Cardiology

STEMI Definition

Positive ECG with ST-elevation, positive troponins

NSTEMI Definition

Inconclusive ECG/ST depression with positive troponins

Unstable Angina Definition

Normal ECG and normal troponins with angina pain

ACS symptoms

Angina at rest lasting more than 20 minutes and not relieved by GTN, nausea, sweating, dyspnoea, and palpitations

Immediate management of ACS

• aspirin 300mg

• O₂ if sats <94%

• paracetamol 1g (or morphine if severe pain)

• GTN spray

• maybe ondansetron 4mg IV

  
  

When is GTN spray cautioned in ACS management/

hypotension

6As of ACS (secondary prevention and unstable angina)

• aspirin 75mg OD

• antiplatelet (e.g clopidogrel for 12 months)

• atorvastatin 80mg OD

• ACEi

• atenolol

• aldosterone antagonist (heart failure, e.g. eplerenone)

STEMI criteria

• Symptoms lasting ≥20 minutes with ECG changes in ≥2 contiguous leads:

  • 2.5 mm ST elevation in V2-3 in males ≤40 years, ≥2.0 mm in males >40 years.

  • 1.5 mm ST elevation in V2-3 in females.

    • 1 mm ST elevation in other leads, new left bundle branch block (LBBB) is always pathological.

Decision about PCI

symptoms <12 hours and PCI possible within 2 hours

STEMI management if <12 hours symptoms and PCI possible within 2 hours

• prasugrel (clopidogrel if on anticoagulants or ticagrelor if high risk of bleeding)

• radial access preferred to femoral

• unfractioned heparin and bailout glycoprotein IIb/IIIa inhibitor

STEMI management if PCI not possible within 2 hours

• alteplase + antithrombins

• then ticagrelor

• if no ECG resolution after 60-90 minutes, PCI

NSTEMI management if GRACE score <3%

fondaparinux and ticagrelor

NSTEMI management if GRACE score >3%

• If unstable, perform immediate PCI

• If stable, perform PCI within 72 hours and provide Fondaparinux, Prasugrel or Ticagrelor, and UFH.

What to consider and avoid for MI associated with cocaine use

• consider IV benzodiazepine

• avoid beta-blockers

Stage 1 hypertension

• Clinic BP ≥140/90, ABPM ≥135/85

Stage 2 hypertension

• Clinic BP ≥160/100, ABPM ≥150/95

Stage 3 hypertension

• Clinic BP ≥180/120 = Hypertensive crisis

Hypertensive retinopathy grade 1

barely detectable arterial narrowing

Hypertensive retinopathy grade 2

obvious narrowing with focal irregularities

Hypertensive retinopathy grade 3

flame and dot-blot haemorrhages, exudates, cotton wool spots

Hypertensive retinopathy grade 4

papilloedema

ACEi side effects

• dry cough, angioedema, hyperkalaemia

Beta blocker side effects

bronchospasm, fatigue, cold extremities

CCB side effects

flushing, bradycardia, hypotensions

Thiazide-like diuretic side effects

electrolyte imbalances, hypercalcaemia, gout potential

Hypertension management if T2M or <55

1. ACEi/ARB

2. +CCB

3. +thiazide-like diuretic

4. +spironolactone if K <4.5, alpha/beta-blocker if K >4.5

Hypertension management if >55 or afro-caribbean

1. CCB

2. +ARB (if black) or +ACEi

3. +thiazide-like diuretic

4. +spironolactone if K <4.5 or alpha/beta-blocker if K >4.5

Define stable angina

chest pain lasting <20 minutes and provoked by exertion, relieved by rest or GTNs

Which groups may get atypical angina presentation?

women and the elderly

Immediate relief angina

sublingual GTN

Long-term management angina

• antiplatelets

• statins

• beta-blockers

• lifestyle changes

Definition atrial fibrillation

• Supraventricular tachyarrhythmia characterized by uncoordinated atrial contractions

Symptoms atrial fibrillation

• Palpitations, shortness of breath, chest pain, fatigue, dizziness, syncope

Management of atrial fibrillation

• rhythm control = sodium or potassium channel blockers

• rate control = beta-blockers or CCBs

• anticoagulation based on CHADS2VASC and ORBIT scores

Shockable rhythms

VF and pulseless VT

Non-shockable rhythms

pulseless electrical activity and asystole

Management non-shockable rhythms

adrenaline and CPR

Ventricular fibrillation ECG

wide QRS with irregularly irregular pattern

V fib managment

immediate DC cardioversion ± amiodarone or lidocaine

V tach management

• stable = 1st line amiodarone, 2nd line lidocaine and procainamide

  • unstable = immediate DC cardioversion

1st line medical management bradycardia

atropine boluses to 3mg total

Cardiac tamponade

accumulation of fluid in the pericardial space leading to decreased cardiac output

Signs and symptoms of cardiac tamponade

• Beck’s triad - hypotension, elevated JVP, muffled heart sounds

• dyspnoea

• pulsus paradoxus

Pulsus paradoxus

drop in BP of 10mmhg on inspiration (cardiac tamponade)

Management cardiac tamponade

pericardiocentesis

Most common PE ECG sign

sinus tachycardia

Wells score interpretation

• <4 = d dimer

• >4 = CTPA

Signs and symptoms acute pericarditis

• chest pain improved on sitting upright or leaning forwards

• pericardial rub on auscultation

• PR depression or ST elevation on ECG

  
  

Management acute heart failure with reduced LVEF

beta blocker and ACEi first line

aldosterone agonist after

1st line acute pericarditis treatment (no TB)

NSAID and colchicine

When are nitrates contraindicated in ACS?

hypotension

With what class of antibiotics must statins be stopped and why?

macrolide due to rhabdomyolysis risk

Left ventricular free wall rupture

• complication of MI

• bibasal crackles

• SOB

• raised JVP

• muffled heart sounds

  • decrease in BP on inspiration

First line SVT management

vagal manoeuvres

Which cardiac drug is contraindicated in V tach?

CCB as can reduce contractility even further

2nd line SVT management

adenosine:

• 6mg

• 12mg

• 18mg

V fib management after 3 shocks and adrenaline

300mg amiodarone

How long is a provoked PE treated for?

3 months

Are statins contraindicated in pregnancy?

yes

Which anticoagulant are mechanical valve replacement patients treated with?

wafarin

Most common causes of aortic stenosis in old vs young

• old = calcification

• young = bicuspid valve

What is the first line long-term drug management of ischaemic stroke/TIA?

clopidogrel