Ischaemic Heart Disease And Atrial Fibrillation Flashcards
What is a MI ?
Necrosis of a section of myocardial tissue due to ischaemia ( an inadequate supply of blood to affected tissue ).
What usually causes an MI ?
An atheromatous plaque that ruptures or erodes in a coronary artery causing a thrombus to form. This can partially or completely block the blood flow in the artery.
What are some risk factors for a MI ?
Male sex
Advancing age
Obesity
Smoking
Hypertension
Physical inactivity
Hypercholesterolaemia
DM
Family history
What are some complications of a MI ?
Heart failure
Stroke
Depression
Sudden death
What lifestyle management should be given to prevent recurrence of a MI ?
Stop smoking
Cardioprotective diet : low salt, low sugar, wholegrain
Increase physical activity
Weight loss
Limit alcohol
What medications should be started when someone has had an MI ?
ACEi
Aspirin + Clopidogrel
Beta blocker
Statin
What indicates a MI ?
Detection of high troponin levels
Symptoms of ischaemia
ECG showing ST-T changes or new left bundle branch block
Development of pathological Q waves
What are some differentials for an MI ?
Cardiac :
- pericarditis
- myocarditis
- mitral valve prolapse
- Aortic dissection
Pulmonary :
- PE
GI :
- peptic ulcer
- pancreatitis
- cholecystitis
What is angina ?
A clinical syndrome of chest pain or pressure that accompanies periods of MI. It is usually aggravated by by activities which increase myocardial demand for oxygen.
What are the clinical features of angina ?
Tight, dull or heavy discomfort often seen retrosternally or left side
Fatigue
Nausea
What are some conditions which precipitate atherosclerosis ?
Hypertension
Hypercholesterolaemia
Smoking
Diabetes
What are some differentials for angina ?
Aortic stenosis
Hypertrophic cardiomyopathy
Mitral valve prolapse
Aortic dissection
PE
GORD
Gastritis
Pancreatitis
What investigations should be performed when suspecting angina ?
Blood tests
CXR
ECG
What medication should be used for an acute attack of angina ?
Short acting nitrate
What is the management of unstable angina ?
Aspirin and antithrombin therapy
Offer fondaparinux
Offer coronary angiography with follow on PCI within 72 hours of admission
What is the management of chronic angina ?
Lifestyle measures - increase physical activity, stop smoking, increase food and veg, weight control.
Manage stress
GTN spray
Consider aspirin, ACEi
Offer statin and treatment for high blood pressure
What is atrial fibrillation ?
A supraventricular tachyarrhythmia characterised by ineffective, chaotic, irregular and rapid atrial activity resulting in the deterioration of atrial mechanical function.
What score should be used to assess stroke risk in patients with AFIB and when should it be used ?
CHA2DS2-VASc stroke risk score
Symptomatic or asymptomatic paroxysmal persistent or permanent atrial fibrillation
Atrial flutter
Continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm
When should you offer an anticoagulant in AFIB and which one should you offer ?
The CHA2DS2-VASc score is 2 or above
Apixaban, dabigatran, edoxaban and rivaroxaban
What should be offered if a DOAC is contra-indicated in AFIB ?
Vitamin K antagonist
What is the primary pathologic change in AFIB ?
Progressive fibrosis of the atria which is primarily due to atrial dilation.
What are some potential causes of AFIB ?
Hypertension
Cardiac valve disease
Coronary artery disease
Left ventricular systolic dysfunction
Thyrotoxicosis
Sepsis
What are some features of paroxysmal AFIB ?
It is usually self terminating and recurrent
Episodes may last up to 7 days and after 48 hours the probability of spontaneous conversion is low and anticoagulation is required.
Often more asymptomatic
What is persistent AFIB ?
Does not self terminate and lasts for more than 7 days or cardioversion is needed to restore sinus rhythm
Recurrent
What are some clinical features of AFIB ?
Asymptomatic
Palpitations
Chest pain
Hypotension
Dyspnoea
Dizziness / syncope
What should an initial evaluation of AF involve ?
Determination of the European Heart rhythm association score
Estimation of stroke risk
Search for conditions associated with AF - hypertension
Search for complications of arrhythmia - stroke
What should be included in the physical exam into of an AFIB patient ?
BP
HR
Presence of a cardiac murmur
Evidence of heart failure
What score is used to assess bleeding risk in patients with AF ?
ORBIT bleeding risk score
When should you offer monitoring and support to modify risk factors for bleeding ?
Uncontrolled hypertension
Poor control of INR in patients on vit K antagonists
Harmful alcohol consumption
Reversible causes of anaemia
Medications such as antiplatelets, SSRI’s and NSAIDs
What is the principle investigation for AF ?
ECG and should be done in all patients whether symptomatic or not - irregular pulse
12 lead ECG
What should be performed if paroxysmal AF is suspected and isn’t detected by standard ECG recording ?
A 24 hour ambulatory ECG monitor should be used
Other than ECG what investigations should be performed when suspecting AF ?
FBC
U & E
Thyroid function test
CXR
Echocardiography
What are the main goals of management of AF ?
Urgent control of the ventricular rate
Restoration of sinus rhythm by drugs or electrical means
Prevention of thromboembolic complications
Prevention of recurrence
What is DC cardioversion of AF ?
Requires a light general anaesthetic or sedation with IV diazepam
The DC shock is synchronised with an R wave and presence of 2 or more consecutive P waves after shock delivery is considered an indication of success
What are some non-drug management options of AF ?
DC cardioversion
Pacemaker implantation
Radio frequency ablation
Surgical intervention
What are the 3 aims in the drug treatment of AF ?
Control the ventricular rate
Chemical cardioversion to sinus rhythm
Prevention of thromboembolism
what medications should be given for AF ?
Beta blocker or rate limiting CCB
Anticoagulation - warfarin or DOAC
What should be avoided in patients with paroxysmal AF ?
Alcohol and caffeine
What are some complications of AF ?
Stroke
Thromboembolism
HF
What follow up should be organised for patients with AF ?
Within 1 week of starting rate control meds have a follow up to assess if the patient is tolerating the drug and review symptoms, HR and BP.
When on warfarin a patient should have their INR measured daily until it is within the desired range.
How should i review a person with AF ?
Check symptoms
Review medications
Reassess the persons stroke risk using the CHA2DS2-VASc assessment tool and bleeding risk
Assess cardiovascular risk
Assess for complications or AF
