0
Q
How many patients per year are admitted due to acute coronary syndromes in the UK .?
A
114,000
1
Q
What conditions are included under ‘acute coronary syndromes’
A
NSTEMI
STEMI
unstable angina
2
Q
What is the annual Incidence of non ST elevated acute coronary syndromes ?
A
3 per 1000
3
Q
What percentage of artery narrowing is required to produce downstream Ischaemia and chest pain ?
A
70% = unstable angina and NSTEMI
4
Q
What percentage of artery narrowing is required to cause an infarction ?
A
100% = STEMI
5
Q
What are the modifiable risk factors for atherosclerosis which contribute to ACS ?
A
Smoking, obesity, inactivity
Hypertension, diabetes, dyslipidaemia
6
Q
What are the non modifiable risk factors for atherosclerosis contributing to risk of ACS ?
A
- Increasing age
- male
- family history of premature heart disease
- premature menopause
7
Q
What are the non-atherosclerotic risk factors that may cause ACS in younger patients ?
A
- coronary emboli e.g. Due to infected heart valve
- coronary occlusion secondary to: vasculitis, coronary artery spasm, cocaine use, congenital, trauma
8
Q
What things should be checked for in the initial assessment for ACS?
A
- Chest pain (and radiation) >15 mins
- associated nausea/vomiting/sweating/SOB with chest pain
- New onset chest pain, or abrupt deterioration in stable angina, with recurrent pain frequently with little exertion often lasting longer than 15 mins
9
Q
What is the immediate management of ACS ?
A
ROMANCE:
- Reassure
- Oxygen - sats < 94%
- Morphine (IV Opioids)
- Aspirin - loading dose 300mg ASAP
- Nitrates - (GTN- pain relief, still offer morphine)
- Clopidogrel - (offer in hospital antiplatlet)
- ECG - resting 12 lead ASAP /enoxaparin antithrombin
10
Q
What oxygen sats should be aimed for in people with COPD ?
A
88-92%
11
Q
What drug should be given when having percutaneous coronary intervention to reduce risk of immediate vascular occlusion ?
A
Glycoprotein IIb/IIIa inhibitor
12
Q
Which patients are rate limiting calcium channel blockers contraindicated in and why ?
A
Those with left ventricular dysfunction as May precipitate heart failure
13
Q
What is the long term management of NSTEMI and unstable angina ?
A
Beta blocker
LMWH
Nitrates
PCI if high risk
14
Q
What is the longterm management of STEMI ?
A
- PCI/Thrombolysis
- Beta blocker
- ACE inhibitor
- Aspirin (+/- clopidogrel!/ warfarin)
- query statin
15
Q
Which conditions present similarly to ACS ?
A
- stable angina
- pericarditis
- myocarditis
- aortic dissection
- PE
- oesophageal reflux/spasm
- cholecystitis/ acute pancreatitis
16
Q
What are the complications of ACS ?
A
Arrhythmias
Mitral regurgitation (due to Ischaemia to papillary muscles)
Cardiogenic shock
Acute MI
Conduction disturbances e.g. AV or bundle branch block
17
Q
In which acute coronary syndromes is troponin raised in ?
A
STEMI and NSTEMI
NOT unstable angina
18
Q
How is the history of unstable angina differentiated from that of an MI ?
A
Chest pain lasts less than 15/20 mins
19
Q
What ECG changes would be Seen in a STEMI ?
A
ST elevation >2mm in 2 consecutive chest leads
OR
>1mm in 2 limb leads
Tall T waves
20
Q
What ECG changes are seen in NSTE-ACS ?
A
ST depression or T wave inversion
In unstable angina may be normal. Some time has passed since episode
21
Q
What is the typical presentation of ACS ?
A
-Central chest pain radiating to left arm/jaw
Associates with :
- nausea, vomiting, sweating, SOB,
- increased pulse, decreased blood pressure
22
Q
When is cardiac troponin usually tested ?
A
6-12 hrs after onset of pain
23
Q
What does the global registry of acute coronary events (GRACE) predict ?
A
6 month mortality
24
What are the classic radiological signs of heart failure on a CXR ?
- cardiomegaly (>50% cardio thoracic ratio)
- Classical perihilar bat wings (diffuse interstitial/alveolar shadowing)
- prominent upper lobe veins
- Pleural effusion
*apart from pulmonary congestion CXR findings are only predictive for HF where there is coexisting typical signs and symptoms*
25
What percentage of the population have atrial fibrillation ?
1%
26
What percentage of the over 85s have atrial fibrillation ?
18%
27
What is the pathogenesis of atrial fibrillation ?
- The regular Impulses produced by the SA are overwhelmed by rapid electrical discharges produced by the atria (and adj. pul veins)
- atria respond to this rapid rate by uncoordinated mechanical action
- small proportion of impulses conducted to ventricles
- causes irregularly irregular rhythm
28
What is paroxysmal AF ?
AF which spontaneously terminates within 7 days (usually 2)
29
What is recurrent AF ?
2 or more episodes which can be paroxysmal or persistent
30
What is persistent AF ?
AF lasting > 7days which is not self limiting and unlikely to revert without treatment
31
What is permanent AF ?
Long term (>1yr) which isn't successfully terminated by cardio version or if it is relapses soon after
32
What are the main risk factors for AF ?
- Hypertension
- thyrotoxicosis
- coronary artery disease
- alcohol
- rheumatic fever
*any condition that increases atrial pressure e.g. Atrial fibrosis, mitral stenosis*
33
What is the typical presentation of AF ?
- Irregularly irregular pulse on palpation
- palpitations
- SOB
- syncope/dizziness
34
What is the characteristic findings on an ECG in AF ?
* Variable R-R intervals
- absent p waves
- QRS rapid and irregular
- tachycardia
35
Which blood tests should be used to investigate AF ?
- TFTs - hyperthyroidism
- U&Es - abn. k+ can potentiate arrhythmias
- FBC - anaemia can potentiate HF
- LFTs and coag screen if pre warfarin
36
What are the main aims of management of AF ?
- control arrhythmia
- thromboprophylaxis
- treat any underlying cause
- treat any associated HF
37
What are the complications of AF ?
- stagnation of atrial blood leading to thrombus and embolism risk
- decreased cardiac output (esp. In exercise) > HF
38
Which other conditions present similarly to AF ?
- atrial flutter
- Supraventricular tachycardias
- Wolff-Parkinson-White syndrome
39
When would an urgent referral be needed in AF ?
- pulse > 150
- loss of consciousness/severe dizziness/chest pain
- stroke/TIA/acute HF
40
What is first line strategy for treatment of AF ?
Rate control
41
When might monotherapy digoxin be appropriate to treat AF ?
In relatively sedentary patients as is only effective at rate control during rest
43
When is rhythm control preferred as first line treatment for AF ?
In paroxysmal AF
44
What is the long term drug treatment for rhythm controls?
Beta blockers
45
What is the short term option for rhythm control ?
IV Antiarrythmics e.g. Amiodarone
46
What is cardio version ?
Rhythm control by drugs or electricity
47
What is the treatment option for AF if drug treatment had failed ?
Left atrial ablation - removal of some tissue in atria to block trigger points of fibrillation usually near entrance of pulmonary vein
48
What is the most common underlying cause of congestive heart failure ?
Coronary artery disease
49
What percentage of the population has essential hypertension ?
20-30%
50
Which ethnic group is predisposed to essential hypertension ?
Black Africans (40-45%)
51
What are the risk factors for essential hypertension ?
```
Genetic
Low birth weight
Obesity
Alcohol
Diet/exercise
Stress
Diabetes
```
52
What is second line strategy for treatment of AF ?
Rhythm control
53
What is the rare endocrinopathy causing hypertension that present characteristically with: sweating, headache, palpitations and episodes of feeling like 'about to die'
Phaechromocytoma (tumour of adrenal glands)
54
How does hypertension usually present ?
```
Usually asymptomatic
May present with:
- headaches
- epistaxis
- nocturia
- end organ damage
```
55
3 areas to be investigated with hypertension ?
- end organ damage
- CV disease prevention
- specific investigations
56
How would you investigate for end organ damage ?
- urinalysis - protein and blood
- U&Es and e GFR
- renal ultrasound
- ECG
- echo
57
What constitutes stage 1 hypertension ?
Average > 135/85
58
What constitutes stage 2 hypertension ?
Average >150/95
59
When do you treat stage 1 hypertension with medication ?
- > 80 yrs
- end organ damage
- diabetes
- CVD risk > 20%
60
What is the initial drug treatment for hypertension in those <55 and not Afro Caribbean ?
- ace inhibitor
| Beta blocker if not tolerated
61
Initial treatment for those aged over 55 or Afro Caribbean ?
Calcium channel blocker
62
Second line treatment for hypertension ?
Ace inhibitor and calcium channel blocker
- A2RA + CCB in black
63
Third line treatment for hypertension ?
- ACEi
- CCB
- thiazide diuretic
64
What is the prevalence of stable angina in those aged 65-74?
14% men
| 8% women
65
What are the risk factors for stable angina ?
- diabetes
- hypertension
- family history
- anaemia
- cardiac outflow abnormalities
66
What is prinzmetals (variant) angina ?
- Angina occurring unprovoked, usually at rest
- due to coronary spasm
- more common in women
67
What is the classical presentation of angina ?
- constricting chest discomfort
- radiation to left arm and jaw
- lasting
68
What examinations should be carried out on some one with suspected angina ? (5)
- BMI
- BP
- pulse
- auscultation for heart murmurs
- look for signs of PVD
69
What blood tests should be done in suspected angina ? (6)
- FBC - anaemia
- U&ES - renal function
- cholesterol
- fasting glucose - if diabetes status not confirmed
- cardiac enzymes - if MI. Suspected
- TFTs - hyper makes heart work harder, hypo associated with increased cholesterol
70
What ECG changes are typical of CAD ? (3)
- pathological T waves
- LBBB
- ST and T Wave abnormalities (flattening or inversion)
71
What are the complications of stable angina ? (4)
- unstable angina
- MI
- Anxiety and depression
- decreased health and quality of life
72
What is the likelyhood of having an MI within one year of being diagnosed with stable angina ?
1/10
73
What is the first line drug treatment of stable angina (besides GTN) ?
Beta blockers or calcium channel blockers
- aspirin and statins
74
What drug treatment should be considered for diabetic patients with stable angina ?
ACEi
75
Which conditions present similarly to stable angina ?
- MI - pain > 5 mins
- GORD - burning pain aggravated by exercise/eating
- acute pericarditis - more constant, worse lying flat and on inspiration, swallowing and movement
- MSK
- acute cholecystitis - not related to exercise
- PE/pleuritic pain - sharp on deep inspiration
76
What should be the initial investigation in patients with suspected DVT ?
Duplex ultrasound
77
What is the gold standard for investigating DVT ?
Contrast venography
78
What is the annual incidence of DVT ?
1/1000
79
What is thrombosis ?
Solidification of blood contents, causing aggregation of platelets on teh side of vessels (due to coagulation cascade)
80
What is Virchow's triad?
Essential things for thrombosis to form:
1. Change in blood flow e.g. Atheroma, immobility
2. Endothelial damage e.g. Inflammation, hypertension
3. Change in blood constituents e.g. Drugs, malignancy, pregnancy
81
What are the major risk factors for DVT ?
- prior history of venous thromboembolism
- > 60 yrs
- surgery
- obesity
- prolonged travel
- immobility
- pregnancy
82
How does a DVT present?
pain in calf, often associated with:
- swelling
- redness
- warmth
- engorged superficial veins
- ankle oedema
- tenderness along line of deep veins
-*65% asymptomatic or features of PE*
83
Bilateral leg oedema due to DVT would involve a clot forming where ?
- iliac bifurcation
- pelvic veins
- vena cava
84
What is Homan's sign ?
Pain in calf on dorsiflexion of foot while knee fully extended
*not specific for DVT and so not helpful in diagnosis *
85
A DVT forming where is most likely to cause a PE ?
Ileofemoral thrombosis
86
What are the long term complications of DVT ?
- Venous eczema
- swollen limb
- oedema
Due to damaged venous valves
87
What investigations should be carried out on a suspected DVT case ?
- D-dimer
- Duplex Ultrasound
- wells score
88
What is a D-dimer ?
Crossed linked products of fibrin degradation - high sensitivity, poor specificity
89
What is the Well's score ?
DVT probability score, affects how quickly get ultrasound
+1 for:
- active cancer
- calf swelling >3cm
- swollen unilateral superficial veins
- unilateral pitting oedema
- previous DVT
- tenderness along line of deep vein
- paralysis, paresis, recent immobility
- recently bed ridden
-2 points if another diagnosis is likely
90
If someone has an unprovoked DVT what is it important to check for ?
Cancer
91
If someone has an unprovoked DVT and has a 1st degree relative who has also had an unprovoked DVT, what should be investigated for ?
Hereditary thrombophilia
92
Management of DVT (drug)
LMWH (UFH in renal impairment)
- heparin stopped when warfarin in right INR ~ 1-3 months
- if recurrent long term anticoagulant
93
Lifestyle changes for the management of DVT
- pressure stockings (on affected leg only) - for 2yrs
- weight loss
- smoking cessation
- increase mobility
94
What are the 9 main question to screen someone presenting with a swollen leg ?
1. Both legs
2. Pregnant
3. Mobile
4. Trauma
5. Pitting oedema
6. Past disease/medications
7. Pain
8. Skin changes
9. Oedema anywhere else
95
Differential diagnosis in someone with swollen leg
- trauma
- superficial thrombophlebitis
- cellulitis
- vasculitis
96
What causes a bounding pulse ?
- CO2 retention
- liver failure
- sepsis
97
What causes a small volume pulse?.
- aortic stenosis
- shock
- pericardial effusion
98
Causes of collapsing pulse ?
- aortic incompetence
- AV malformation
- patent ductus arteriosus
99
What causes a bounding pulse ?
- CO2 retention
- liver failure
- sepsis
100
What causes a small volume pulse?.
- aortic stenosis
- shock
- pericardial effusion
101
Causes of collapsing pulse ?
- aortic incompetence
- AV malformation
- patent ductus arteriosus
Core Conditions
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