Week 4 - Cardiovascular Disease Flashcards
What are the RF for ACS?
Smoking
DM
FHx
HT
High cholesterol
What is the difference between STEMI and NSTEMI?
STEMI results from complete and prolonged occlusion of an epicardial coronary blood vessel and is defined based on ECG criteria.
NSTEMI usually results from severe coronary artery narrowing, transient occlusion, or microembolization of thrombus and/or atheromatous material.
What are the 3 types of ACS?
STEMI
NSTEMI
Unstable angina
What is the criteria for an MI?
Myocardial injury - evidenced by troponin that changes
Also requires clinical presentation consistent with acute MI ischaemia - i.e. chest pain +/- ECG changes.
What can cause troponin to be raised apart from MI?
What is the acute management for ACS?
Aspirin
Fondaparinux
Bisoprolol
GTN
Consider statin + revascularisation if within window
Blockage to which coronary artery can cause ST elevation in V2-5?
LAD
If a STEMI deteriorates into Vfib - what should you do?
Shock them
What is the treatment of choice for STEMI?
PCI
Load P with Prasugrel or Ticagrelor
If PCI cannot be achieved in <2hr - consider Alteplase / Tenecteplase.
What is the management for Non-STE ACS?
Which Ps are very low risk Non-STE ACS?
Those with atypical chest pain, very mild troponin rise and no real ECG changes that are completely fine when they arrive at hospital.
What complications can arise from acute MI?
Poor ventricular function -> pul oedema, shock
Arrhythmias
Mechanical problems - cardiac rupture, VSD, mitral valve dysfunction or rupture
Reinfarction
How do Ps with papillary muscle rupture present in the context of an MI?
Acute severe breathlessness and often shock
Pan systolic murmur
What Rx is given for secondary prevention of ACS?
Higher risk - Ticagrelor or Prasugrel
Lower risk, frailer Ps = Clopidogrel as less bleeding risk
Rampiril - as when you have a scar on your heart it can stretch and remodel and progress to HF in the months and years after an MI.
What things can cause secondary HT?
Which drugs can cause HT?
Why do we do postural drop BP for cardiac exam?
Volume depletion is an indicator for phaeochromocytoma
What is the commonest cause of AF?
Hypertension
What are the signs of HF?
Raised JVP
Oedema
Chest crackles
Murmurs
What is the second commonest cause of HF?
HT
How is hypertensive retinopathy graded?
Grade 1 - 4 (papilloedema)
What blood tests should you do for Ps with HT?
FBC
Renal function / electrolytes
Blood glucose
LFTs
Aldosterone / renin ratio
How can Conn’s syndrome present in bloods?
Low K+
What endocrine conditions can be indicated by high Na and low K+?
Cushing’s syndrome, Hyperaldosteronism
Although cortisol is a glucocorticoid, at high levels, it can bind to mineralocorticoid receptors in the kidneys. Normally, cortisol is inactivated to cortisone by the enzyme 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) in mineralocorticoid target tissues, preventing this binding. However, the high levels of cortisol in Cushing’s disease can overwhelm this inactivation process.
When cortisol binds to mineralocorticoid receptors, it mimics the action of aldosterone, a hormone that regulates sodium and potassium balance.
How can ECGs change in HT?
Can get LVH
Can get strain pattern (lateral T wave inversion)
LBBB
How do we calculate LVH?
Sokalov-Lyon criteria
Tallest R in V5/6
+
S wave V1
> 35mm = LVH
What is the lifestyle advice regarding
- Alcohol
- Salt
- Exercise
- Smoking
- Caffeine
for Ps with HT?
What is the lifestyle advice regarding
- Weight
- Diet
for Ps with HT?
What medication should you prescribe for Ps with HT?
What is the BP target for Ps with diabetes?
130/80
What would you be worried about if Ps displayed the following Sx and had hypertensive emergency?
- Visual disturbance + headache
- Confusion, seizures
- Pulmonary oedema
- Acute chest pain, AR murmur + absent pulses
- Seizures + pregnancy
- Accelerated hypertension
- Hypertensive encephalopathy
- Acute HF
- Aortic dissection
- Eclampsia
Why is sodium nitroprusside used rarely?
V short acting
Has to be titrated precisely
Very sensitive to sunlight
What is the Rx for hypertensive emergency?
IV Labetalol
IV Nitrates - GTN, Isosorbide dinitrate
poss Sodium nitroprusside
What does this ECG show?
Atrial Fibrillation
Rapid, irregular
No clear P waves
Which is the most common serious arrhythmia?
AF
What are the three types of AF in terms of timings?
Paroxsymal
Persistent
Permanent
What can be non-cardiac causes of AF?
Hypothyroid
Hyperthyroid (less common than hypo)
Alcohol abuse
Chronic lung disease - puts strain on RHS heart -> AF
Low K+
What can be cardiac causes of AF?
HF
lVH
Valvular disease
CHD
What investigation should you do for CHD?
CT coronary angiogram
Which score is used to determine anticoagulation for AF?
CHA2DS2VASC
Greater than 1 = anticoagulant
How is paroxysmal AF managed?
Maintain sinus rhythm until ablation
= Bisoprolol, Flecanide, Amiodarone
How is persistent AF managed?
Cardioversion - DC shock or Chemical (Flecanide, Amiodarone)
How is permanent AF managed?
Rate control
= Bisoprolol, Diltiazem/Verapamil, Digoxin, Amiodarone
(all drugs that block conduction through the AVN)
Which is the most effective anti-arrhythmic drug?
Amiodarone
What are the SEs of amiodarone?
`
What monitoring should Ps on amiodarone have?
6m liver function
6m thyroid function
Annual CXR
What does this ECG show?
Atrial flutter - 4:1 conduction
What does this ECG show?
Atrial flutter - 2:1
tachycardia
What causes atrial flutter?
Macro re-entry circuit around the atria
How is atrial flutter treated?
Cardioversion
Ablation if recurrent
Atrial stabilising drugs
If rate is faster than 150 - what is likely to be the cause?
SVT (not atrial flutter)
What does this ECG show?
SVT
How does SVT appear on ECG?
Regular
Narrow Complex
Rate usually 160-240
Which Ps are more likely to get SVT?
Younger Ps
How is SVT managed?
Vagotonic manoeuvres
IV adenosine (not if asthmatic!)
IV Verapamil (not if on β blockers!)
DC Cardioversion
When should IV adenosine not be used?
If P is asthmatic
When should IV verapamil not be used?
If P is on β blockers
What is the Rx to prevent atrial tachycardia?
Atrial stabiliser - bisoprolol
What is the Rx to prevent AVNRT?
AV node blocker - Bisoprolol, Verapamil
What is the Rx to prevent AVRT (e.g. WPW)?
Accessory pathway blocker - Flecanide
What does this ECG show?
This shows WPW - P waves + slurred delta waves upstroke into the R wave, short PR interval
Means P has an accessory pathway which is very amenable to ablation
What does his ECG show?
Fast - 150 bpm
Complexes are very broad
Broad complex tachycardia = Ventricular tachycardia until proven otherwise
What causes VT?
Re-entry circuit within the ventricles
- can be from a scar
- infarction
- DCM
- HCM
- channelopathy
What makes VT high risk?
Poor LV function
IHD
Syncope = tolerating the arrhythmia poorly and loses consciousness
What should you do for a P with VT?
Revert to sinus asap
Investigate if underlying heart disease - echo, CAG, CMRI
What should you maintain K at in a P with VT?
> 4.5 - less than 4.5 inc risk of recurrent arrhythmia
Which drug should you give to Ps with structural heart disease and VT?
Amiodarone
Which drug should you give to Ps with ischaemic VT or long QT syndrome and VT?
β blockers (bisoprolol)
Which are the only two rhythms that you defibrillate?
Pulseless VT
VFib
What is seen on this ECG?
Ventricular fibrillation
Ventricular fibrillation = chaotic, no clearly defined QRS complexes - incompatible with CO - fatal without defibrillation
Which channelopathy can be associated with deafness, and may be triggered by sudden shock (cold water, alarm clocks)?
Long QT syndrome
Which channels are involved in long QT syndrome?
Na and K
Which channelopathy is brought on by exercise? Which channel is involved?
Catecholaminergic polymorphic VT
Ca channel
Which channelopathy can occur during sleep or with fever?
Which channel is involved?
Brugada syndrome
Na channel
Who should have an ICD?
