passmed cardio Flashcards
Persistent ST elevation after previous MI, is very suggestive of:
and what is a possible consequence of this…
Persistent ST elevation after previous MI, is very suggestive of a left ventricle aneurysm.
Blood stagnates around a left ventricle aneurysm, thereby promoting platelet adherence and thrombus formation.
so can lead to embolic stroke or other systemic embolisms.
general factors potentiating warfarin?
list 3 drugs that will increase INR in people on warfarin (inhibiting the P450 system - allows warfarin to crack on and anticoagulate for longer..)
list 3 drugs that will decrease INR in people on warfarin
(processing it quicker - clots more likely - inducing the cP450 system)
liver disease
P450 enzyme inhibitors
cranberry juice
NSAIDs - displace warfarin from plasma albumin and inhibit platelet function.
INR increasers: antibiotics: ciprofloxacin, erythromycin isoniazid cimetidine,omeprazole amiodarone allopurinol imidazoles: ketoconazole, fluconazole SSRIs: fluoxetine, sertraline ritonavir sodium valproate acute alcohol intake quinupristin
INR decreasers: antiepileptics: phenytoin, carbamazepine barbiturates: phenobarbitone rifampicin St John's Wort chronic alcohol intake griseofulvin smoking (affects CYP1A2, reason why smokers require more aminophylline)
when something sounds like ACS - but has
chest pain in the back - what are you thinking?
if you see ST elevation in leads II,III and aVF - what are you thinking now?
think aortic dissection!!
Inferior ST elevation - this may be found on the ECG of patients with thoracic aortic dissection involving the ostium of the right coronary artery (makes sense tbf..)
duke criteria - what is it for and what are the criteria…
- IE
to diagnose - need pathological criteria to be positive / 2 major criteria / 1 maj and 3 minor / 5 minor..
major: 1. POSITIVE BLOOD CULTURES - 2 positive BCs showing organisms consistent with IE: strep viridans (ie gram positive streptococci) 2. evideence of endocardial involvement (positive echo / new valvular regurg)
minor:
fever >38
predisposing heart condition or IVDU
micro evidence that doesnt meet the major criteria
vascular phenomena: eg. janeway lesions and splinter haemorrhages..
immunological phenomena:
GN / Osler’s nodes / Roth spots…
which medications should all patients post MI recieve
what lifestyle modificaitons
All patients should be offered the following drugs:
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
Some selected lifestyle points:
diet: advise a Mediterranean style diet, switch butter and cheese for plant oil based products. Do not recommend omega-3 supplements or eating oily fish
exercise: advise 20-30 mins a day until patients are ‘slightly breathless’
sexual activity may resume 4 weeks after an uncomplicated MI. Reassure patients that sex does not increase their likelihood of a further MI. PDE5 inhibitors (e.g, sildenafil) may be used 6 months after a MI. They should however be avoided in patient prescribed either nitrates or nicorandil
when to operate in someone with aortic stenosis
Aortic stenosis management: AVR if symptomatic, otherwise cut-off is gradient of 40 mmHg across the valve and features of LV systolic dysfunction
what investigation NEEDS to be done prior to a CTPA in a suspceted PE?
CXR - to rule out other pathologies causing chest pain, such as a pneumothorax.
this should happen prior to a CTPA or V/Q in suspected PE’s.
differentiation of aortic sclerosis and aortic stenosis?
both have ejection systolic murmurs heard best in the aortic region
BUT
Aortic STENOSIS will likely have radiation to the carotids AND ECG changes
aortic sclerosis probably won’t have either of them..
man presenting with dyspnoea, peripheral oedema and a positive Kussmaul’s sign (the raised JVP that doesn’t fall with inspiration) - what do you suspect….
what would you suspect with a negative kussmauls sign (raised JVP that falls with inspiration…)
constrictive pericarditis - CONSTRICTIVE - hence when you breath in it rises…
cardiac tamponade…
(also get pulsus paradoxus in constrictive pericarditis - decrease in SV significant on inspiration…)
falling BP, rising JVP and muffled heart sound
whats the triad?
what is it characteristic of..?
Beck’s triad
cardiac tamponade
how to remeber RBBB and LBBB
One of the most common ways to remember the difference between LBBB and RBBB is WiLLiaM MaRRoW
in LBBB there is a ‘W’ in V1 and a ‘M’ in V6
in RBBB there is a ‘M’ in V1 and a ‘W’ in V6
antiplatelets and mechanisms of action..
Medication Mechanism of action
Aspirin Antiplatelet - inhibits the production of thromboxane A2
Clopidogrel Antiplatelet - inhibits ADP binding to its platelet receptor
Enoxaparin Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa
Fondaparinux Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa
Bivalirudin Reversible direct thrombin inhibitor
Abciximab, eptifibatide, tirofiban Glycoprotein IIb/IIIa receptor antagonists
1st line HF management:
- drugs
2.
?salt and water restrict to 1.5l per day…
diet advice
cardiac rehab..?
- first line ACEi + b-blocker - start 1 at a time..
2nd line - aldosterone antagonist (spironolactone)
3 rd line - cardiac resynchronisation therapy or digoxin** or ivabradine
diuretics for fluid overload
annual influenza vaccine
one off (unless hyposplenia etc..) pneumococcal vaccine
Complete heart block following a MI? - -which artery is the lesion in..
Complete heart block following a MI? - right coronary artery lesion
why might you get hypertension in aortic dissection?
catecholoamine surge
