Hypertension & Acute Coronary Syndrome Flashcards
What are the big 3 causes of chest pain?
Acute coronary syndrome
Pulmonary embolism
Acute aortic syndrome
What is acute aortic syndrome?
AAA
Dissection
Rupture
Penetrating ulcer
What is acute coronary syndrome?
STEMI, NSTEMI, unstable angina
What are the main types of hypertension?
Essential and secondary hypertension
Essential hypertension = cause unknown
What endocrine syndrome is a common cause of secondary hypertension?
Conn’s syndrome
Hyperaldosteronism
What is stage 1, 2 and 3 hypertension
-give the clinic and the ABPM/HBPM readings
1 clinic >140/90, home >130/85
2 clinic >160/100, home >150/95
3 clinic sBP >180 or dBP >120 = severe
What is masked hypertension?
Clinic less than 140/90 but home readings higher
What is accelerated AKA malignant hypertension?
> 180/20 plus hypertensive retinopathy or papilledema
What is the white coat effect?
> 20 systolic or 10 diastolic difference between clinic and average home readings
In basic terms, why does hypertension predispose heart failure?
Heart strain due to pumping against increased resistance
When do you offer ABPM?
If clinic >140/90
What test would you do if you suspected Conn’s syndrome?
Renin aldosterone ratio blood test
What is the 1st and 2nd line management of hypertension?
1st: If aged under 55 years ACEI or ARB
If aged over 55 years or black skin CCB
2nd: aged under 55: (ACEI or ARB) + (CCB or thiazide diuretic)
aged >55 or block skin: CCB + (ACEI or ARB or thiazide)
What is the 3rd line management of hypertension?
ACEI/ARB + CCB + thiazide diuretic
What is the 4th line management of hypertension?
Confirm elevated BP with ABPM
If K <4.5 add low dose spironolactone
If K >4.5 add alpha blocker or beta blocker
What stage of hypertension management is considered resistant hypertension?
4th line management
If blood pressure is uncontrolled on X number of drugs at optimal doses, seek expert help.. how many is X?
4
Which antihypertensive causes angioedema as a SE?
ACEI
Which antihypertensive causes urticaria as a SE?
ARB
Which antihypertensive causes bronchospasm as a SE?
BB
Which antihypertensive causes gout as a SE?
Diuretics
Which antihypertensive causes gingival hypertrophy as a SE?
CCB
Which antihypertensive causes ankle edema as a SE?
CCB
Which antihypertensive causes is also an antiandrogen?
Spironolactone
Which antihypertensive is contraindicated in bilateral renal artery stenosis?
ACEI
Also contraindicated in pregnancy and severe CKD
What is the mechanism of labetalol?
Alpha and beta blocker
What is the mechanism of prazosin?
A1 alpha blocker
What is the BP targets in hypertension?
Age under 80 clinic <140/90
Age over 80 clinic <150/90
What is the effect of spironolactone and thiazide diuretics on potassium?
Thiazide diuretics case hypokalaemia
Spironolactone is potassium sparing - hyperkalaemia
What group of antihypertensives should be used with caution in heart failure
BB
Out of LDL and HDL, which is the good and bad cholesterol
LDL bad, HDL good
What is name of the scoring system for cardiovascular risk? At what cut off should you start primary prevention?
ASSIGN
>20
(Primary prevention is to prevent an event, secondary prevention is after an event to prevent recurrence)
What is the mechanism of statins?
HMG Co-A reductase inhibitor
Xanthomata, xanthelasma and xanthoma are all presentations of dyslipidaemia - which body parts do each refer to?
Xanthomata - fingers
Xanthelasma - eyes
Xanthoma - joints
What sign can be seen in the iris of the eye in severe dyslipidaemia?
Corneal arcus
What food interacts with statins?
Grapefruit juice
Also alcohol, St Johns wort, clarithromycin
Name 4 side effects of statins
Myalgia
Rhabdomyolisis
Raised CK
Transient raise in ALT and AST
What is the 1st line statin?
Atorvastatin
(second line simvastatin)
(statins are taken at night)
What blood tests should you monitor when initiating statins? And when?
At 3 months check LFTs and lipids (total cholesterol, triglycerides, HDL)
Recheck at 1yr
In high cholesterol, what percentage reduction are you aiming for in non-HDL? What do you do if not achieved?
40% reduction in non-HDL cholesterol
If not titrate dose up
What is the second line management of high cholesterol?
Ezetimibe
Put the stages of atherosclerosis in the correct order:
- Atherosclerotic plaque
- Normal
- Fibrous plaque
- Plaque rupture + thrombosis
- Fatty streak
Normal Fatty steak Fibrous plaque Atherosclerotic plaque Plaque rupture + thrombosis
Here are the stages of atherosclerosis:
normal > fatty streak > fibrous plaque > atherosclerotic plaque > plaque rupture + thrombosis
Which stages are clinically silent? At which stages do you see stable angina or intermittent claudication? At which stages to do see ACS, CVAs or leg ischaemia?
Normal / fatty streak both clinically silent
Fibrous plaques and atherosclerotic plaques cause stable angina and intermittent claudication
Plaque rupture causes ACS, CVAs and leg ischaemia
How would you clinically differentiate stable and unstable angina - in terms of triggers and relief
Stable angina is relieved by rest and GTN and provoked by exercise or the cold
Unstable angina occurs at rest and the pain is more intense
What are troponins in unstable angina?
Normal
How could you clinically differentiate an NSTEMI and unstable angina?
Unstable angina typically lasts under 15 minutes unlike a NSTEMI
What test is diagnostic of stable angina?
None - it is a clinical diagnosis
Though perform an ECG, FBC, U+Es, LFTs, a lipid profile, HbA1C and fasting glucose for the work up
GTN vasodilates or vasoconstricts
Vasodilates
During angina symptoms, after how many minutes could you repeat a dose of GTN?
After 5 minutes repeat
If pain still present 5 minutes after the repeat dose, call an ambulance
What is the basic pathology of unstable angina?
Plaque rupture - with a platelet rich clot on top
What scar does a CABG leave? What scar does percutaneous coronary intervention with balloon angioplasty leave? What vein is harvested in a CABG?
CABG - median sternotomy scar
CABG harvest great saphenous vein in the leg
PCI - scar at site of entry at brachial/ femoral artery
What 3 drugs comprise 1st line management of angina
GTN +
75mg aspirin +
BB eg bisoprolol 5mg
(2nd line switch BB to or add CCB eg amlodipine)
(3rd line nicorandil)
(Also a statin)
What is the difference between an STEMI and NSTEMI in terms of basic pathophysiology?
NSTEMI = artery open but severe narrowing STEMI = lumen blocked causing ischemia (time = muscle)
How long do symptoms last in an acute MI?
Longer than 20 mins
What are the ECG features of an NSTEMI?
ST segment depression
T wave inversion
May be normal
What are the ECG features of a STEMI?
> 1mm elevation in 2 adjacent limb leads or >2mm elevation in 1 chest lead
New LBBB
T wave inversion
A lateral MI is due to occlusion of which vessel and where would it be seen on an ECG?
Lateral = left circumflex
aVL, I, v5, v6
An inferior MI is due to occlusion of which vessel and where would it be seen on an ECG?
Inferior = right coronary
aVF, II, III
An anterior MI is due to occlusion of which vessel and where would it be seen on an ECG? BIT CONFUSED IF LEFT CORONARY OR LAD
LEFT CORONARY OR LAD
When to troponins peak? When should they be measured? Why do you need to interpret troponins with caution?
Peak 12-24hr
Measure at onset + repeat at 12hr
Non-specific myocardial damage
(also raised by PE, CKD, sepsis, myocarditis, aortic dissection)
What is the biggest cause of death in acute MI?
Go into v-fib
What is the 1st line Ix for an MI, how quickly should it be given?
12 lead ECG within 10 min of arrival
patients admitted to CCU, HDU or telemetry bed
What is reperfusion therapy for a MI?
PCI or fibrinolysis
If patients with an acute STEMI are not deemed eligible for reperfusion therapy (PCI or thrombolysis) what should they be given?
180mg ticagrelor antiplatelet + aspirin antiplatelet
What are the indications for angiography with PCI (cath lab) for STEMI?
If under 12hr since symptom onset and PCI available within 120mins
What are the indications for thrombolysis for STEMI?
If under 12hr since symptom onset and PCI not available within 120mins
What drugs are given adjuvant to PCI?
Prasugrel and aspirin
What 3 drugs is given for thrombolysis?
Streptokinase
300mg aspirin
180mg ticagrelor
What is initial Mx of an NSTEMI?
BATMAN BB Aspirin 300mg ASAP Ticagrelor Morphine Anticoagulant LMWH fondaparinux 2.5mg (not if going for angiograpy) Nitrate GTN
How do you decide if NSTEMI patients get angiography?
Use scoring system eg GRACE to predict 6 month mortality. If risk >3% angiography (immediate if clinically unstable, within 72hr if stable)
If risk <3% conservative Mx without angiography unless younger patient
What is the conservative management for NSTEMI without angiography?
Ticagrelor + aspirin + fondaparinux
What is the long term management secondary prevention post heart attack?
Cardiac rehab + ACEI + dual antiplatlet therapy + statin
(ACEI rampipril continue indefinitely)
(Dual antiplatelet aspirin + another for 12mth)
(Statin 80mg atorvastatin)
What are the exercise recommendations for cardiac rehab?
20-30 minutes a day to the point of slight breathlessness
What is the mechanism of Dressler’s syndrome? How long post MI does it occur? How would it appear on an ECG?
Autoimmune
2-6wk
Global ST elevation
Management of Dressler’s syndrome?
NSAIDs
How soon after an MI does a VSD present? What murmur does it cause? How is it diagnosed? What is the management?
In 1st week
Pan-systolic murmur
Echo
Surgical
3 wk after an MI a patient presents with fever, pleuritic chest pain and a pericardial rub - what is the diagnosis?
Dressler’s syndrome
with associated pericardial effusion
How soon after an MI does LV free wall rupture present? What is the management
After 1-2 weeks
Urgent pericardiocentesis + thoracotomy
Persistent ST elevation and left ventricular failure following an MI could be caused by what?
LV aneurysm
An early-to-mid systolic murmur following an inferoposterior MI is caused by what?
Acute mitral regurgitation
