IHD, Angina + MI Flashcards
Stable angina?
Onset on exertion, relief with rest/GTN
Unstable angina?
Onset at rest, some relief from GTN
NSTEMI?
No egg changes, rise in troponin
STEMI?
ST elevation + troponin rise
New onset bundle branch block?
MI until proven otherwise - treat as STEMI
Causes of troponin elevation?
MI Heart failure Myocarditis/pericarditis LVH CKD Diabetes CPR/cardioversion
Syndrome X?
Angina triggered by emotion/anxiety, no abnormalities of arteriography
Prinzmetal’s variant angina?
Vasospasm of coronary arteries, at rest with ST segment elevation
ACS treatment?
Oxygen Morphine Aspirin Nitrates Beta blockers Clopidogrel Reperfusion
Thrombolysis drugs?
Alteplase,
Reteplase
Streptokinase
Tenecteplase
Post MI cocktail?
ACE
Beta blocker
Statin
Dual antiplatelet
When can second antiplatelet be stopped?
12 months post MI
ST elevation V1-V6?
Anterior MI - LAD
ST elevation II, III, aVf?
Inferior MI - RCA
What does RCA supply?
NODES - SAN + AVN
ST elevation - I, aVL, V5, V6?
Lateral MI - left circumflex
Common causes of chest pain?
Angina ACD Oesophagitis PE Pneumothorax dissecting AA chest wall pain
What is troponin I bound to?
Myosin
Consequences of MI?
Death Arrhythmia Rupture Tamponade Heart failure Valve disease Aneurysm Dressler's syndrome Embolism Recurrence
What is cardiac tamponade?
Reduced ventricular filling due to accumulation of blood/pus/clots in pericardial space
Triad of acute cardiac tamponade?
Distant heart sound
Decreased arterial blood pressure
Distended neck veins
(also pulses paradoxus present)
What is dressler’s syndrome?
Late onset pericarditis - 6 weeks post MI Fever Pleuritic pain Pericardial effusion Raised ESR
What is pulsus paradoxus?
Large drop in BP on inspiration
What is pericarditis?
Inflammation of pericardium - protective covering of the heart
Viral causes of pericarditis?
Coxsackie B echovirus
Bacterial causes of pericarditis?
Rare - staph - fatal, strep, pneumococcal, meningococcal
Where to listen for pericardial friction rub?
Lower left sternal edge, expiration, patient leaning forwards
Symptoms of pericarditis?
Pain
Fever
Dyspnoea
Pericardial friction rub
ECG of pericarditis?
Diagnostic - saddle snapped ST elevation
PR segment depression
Treatment of pericarditis?
Bed rest and NSAIDs
Constrictive pericarditis?
Thickened pericardium due to chronic inflammation - bacteria, TB, rheumatic heart disease - affects ventricular filling
Decubitus angina?
Triggered by lying flat
Most common cardiac tumour?
Myxoma - benign
Secondary hypertension?
Renal conditions Thyroid Cushing's Preeclampsia Hyperaldosteronism Obstructive sleep apnoea Malignancy Acromegaly Coarction Conn's Pheochromocytoma,
Signs of hypercholesterolemia?
Xanthelasmas
Corneal arcus
Xanthomas on elbows, knees, and buttocks
Mild hypertension?
140/90
Moderate hypertension?
160/100
Severe hypertension?
180/110
Other investigations when diagnosing hypertension?
Urinalysis - renal disease
Blood glucose - diabetes
Lipid profile - cardiovascular risk
ECG - LVH
What is coarctation of the aorta?
Congenital narrowing of the aorta, usually distal to the ligamentum arteriosum
Finding in coarctation?
Hypertension in upper limb, absent/weak pulses in lower limb
Isolated systolic hypertension?
Rise in systolic but not diastolic - hyperthyroidism, artery stiffness, diabetes or valvular disease
White collar syndrome?
Raise in blood pressure when taken by a medical professional but normal at home
Consequences of hypertension?
Cardiovascular disease Renal disease Heart failure Retinopathy Acute dissection
How does hyperthyroidism cause hypertension?
Thyroxine exacerbates the effect of sympathetic nervous system = increased vascular resistance + cardiac output
How does hypothyroidism cause hypertension?
slows heart rate, vascular resistance increases to compensate
Conn’s syndrome?
Hyperaldosteronism due to adrenal adenoma
Most common cause of hyperaldosteronism?
Adrenal hyperplasia
Cushing’s syndrome?
Excess cortisol secretion - pituitary or adrenal tumour or use of exogenous steroids
Initial antihypertensive for <55 non-black
Ace inhibitor, beta blocker if not tolerated
Initial antihypertensive >55 black
Calcium channel blocker or thiazide like diuretic if not suitable
Step 2 hypertension treatment?
ACE + CCB or ACE + diuretic - use ARB in black patients
Step 3 hypertension treatment?
ACE/ARB + CCB + thiazide like diuretics
Step 4 hypertension treatment?
Spironolactone, consider alpha blocker or beta blocker
What is pheochromocytoma?
Rare tumour derived from chromaffin cells that secretes catecholamines, usually in the adrenal medulla
Symptoms of pheochromocytoma?
Headache Sweating Palpitations Tremor Nausea Weakness Anxiety Sense of doom Tremo Hypertensive retinopathy
How to treat dressler’s syndrome?
NSAIDs
Most common cause of death post-MI?
Ventricular fibrillation
When do patients get heart block post MI?
Inferior MIs (most commonly)
Presentation of aneurysm post MI?
Left ventricular aneurysm
Persistent ST elevation in anterior leads
Left ventricular failure
How does a ventricular septal defect present?
Rupture of intraventricular septum
Acute heart failure
Pansystolic murmur
Who gets acute mitral regurgitation post MI?
Infero-posterior infarction
Papillary muscle rupture
Early - mid systolic murmur
What is Kussmaul’s sign?
Increased JVP on inspiration
Sign of constrictive pericarditis
Features of constrictive pericarditis?
Dyspnoea Right heart failure JVP - prominent x and y descent Pericardial knock - loud S3 Kussmaul's sign Pericardial calcification
Cardiac tamponade vs constrictive pericarditis?
CT - absence Y descent
CP - X+Y present
Pulsus paradoxus - CT
Kussmaul’s - CP
Causes of angina
Atheroma Anaemia Coronary artery spasm Tachyarrhythmias Aortic stenosis
Precipitants of angina
Exertion
Emotion
Cold weather
Heavy meals
Symptoms of angina
Pain - central into jaw + neck
Dyspnoea
Nausea
Sweatiness
Management of angina
GTN spray
1st - B-blocker or CCB. ACEi if diabetes. Low dose aspirin
2nd - long acting nitrate, Nicorandil or Ivabradine
3rd - PCI or CABG
What is troponin?
Proteins involved with cardiac and skeletal muscle contraction. Released in myocardial cell damage.
Trop I + T are most cardiac specific
How can you differentiate between rises of troponin?
MI / acute damage - likely to continue rising
Other insults - unlikely to change hour to hour
