ from aortic dissection?
MI = intensity builds
Aortic dissection = maximal pain at onset. Migration of pain caudally and weak left-sided pulse due to subclavian artery involvement
What is required for a diagnosis of orthostatic/postural hypotension?
Systolic drop >20mmHg at 1 or 3 minutes after lying/sitting for 5 minutes
When are pacemakers indicated?
- Symptomatic bradycardia
- Type 2 heart block
- Third degree heart block
- Atrioventricular node ablation for AF
- Severe HF
Describe single-chamber pacemakers
- Lead in either RA or RV
- RA = issue with SAN and conduction through AVN is normal = stimulate depolarisation in RA which passes to LA and ventricles
- RV = conduction through AVN is abnormal = stimulate ventricles directly
Describe dual-chamber pacemakers
- Leads in RA and RV
- Pacemakers coordinates contractions of atria and ventricles
Describe biventricular (triple-chamber) pacemakers
- Leads in RA, RV and LV
- Usually in patients with severe HF
- Coordinate contraction of chambers to optimise heart function = cardiac resynchronisation therapy (CRT)
Describe implantable cardioverter defibrillators
- Continually monitor heart and apply defibrillator shock if ventricular tachycardia or ventricular fibrillation is identified
Used in:
- Previous cardiac arrest
- Hypertrophic obstructive cardiomyopathy
- Long QT syndrome
How are pacemakers identified on ECGs?
Sharp vertical line
- Before P wave = atria
- Before QRS complex = ventricles
What is the management for bradycardia?
500mcg IV atropine
What is the management for supraventricular tachycardia?
- Vagal manoeuvres
- IV adenosine 6mg/12mg/18mg (verapamil if asthmatic)
- Electrical cardioversion
Prophylaxis = beta blockers/radiofrequency ablation
Give 4 examples of calcium channel blockers
- Amlodipine
- Lercanidipine
- Diltiazem
- Verapamil
