MedEd chest pain Flashcards
what are the 2 types of IHD?
stable angina
ACS
what are the 3 types of ACS?
unstable angina
NSTEMI
STEMI
how do you differentiate unstable angina, NSTEMI and STEMI?
unstable angina= troponin negative
NSTEMI= troponin positive and no ST elevation
STEMI= troponin positive and ST elevation
what ix are done for stable angina?
resting ECG
lipid profile
Hba1c
how is stable angina managed?
antiplatelet- aspirin or clopidogrel OD
statin
may also give sublingual GTN spray and beta blocker/CCB
what antiplatelets might be given in stable angina
aspirin or clopidogrel OD
what is troponin in unstable angina?
negative
what ix are done for unstable angina? what will you see
ECG- no changes troponin CXR FBC GRACE score
how is unstable angina managed first line?
300mg aspirin and continue indefinetely
give an antithrombin- fondaparinux
what antithrombin is given for unstable angina first line management?
fondaparinux
what score is calculated to decide long term managment for unstable angina and what is done according to scores?
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
what score is calculated to decide long term managment for unstable angina
GRACE score
what is troponin in NSTEMI?
positive
how do signs and symptoms of NSTEMI differ between men and women?
men= chest pain, sweating, SOB, nausea female= chest pain, upper back pain and sweating
what ECG changes are seen in NSTEMI?
ST depression
t wave inversion
what is management for NSTEMI?
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
in what patients might MI be silent?
diabetic patients
elderly
what are ECG changes in STEMI?
tall T waves
ST depression
ST elevation dependant on artery affected
new onset LBBB
what leads are affected in lateral STEMI?
I, avL, V5 and V6
what leads are affected in inferior STEMI?
II, III, avF
what leads are affected in anterior/septal STEMI?
V1-V4
what artery is compromised in lateral STEMI?
LCx
what artery is compromised in anterior STEMI?
RCA and/or Lcx
what artery is compromised in anterior/septal STEMI?
LAD
what is seen in lead V1 and V6 in LBBB and RBBB and how do you remember this
Left= WiLLiaM so v1 you see W and v6 you see M Right= MaRRoW so v1 you see M and v6 you see W
how is STEMI managed if they present within 12 hrs and PCI is possible in 2h?
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
what antithrombins are given in STEMI?
unfractionated heparin
glpIIb/IIIa inhibitor
how is STEMI managed if they present after 12 hrs or PCI is not possible in 2h?
fibrinolysis- alteplase and antithrombin
bleeding risk low- ticagrelor and aspirin
bleeding risk high- clopi and aspirin
what fibrinolysis is given if something is high risk vs low risk of bleeding?
low risk= ticagrelor and aspirin
high risk= clopi and aspirin
what acronym is used to remember the complications of STEMI/ACS and what does it stand for?
DARTH VADER: death arrhythmia rupture (ventricular or septal wall) tamponade heart failure valvular disease aneurysm (ventricular) dressler's syndrome embolism recurrence
what is dressler’s syndrome?
inflammation of the pericardium post STEMI/ACS due to an autoimmune reaction
how will dressler’s syndrome present?
2-10 days after MI
chest pain (pleuritic)
fever
pericardial rub
what will you see on ECG in dressler’s syndrome?
diffuse ST elevation
PR depression
what is pericarditis?
inflammation of the pericardium
what is the pericardium filled with?
fluid
what are causes of pericarditis and how do you catagorise them?
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
what is the most common cause of pericarditis?
coxsackie B/A9 virus
who is most likely to get pericarditis?
20-50 y/o men
how does pericarditis present?
pleuritic chest pain pericardial rub fever nausea dyspnoea
describe chest pain in pericarditis
pleuritic
sharp
centrally located
relieved by sitting up and leaning forward
when are where is a pericardial rub heard best? what part of the steth should you use to auscultate it?
it is heard at the left sternal edge
when the patient is leaning forward on expiration
what triad is used for cardiac tamponade?
becks
what is cardiac tamponade?
fluid build up in the pericardium and restricts the heart from pumping
what is becks triad?
distended neck veins
decreased BP
distorted (muffled) heart sounds
what is becks tried used for? how do you remember it
it is used to recognise pericarditis
you remember it as the 3 Ds (distended neck veins, distorted/muffled heart sounds, decreased BP)
what ix are done for pericarditis? why are they done and what will you see?
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
what does a globular heart on CXR indicate?
pericardial effusion
if there is pericardial effusion what might you see on CXR?
a globular heart
how is pericarditis managed?
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
how is pericarditis medically managed?
NSAIDs (+PPI)
colcichine
exercise restrict
how is cardiac tamponade treated?
pericardiocentesis
how is pericardiocentesis carried out?
insert needle 45 degrees to the xiphoid process
how is recurrent cardiac tamponade treated?
surgery- pericardiectomy where part of the pericardium is removed to allow the heart to expand and contract properly
define atrial fibrillation
a supraventricular tachycardia with inappropriate electrical activity and ineffective atrial contraction
what are the types of AF?
paroxysmal= terminates in 7 days persistent= continues for more than 7 days permanent= cannot achieve sinus rhythm
what is paroxysmal AF?
AF which terminated in 7 days
who is more likely to get AF?
older people
male sex
what are signs and symptoms of AF?
irregularly irregular pulse
palpitations
chest pain
SOB/fatigue
what ix are done for AF?
ECG
Bloods- LFTs, TFTs, UEs
Echo
how is AF managed?
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
what are the main complications of AF?
thromboembolism (stroke)
worsening HF
how is AF managed based off CHADSVASC score?
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)
if a DOAC is contraindicated in AF what is given instead?
vitamin K antagonist
what is the main vit K antagonist?
warfarin
what type of drug is warfarin?
vit K antagonist
what type of drugs are verapamil and diltiazem?
rate limiting CCBs
what is haemodynamic instability?
BP <90/60 mmHg
how is AF managed if a patient is haemodynamically unstable and how do you identify this?
if BP <90/60 mmHg
immediate DCC
how is AF managed if a patient is haemodynamically stable and arrythmia has been present for <48 hrs?
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)
how is AF managed if a patient is haemodynamically stable and arrythmia has been present for >48 hrs?
rate control and anticoagulate (with heparin) for 3 weeks min
then assess with CHADSVASC for DOAC use
after 3 weeks DCC
how is pharmacological cardioversion in AF carried out?
flecanide is given if the patient doesnt have IHD
amiodarone is given if the patient has IHD
how is rate control carried out in AF?
start with a beta blocker or rate limiting CCB
if this doesnt manage rate then use digoxin
how does atrial flutter differ from AF?
it is faster and ore regular than AF
a sawtooth pattern is seen on ECG
ix and management are the same as in AF
what is wolff parkinson white syndrome?
a congenital accessory pathway which conducts electrical signals between atria and ventricles
what pathway is present in wolff parkinson white?
bundle of kent
what are causes and associations of wolff parkinson white?
mitral valve prolapse
HOCM
ebsteins abnormality
what are signs and symptoms of wolff parkinson white?
palpitations chest pain SOB syncope dizziness
what ix are done for wolff parkinson white syndrome? what will you see
12 lead ECG- slurred upstroke/dela wave, short PR interval and broad QRS complex
echo
might see HOCM or ebsteins abnormality
what is seen on ECG in wolff parkinson white syndrome?
slurred upstroke/delta wave
short PR interval
broad QRS complex
how is wolff parkinson white managed?
if unstable- DCC
if stable- vagal manoeuvres (carotid sinus massage or valsalve), IV adenosine, temp pacemaker DCC
what is supraventicular tachyacrdia?
a regular, narrow complex tachycardia (>100bpm) with no p waves
what are the 2 types of supraventricular tachycardia and how do they differ?
AVNRT- functional re entry circuit (there is a functional conduction block)
AVRT- anatomical reentry circuit (bundle of kent)
what are the general arrhythmia signs and symptoms?
palpitations syncope dizziness chest pain SOB
what medication can cause SVT and how?
digoxin if levels are too high
what is seen on ECG in AVNRT?
absent p waves
tachycardia
what is seen on ECG in AVRT?
flipped p waves (retrograde) after the QRS complex
tachycardia
how is SVT managed?
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
what is v tach?
a regular broad complex tachycardia where HR is >100 bmp
how many areas of depolarisation are there in vtach? how is this different from normal?
lots instead of just one
what ix are done for vtach?
ECG
UEs
troponin and CK MB
what are the 2 types of vtach on ECG and what do you see?
monomorphic- regular broad complex QRS complexes (all the same shape)
polymorphic- different shapes of QRS complex, aka torsades de pointe
what is torsades de point?
polymorphic ventricular tachycardia
how is v tach managed?
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
what is v fib?
irregular broad complex tachycardia where ventricles contract out of sync
what ix are done for v fib?
ECG
ABG
how is v fib managed?
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
what are the 2 shockable rhythms?
pulseless VT
v fib
how is adrenaline given in v fib?
IV 1mg every 3-5 mins
how is amiodarone given in v fib?
IV 300mg after 3 shocks over 3 mins
what are the types of heart block?
1st degree
2nd degree: mobtiz I/wenckebach or mobitz II
3rd degree
what is wenkebach?
2nd degree heart block type 1
what else is wenkebach known as?
2nd degree mobtiz type I heart block
which heart blocks are symptomatic vs asymptomatic?
asymptomatic= 1st degree and 2nd degree mobitz I symptomatic= 2nd degree mobtiz II and 3rd degree
what is a stoke adams attack? describe what happens in it
very sudden onset high degree AV block which causes syncope due to lack of perfusion to the brain
what drugs can cause heart block?
beta blockers
CCBs
what metabolic imbalances can cause heart block?
hyperkalemia
what are some causes of heart block?
post MI/ ACS
drugs- beta blockers or CCBs
hyperkalemia
hypertension
what are the ECG changes in the different types of heart block?
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
what ix are done for heart block?
ECG
troponin
serum electrolytes
serum digoxin
how is heart block managed?
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
