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Year 3 > MedEd chest pain > Flashcards

MedEd chest pain Flashcards

1
Q

what are the 2 types of IHD?

A

stable angina

ACS

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2
Q

what are the 3 types of ACS?

A

unstable angina
NSTEMI
STEMI

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3
Q

how do you differentiate unstable angina, NSTEMI and STEMI?

A

unstable angina= troponin negative
NSTEMI= troponin positive and no ST elevation
STEMI= troponin positive and ST elevation

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4
Q

what ix are done for stable angina?

A

resting ECG
lipid profile
Hba1c

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5
Q

how is stable angina managed?

A

antiplatelet- aspirin or clopidogrel OD
statin
may also give sublingual GTN spray and beta blocker/CCB

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6
Q

what antiplatelets might be given in stable angina

A

aspirin or clopidogrel OD

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7
Q

what is troponin in unstable angina?

A

negative

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8
Q

what ix are done for unstable angina? what will you see

A 
ECG- no changes
troponin
CXR
FBC
GRACE score
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9
Q

how is unstable angina managed first line?

A

300mg aspirin and continue indefinetely

give an antithrombin- fondaparinux

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10
Q

what antithrombin is given for unstable angina first line management?

A

fondaparinux

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11
Q

what score is calculated to decide long term managment for unstable angina and what is done according to scores?

A

calculate the GRACE score
low risk= aspirin and ticagrelor (if bleeding risk apsirin and clopi)
intermediate/high risk= aniography if unstable, angiography and follow up PCI if needed, then ticegrelor and aspirin

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12
Q

what score is calculated to decide long term managment for unstable angina

A

GRACE score

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13
Q

what is troponin in NSTEMI?

A

positive

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14
Q

how do signs and symptoms of NSTEMI differ between men and women?

A 
men= chest pain, sweating, SOB, nausea 
female= chest pain, upper back pain and sweating
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15
Q

what ECG changes are seen in NSTEMI?

A

ST depression

t wave inversion

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16
Q

what is management for NSTEMI?

A

same as unstabe angina
first line: 300mg aspirin and fondaparinoux
calculate grace score
if low risk: ticagrelor and aspirin (if bleeding risk aspirin and clopi)
if high risk: angiography if unstable +PCI if needed, then ticagrelor and apsirin

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17
Q

in what patients might MI be silent?

A

diabetic patients

elderly

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18
Q

what are ECG changes in STEMI?

A

tall T waves
ST depression
ST elevation dependant on artery affected
new onset LBBB

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19
Q

what leads are affected in lateral STEMI?

A

I, avL, V5 and V6

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20
Q

what leads are affected in inferior STEMI?

A

II, III, avF

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21
Q

what leads are affected in anterior/septal STEMI?

A

V1-V4

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22
Q

what artery is compromised in lateral STEMI?

A

LCx

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23
Q

what artery is compromised in anterior STEMI?

A

RCA and/or Lcx

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24
Q

what artery is compromised in anterior/septal STEMI?

A

LAD

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25
Q

what is seen in lead V1 and V6 in LBBB and RBBB and how do you remember this

A 
Left= WiLLiaM so v1 you see W and v6 you see M
Right= MaRRoW so v1 you see M and v6 you see W
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26
Q

how is STEMI managed if they present within 12 hrs and PCI is possible in 2h?

A

300mg aspirin
PCI and angio
if taking anticoags give clopi and aspirin
if not taking anticoags give prasugrel and apsirin
add antithrombins (unfractionated heparin and GlpIIb/IIIa inhibitor
offer drug eluting stent

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27
Q

what antithrombins are given in STEMI?

A

unfractionated heparin

glpIIb/IIIa inhibitor

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28
Q

how is STEMI managed if they present after 12 hrs or PCI is not possible in 2h?

A

fibrinolysis- alteplase and antithrombin
bleeding risk low- ticagrelor and aspirin
bleeding risk high- clopi and aspirin

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29
Q

what fibrinolysis is given if something is high risk vs low risk of bleeding?

A

low risk= ticagrelor and aspirin

high risk= clopi and aspirin

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30
Q

what acronym is used to remember the complications of STEMI/ACS and what does it stand for?

A 
DARTH VADER:
death
arrhythmia 
rupture (ventricular or septal wall) 
tamponade
heart failure 
valvular disease 
aneurysm (ventricular) 
dressler's syndrome 
embolism 
recurrence
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31
Q

what is dressler’s syndrome?

A

inflammation of the pericardium post STEMI/ACS due to an autoimmune reaction

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32
Q

how will dressler’s syndrome present?

A

2-10 days after MI
chest pain (pleuritic)
fever
pericardial rub

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33
Q

what will you see on ECG in dressler’s syndrome?

A

diffuse ST elevation

PR depression

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34
Q

what is pericarditis?

A

inflammation of the pericardium

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35
Q

what is the pericardium filled with?

A

fluid

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36
Q

what are causes of pericarditis and how do you catagorise them?

A

inflammation- dressler’s syndrome, systemic disease eg SLE, sarcoidosis, trauma
infection- coxsackie B/A9 most commonly, mumps, TB
malignancy- also from radiotherapy or anti cancer drugs

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37
Q

what is the most common cause of pericarditis?

A

coxsackie B/A9 virus

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38
Q

who is most likely to get pericarditis?

A

20-50 y/o men

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39
Q

how does pericarditis present?

A 
pleuritic chest pain
pericardial rub
fever 
nausea
dyspnoea
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40
Q

describe chest pain in pericarditis

A

pleuritic
sharp
centrally located
relieved by sitting up and leaning forward

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41
Q

when are where is a pericardial rub heard best? what part of the steth should you use to auscultate it?

A

it is heard at the left sternal edge

when the patient is leaning forward on expiration

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42
Q

what triad is used for cardiac tamponade?

A

becks

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43
Q

what is cardiac tamponade?

A

fluid build up in the pericardium and restricts the heart from pumping

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44
Q

what is becks triad?

A

distended neck veins
decreased BP
distorted (muffled) heart sounds

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45
Q

what is becks tried used for? how do you remember it

A

it is used to recognise pericarditis

you remember it as the 3 Ds (distended neck veins, distorted/muffled heart sounds, decreased BP)

46
Q

what ix are done for pericarditis? why are they done and what will you see?

A

ECG- widespread saddle shaped ST elevation, V2-V6 PR depression
troponin- rule out ACS
CRP- look for inflammation
FBC- if infected WCC may be high
LFTs- tamponade can cause congestion
CXR- is there is effusion you see globular heart
Echo- better at detecting pericardial effusion

47
Q

what does a globular heart on CXR indicate?

A

pericardial effusion

48
Q

if there is pericardial effusion what might you see on CXR?

A

a globular heart

49
Q

how is pericarditis managed?

A 
if idiopathic or viral: NSAIDs (+PPI), colchicine and exercise restrict 
if not idiopathic or viral: do medical management and treat cause
if purulent (pus): IV abx, medical management and consider pericardiocentesis
50
Q

how is pericarditis medically managed?

A

NSAIDs (+PPI)
colcichine
exercise restrict

51
Q

how is cardiac tamponade treated?

A

pericardiocentesis

52
Q

how is pericardiocentesis carried out?

A

insert needle 45 degrees to the xiphoid process

53
Q

how is recurrent cardiac tamponade treated?

A

surgery- pericardiectomy where part of the pericardium is removed to allow the heart to expand and contract properly

54
Q

define atrial fibrillation

A

a supraventricular tachycardia with inappropriate electrical activity and ineffective atrial contraction

55
Q

what are the types of AF?

A 
paroxysmal= terminates in 7 days 
persistent= continues for more than 7 days 
permanent= cannot achieve sinus rhythm
56
Q

what is paroxysmal AF?

A

AF which terminated in 7 days

57
Q

who is more likely to get AF?

A

older people

male sex

58
Q

what are signs and symptoms of AF?

A

irregularly irregular pulse
palpitations
chest pain
SOB/fatigue

59
Q

what ix are done for AF?

A

ECG
Bloods- LFTs, TFTs, UEs
Echo

60
Q

how is AF managed?

A

assess stroke risk with CHADSVASC
if haemodynamically unstable- immediate DCC
if arrhythmia <48 hrs and stable- rate (beta blocker or rate limiting CCB and if not controlled add digoxin) OR rhytmn control (DCC or pharmacological cardioversion= flecanide if no IHD and amiodarone if IHD)
if arrhythmia >48 hrs- offer rate control and anticoagulation (with heparin) for 3 weeks minimum then assess with CHADSVASC for DOAC us, after 3 weeks DCC

61
Q

what are the main complications of AF?

A

thromboembolism (stroke)

worsening HF

62
Q

how is AF managed based off CHADSVASC score?

A

if >1= offer DOAC
if 1 consider DOAC
if DOAC is contraindicated give vit K antagonist
ignore if there is only a score for gender (1 in females does not count)

63
Q

if a DOAC is contraindicated in AF what is given instead?

A

vitamin K antagonist

64
Q

what is the main vit K antagonist?

A

warfarin

65
Q

what type of drug is warfarin?

A

vit K antagonist

66
Q

what type of drugs are verapamil and diltiazem?

A

rate limiting CCBs

67
Q

what is haemodynamic instability?

A

BP <90/60 mmHg

68
Q

how is AF managed if a patient is haemodynamically unstable and how do you identify this?

A

if BP <90/60 mmHg

immediate DCC

69
Q

how is AF managed if a patient is haemodynamically stable and arrythmia has been present for <48 hrs?

A

offer rate control- beta blocker or rate limiting CBB and if still not controlled digoxin
offer rhythmn control after rate control- DCC or pharmacological cardioversion (amiodarone if they have IHD and flecanide if they dont have IHD)

70
Q

how is AF managed if a patient is haemodynamically stable and arrythmia has been present for >48 hrs?

A

rate control and anticoagulate (with heparin) for 3 weeks min
then assess with CHADSVASC for DOAC use
after 3 weeks DCC

71
Q

how is pharmacological cardioversion in AF carried out?

A

flecanide is given if the patient doesnt have IHD

amiodarone is given if the patient has IHD

72
Q

how is rate control carried out in AF?

A

start with a beta blocker or rate limiting CCB

if this doesnt manage rate then use digoxin

73
Q

how does atrial flutter differ from AF?

A

it is faster and ore regular than AF
a sawtooth pattern is seen on ECG
ix and management are the same as in AF

74
Q

what is wolff parkinson white syndrome?

A

a congenital accessory pathway which conducts electrical signals between atria and ventricles

75
Q

what pathway is present in wolff parkinson white?

A

bundle of kent

76
Q

what are causes and associations of wolff parkinson white?

A

mitral valve prolapse
HOCM
ebsteins abnormality

77
Q

what are signs and symptoms of wolff parkinson white?

A 
palpitations 
chest pain
SOB
syncope
dizziness
78
Q

what ix are done for wolff parkinson white syndrome? what will you see

A

12 lead ECG- slurred upstroke/dela wave, short PR interval and broad QRS complex
echo
might see HOCM or ebsteins abnormality

79
Q

what is seen on ECG in wolff parkinson white syndrome?

A

slurred upstroke/delta wave
short PR interval
broad QRS complex

80
Q

how is wolff parkinson white managed?

A

if unstable- DCC

if stable- vagal manoeuvres (carotid sinus massage or valsalve), IV adenosine, temp pacemaker DCC

81
Q

what is supraventicular tachyacrdia?

A

a regular, narrow complex tachycardia (>100bpm) with no p waves

82
Q

what are the 2 types of supraventricular tachycardia and how do they differ?

A

AVNRT- functional re entry circuit (there is a functional conduction block)
AVRT- anatomical reentry circuit (bundle of kent)

83
Q

what are the general arrhythmia signs and symptoms?

A 
palpitations
syncope
dizziness 
chest pain
SOB
84
Q

what medication can cause SVT and how?

A

digoxin if levels are too high

85
Q

what is seen on ECG in AVNRT?

A

absent p waves

tachycardia

86
Q

what is seen on ECG in AVRT?

A

flipped p waves (retrograde) after the QRS complex

tachycardia

87
Q

how is SVT managed?

A 
valsalva manoeuvre
if no effect 6mg adenosine
if no effect 12mg in 1-2 mins 
if no effect verapamil
if no effect DCC

long term management is radiocatheter ablation

is the patient is haemodynamically unstable start with DCC

88
Q

what is v tach?

A

a regular broad complex tachycardia where HR is >100 bmp

89
Q

how many areas of depolarisation are there in vtach? how is this different from normal?

A

lots instead of just one

90
Q

what ix are done for vtach?

A

ECG
UEs
troponin and CK MB

91
Q

what are the 2 types of vtach on ECG and what do you see?

A

monomorphic- regular broad complex QRS complexes (all the same shape)
polymorphic- different shapes of QRS complex, aka torsades de pointe

92
Q

what is torsades de point?

A

polymorphic ventricular tachycardia

93
Q

how is v tach managed?

A

heamodynamically unstable and VT with pulse= DCC
heamodynamically stable and VT with pulse= IV amiodarone and if this fails DCC
torsades de pointes (polymorphic VT)= IV magnesium sulfate
if pulseless start ALS immediately

94
Q

what is v fib?

A

irregular broad complex tachycardia where ventricles contract out of sync

95
Q

what ix are done for v fib?

A

ECG

ABG

96
Q

how is v fib managed?

A 
adult advanced life support algorithm
give oxygen 
IV 1 mg adrenaline every 3-5 mins 
IV 300mg amiodarone after 3 shocks over 3 mins 
treat reversible causes
97
Q

what are the 2 shockable rhythms?

A

pulseless VT

v fib

98
Q

how is adrenaline given in v fib?

A

IV 1mg every 3-5 mins

99
Q

how is amiodarone given in v fib?

A

IV 300mg after 3 shocks over 3 mins

100
Q

what are the types of heart block?

A

1st degree
2nd degree: mobtiz I/wenckebach or mobitz II
3rd degree

101
Q

what is wenkebach?

A

2nd degree heart block type 1

102
Q

what else is wenkebach known as?

A

2nd degree mobtiz type I heart block

103
Q

which heart blocks are symptomatic vs asymptomatic?

A 
asymptomatic= 1st degree and 2nd degree mobitz I
symptomatic= 2nd degree mobtiz II and 3rd degree
104
Q

what is a stoke adams attack? describe what happens in it

A

very sudden onset high degree AV block which causes syncope due to lack of perfusion to the brain

105
Q

what drugs can cause heart block?

A

beta blockers

CCBs

106
Q

what metabolic imbalances can cause heart block?

A

hyperkalemia

107
Q

what are some causes of heart block?

A

post MI/ ACS
drugs- beta blockers or CCBs
hyperkalemia
hypertension

108
Q

what are the ECG changes in the different types of heart block?

A

1st degree= prolonged PR interval
2nd degree mobitz I= prolonged PR interval until a QRS is dropped
2nd degree mobitz II= QRS complex dropped at a regular ratio eg every 3 beats
3rd degree= no association between p waves and QRS complexes

109
Q

what ix are done for heart block?

A

ECG
troponin
serum electrolytes
serum digoxin

110
Q

how is heart block managed?

A

1st degree/2nd degree mobitz 1 asymptomatic= monitor
1st degree/2nd degree mobitz 1 symptomatic= discontinue AV node blockers and query pacemaker/CRT/ICD
2nd degree mobtiz II/3rd degree asymptomatic/mild symptoms= discontinue AV node blockers and pacemaker/CRT/ICD
2nd degree mobtiz II/3rd degree severe symptoms= discontinue AV node blockers and temporary pacing and pacemaker/CRT/ICD

Year 3 (104 decks)

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