Medicine- cardiology Flashcards
Non-ACS causes of raised troponin
Chronic renal failure
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism
Initial investigations in stable angina
- Physical Examination (heart sounds, signs of heart failure, BMI)
- ECG
- FBC (check for anaemia)
- U+Es (prior to ACEi and other meds)
- LFTs (prior to statins)
- Lipid profile
- Thyroid function tests
- HbA1C and fasting glucose
Treatment for acute NSTEMI
Acute NSTEMI treatment: BATMAN B –
Beta blockers unless contraindicated
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative)
M – Morphine titrated to control pain
A – Anticoagulant: Low Molecular Weight Heparin (LMWH) at treatment dose (e.g. enoxaparin 1mg/kg twice daily for 2-8 days)
N – Nitrates (e.g. GTN) to relieve coronary artery spasm Give oxygen only if their oxygen saturations are dropping (i.e. <95%).
What is Dressler’s Syndrome?
This is also called post-myocardial infarction syndrome. It usually occurs around 2-3 weeks after an MI. It is caused by a localised immune response and causes pericarditis (inflammation of the pericardium around the heart). It is less common as the management of ACS becomes more advanced.
Secondary prevention after ACS
Secondary Prevention Medical Management (6 As)
Aspirin 75mg once daily
Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
Atenolol (or other beta blocker titrated as high as tolerated)
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
Some medical comorbidities which raise the risk of atherosclerosis
Diabetes
Hypertension
Chronic Kidney Disease
Inflammatory conditions such as rheumatoid arthritis
Atypical Antipsychotic Medications
Difference between primary and secondary prevention of cardiovascular disease
Primary Prevention – for patients that have never had cardiovascular disease in the past.
Secondary Prevention – for patients that have had angina, myocardial infarction, TIA, stroke or peripheral vascular disease.
Check LFTs within 3 months of starting a statin and again at 12 months why?
Statins can cause a transient and mild rise in ALT and AST in the first few weeks of use and they often don’t need stopping if the rise is less than 3 times the upper limit of normal.
Notable side effects of statins
Myopathy (check creatine kinase in patients with muscle pain or weakness)
Type 2 Diabetes
Haemorrhagic Strokes (very rarely)
Definition of stable angina
Angina is “stable” when symptoms are always relieved by rest or glyceryl trinitrate (GTN)
Gold standard diagnosis angina
CT Coronary Angiography
What should a person with angina who has chest pain 5 minutes after their second dose of GTN do?
Call an ambulance
Drugs (2) for long term symptomatic angina relief
Beta blocker (e.g. bisoprolol 5mg once daily) or;
Calcium channel blocker (e.g. amlodipine 5mg once daily)
Levine’s sign
Clutching fist over sternum when describing chest pain
TIMI Risk score factors
Historical (1 point for each factor) Age 65 yr 3 risk factors for CAD Known CAD (stenosis 50%) Aspirin use in past 7 d Presentation Recent (24 h) severe angina ST-segment deviation 0.5 mm Increased cardiac markers
How soon after a diagnosis of STEMI do you initiate reperfusion therapy?
Immediately and without waiting for other investigations
Goal of treatment for STEMI
Goal is to re-perfuse artery:
thrombolysis (“EMS-to-needle”) within 30 min or
primary PCI (“EMS-to-balloon”) within 90 min (if available)
Which is better in STEMI, thrombolysis or PTI?
Early PCI (12 h after symptom onset and <90 min after presentation) improves mortality vs. thrombolysis with fewer intra-cranial hemorrhages and recurrent MIs
Absolute contraindications to thrombolysis
- Prior intracranial haemorrhage
- Known vascular lesion
- Intracranial neoplasm
- Closed head or facial trauma
- Ischaemic stoke <3months
- Active bleeding
- Suspected aortic dissection
Useful prognostic factor post STEMI
Resting LVEF
Pre-hospital medications to administer possible ACS
Aspirin, oxygen, SL nitroglycerine and morphine
Goal for stent placement or balloon inflation in STEMI should be within how long?
within 90 min
Goal for thrombolysis in STEMI should be within how long?
within 30 minutes
Indications for CABG
Triple-vessel or left main disease
DM
Plaque morphology unfavourable for PCI
Drugs that lower mortality in MI
Aspirin (chew it)
Beta blockers
Beta blocker contraindications
Systolic BP <90
Cardiogenic shock
Severe bradycardia
Second or third degree heart block
Asthma/ emphysema
Peripheral vascular disease
Uncompensated CHF
Which drug should be administered immediately to unstable anginas who are to be managed conservatively?
Ticagrelor a P2Y12 receptor antagonist + aspirin dual therapy
What does the Framingham data calculate?
10 year risk of CAD in a patient with dyslipidemia
Aneurysm size threshold for surgery in men and women
Men 5-5.5cm
Women 4.5cm
Contraindications to statins
Active liver disease High ALT + AST
Triggers for Acute LVF
Iatrogenic (e.g. aggressive IV fluids in frail elderly patient with impaired left ventricular function)
Sepsis
Myocardial Infarction
Arrhythmias
What is the main measure of left ventricular function on echo?
The ejection fraction. This is the percentage of the blood in the left ventricle which is squeezed out with each ventricular contraction. An ejection fraction above 50% is considered normal.
How is the grade of LV failure calculated?
Use Ejection Fraction to Grade LV Dysfunction • Grade I (EF >60%) (Normal) • Grade II (EF = 40-59%) • Grade III (EF = 21-39%) • Grade IV (EF 20%)
CXR findings in Acute LVF
- Cardiomegaly on CXR - defined as cardiothoracic ratio > 0.5.
- Upper lobe venous diversion
Fluid leaking from oedematous lung tissue causes additional xray findings of:
Bilateral pleural effusions
Fluid in interlobar fissures Fluid in the septal lines (Kerley lines)
Management Acute LVF
Use the simple mnemonic Pour SOD for acute LVF:
Pour away (stop) their IV fluids
Sit up
Oxygen
Diuretics
Diagnosis of chronic heart failure
Clinical presentation
BNP blood test (specifically “N-terminal pro-B-type natriuretic peptide” – NT‑proBNP)
Echocardiogram ECG
First line treatment chronic heart failure
ACE inhibitor (e.g. ramipril titrated as tolerated up to 10mg once daily)
Beta Blocker (e.g. bisoprolol titrated as tolerated up to 10mg once daily)
Aldosterone antagonist when symptoms not controlled with A and B (spironolactone or eplerenone)
Loop diuretics improve symptoms (e.g. furosemide 40mg once daily)
If the cause is an MI add aspirin and a statin
Acute treatment of pulmonary oedema
- L – Lasix (furosemide) 40-500 mg IV
- M – morphine 2-4 mg IV: decreases anxiety and preload (venodilation)
- N – nitroglycerin: topical/IV/SL - use with caution in preload-dependent patients (e.g. right HF or RV infarction) as it may precipitate CV collapse
- O – oxygen: in hypoxemic patients
- P – positive airway pressure (CPAP/BiPAP): decreases preload and need for ventilation when appropriate • P – position: sit patient up with legs hanging down unless patient is hypotensive
Drugs that improve survival in heart failure
ACE inhibitors
Beta Blockers
± Mineralocorticoid receptor antagonists
Major risk factors for dilated cardiomyopathy (3)
Alcohol, cocaine, family history
Precipitants of acute pulmonary oedema
Acute tachy- or bradyarrhythmia
Infection, fever
Acute MI
Severe hypertension
Acute mitral or aortic regurgitation
Increased circulating volume (Na+ ingestion, blood transfusion, pregnancy)
Increased metabolic demands (exercise, hyperthyroidism)
Pulmonary embolism
Noncompliance (sudden discontinuation) of chronic CHF medications
CXR signs of dilated cardiomyopathy
Global cardiomegaly (i.e. globular heart), signs of CHF, pleural effusion
Acute pericarditis triad
- Chest pain
- Friction rub
- ECG changes
Acute pericarditis ECG changes
Diffuse ST elevation and PR depression with reciprocal changes in aVR)
Treatment of acute pericarditis
- treat the underlying disease
- anti-inflammatory agents (i.e. high dose NSAIDs/ASA), analgesics
- colchicine reduces the rate of incessant/recurrent pericarditis (ICAP N Engl J Med 2013; 369:1522-1528)
- physical activity restriction until symptom resolution
Classic quartet of cardiac tamponade
- Hypotension
- Increased JVP
- Tachycardia
- Pulsus paradoxus
Medical vs surgical Rx for TIAs/ carotid artery stenosis- what’s the best evidence?
Medical intervention is superior to surgical intervention for symptomatic carotid artery stenosis in terms of stroke prevention ***
What does this CXR show?
Acute LVF
Homan’s sign
DVT
The sign is present where pain in the calf is produced by passive dorsiflexion of the foot.
What’s this?
AF
No p waves, variable and irregular QRS response
Causes of acute AF
PIRATES
P- Pulmonary disease
I- Ischaemia
R- Rheumatic heart disease
A- Anaemia/ Atrial myxoma
T- Thyrotoxicosis
E- Ethanol
S- Sepsis
What is this? What’s the treatment?
Phlegmasia cerulea dolens
An uncommon severe form of deep venous thrombosiswhich results from extensive thrombotic occlusion (blockage by a thrombus) of the major and the collateral veins of an extremity
Treatment is by catheter-directed thrombolytic therapy, a type of thrombolysis
What does this CXR show?
Aortic dissection
What is this and how does it present?
Kartagener syndrome is characterized by the clinical triad of:
situs inversus
chronic sinusitis and/or nasal polyposis
bronchiectasis
What’s this? And what are some causes of it?
Torsades de pointes
Medications
Hypokalemia (low serum potassium)
Hypomagnesemia (low serum magnesium)
Hypocalcemia (low serum calcium)
Bradycardia (slow heartbeat)
Heart failure
Left ventricular hypertrophy
Hypothermia
Subarachnoid hemorrhage
Hypothyroidism
Dose of clexane (enoxaparin) for DVT Rx
The recommended dosage for treatment of established deep vein thrombosis with CLEXANE is 1.5 mg/kg body weight once daily (150 IU anti-Xa activity/kg body weight)
or
1 mg/kg body weight (100 IU anti-Xa activity/kg bodyweight) twice daily subcutaneously.
An otherwise healthy person with a DVT should be anticoagulated for how long and with what INR?
3-6 months, INR 2-3
What are the primary goals of AF treatment?
Rate control
Prevention of thromboembolism
The three major causes of aortic stenosis
Degenerative calcification
Bicuspid aortic valve
Rheumatic heart disease
Signs of aortic stenosis
Characteristic murmur is systolic, mid-to-late peaking with a crescendo-decrescendo pattern, and radiates to the carotids.
Paradoxical splitting
Aortic stenosis Ix and Mx
Doppler echo is essential to the diagnosis and will show a pressure gradient across the stenotic aortic valve.
Surgical aortic valve replacement was the only effective therapy for aortic stenosis for over 50 years. However there are now transcatheter valve therapies
The DOC in hypertrophic cardiomyopathy, and what sorts of drugs to avoid
Beta blockers. Avoid things that reduce pre-load like diuretics, ACEIs and nitrates
Signs of WPW syndrome on ECG
Short PR interval
Delta waves
Wide QRS complex
Severe sudden chest pain, blood pressure differences between arms, and a widened mediastinum on CXR are suspicious of what?
Aortic dissection
Characteristics of WPW syndrome
Symptoms can include an abnormally fast heartbeat, palpitations, shortness of breath, lightheadedness, or syncope. Rarely, cardiac arrest may occur. The most common type of irregular heartbeat that occurs is known as paroxysmal supraventricular tachycardia
Management of a stable patient with WPW with
a) normal heart rate and
b) tachyarrythmia
a) Amiodarone or procainamide
b) Synchronised cardioversion
Cardiac conditions that require antibiotic prophylaxis before dental procedures
- Prosthetic heart valve
- Valve repair with prosthetic material
- Prior hx of infective endocarditis
- Cyantic congenital heart abnormalities even after repair
Oral amoxycillin an hour before the procedure is the standard regimen
Examples of non-invasive arterial evaluations (2)
Ankle-brachial index
Transcutaneous oxygen measurement
What cardiovascular event is Marfan’s associated with?
Aortic dissection
Which cardiovascular problem is Kawasaki disease associated with?
Coronary artery aneurysms
Which cardiovascular problem is Turner syndrome associated with?
Coarctation of the aorta
Which cardiovascular problem is Down Syndrome associated with?
Ostium primum type of atrial septal defect
Chronic alcohol use does what to the heart?
It causes dilated cardiomyopathy
A harsh systolic crescendo-decrescendo murmur best heard at the left lower sternal border. Valsalva maneuver will increase the intensity of the murmur, as will changing positions from squatting to standing.
Hypertrophic obstructive cardiomyopathy
A systolic murmur with wide splitting of S2 which persists during expiration
Atrial septal defect
Best heard left upper sternal border
An effective treatment for torsades de pointes
Magnesium
Causes of cor pulmonale
Sarcoidosis
Systemic sclerosis
Massive PE
Obstructove sleep apnea
kyphoscoliosis
Obesity with alveolar hypoventilation
End stage pneumoconiosis
Sickle cell anaemia
The most common hereditary thrombophilia
Factor V Leiden
What is angina decubitus?
Decubitus angina occurs when the patient lies down. It is usually a complication of cardiac failure due to the strain on the heart resulting from the increased intravascular volume. Patients usually have severe coronary artery disease.
Asymptomatic severe aortic stenosis patients should be offered what?
Exercise testing
Drugs that slow the heart rate
Beta blockers
Calcium channel blockers
Amiodarone
Digoxin
Antihypertensive for a diabetic patient with proteinuria
ACEI or ARB
Signs of active ischaemia during stress testing
Angina
ST segment changes on ECG
Reduced BP
The coagulation parameter affected by warfarin
Prothrombin time
Virchow triad
Hypercoaguability
Stasis
Endothelial damage
Causes of pericarditis
- Infectious – mainly viral (e.g. coxsackie virus); occasionally bacterial, fungal, TB.
- Immunological – SLE, rheumatic fever
- Uraemia
- Post-myocardial infarction / Dressler’s syndrome
- Trauma
- Following cardiac surgery (post pericardiotomy syndrome)
- Paraneoplastic syndromes
- Drug-induced (e.g. isoniazid, cyclosporin)
- Post-radiotherapy
Calcium Channel Blocker indications
Cardiovascular indications include
- hypertension
- coronary spasm
- angina
- supraventricular dysrhythmias
- hypertrophic cardiomyopathy
- pulmonary hypertension
Also
- Raynaud phenomenon
- subarachnoid hemorrhage
- migraine headaches
Test to confirm diagnosis of hypertension
Home or ambulatory readings
Secondary casues of hypertension
ROPE
Renal disease
Obesity
Pregnancy
Endocrine
Investigations for a newly disgnosed hypertensive patient
- Urine dipstick and albumin-creatinine ratio
- Bloods (HbA1c, U+Es, lipids)
- Fundoscopy
- ECG
First line therapy hypertension <55 and >55
<55 ACEI
>55 CCB
