Heart 2

oelomar's version from 2016-04-27 22:54


Question Answer
What is stable angina?Also known as effort angina, this is the sensation of chest pain, pressure, or squeezing precipitated by activity (e.g. walking/running) with minimal or non-existent symptoms at rest or after administration of sublingual GTN. Symptoms can also be precipitated by cold weather, emotions, and large meals. These symptoms arise as a result of myocardial ischaemia.
What is unstable angina?Also known as crescendo angina, this refers to angina of recent onset (<24h) or a deterioration in previous stable angina with symptoms frequently occurring at rest. It has at least one of the three following features: 1- occurs at rest (or minimal exertion), normally lasting 3-5 minutes; 2- severe and of new onset (in the last 4-6 weeks); 3- occurs with a crescendo pattern (i.e. becoming much worse over the past x amount of time).
What is Prinzmetal angina and who is more affected by it?This refers to an angina that occurs without provocation, usually at rest, as a result of coronary artery spasm. It occurs more frequently in women.
What is refractory angina?This is a type of angina which occurs as a result of severe diffuse coronary artery disease which cannot be treated with PCI, CABG, or medical therapy.
What is cardiac syndrome X?Also known as microvascular angina (when there are findings of microvascular dysfunction), this refers to a condition in which patients have a good history of angina, a positive exercise test, and angiographically normal coronary arteries.
What are the classic ECG changes associated with angina?ST depression ± T wave inversion; unless Prinzmetal angina in which there is ST elevation.
How is stable angina pharmacologically treated?Glyceryl trinitrate (1st line) plus either a beta blocker or a calcium channel blocker. If they are contraindicated or not tolerated, give a long acting nitrate, nicorandil, ivabradine, or ranolazine (these 4 are only given if symptoms not satisfactorily controlled by 2 anti-anginals). If symptoms are not controlled with 3 anti-anginal drugs, consider CABG or PTCA (percutaneous transluminal coronary angioplasty). Offer coronary angiography to decide on treatment.
What types of “secondary prevention” can be used in angina management?Risk factors should be evaluated and steps made to correct them. All patients should take aspirin unless contraindicated. Consider ACE inhibitors for people with stable angina and diabetes. Patients should also be on statins.
When GTN is used to treat episodes of angina, what should people be advised?To repeat the dose 5 minutes after the pain has not gone and to call an emergency ambulance if the pain has not gone 5 minutes after second dose.
Symptomatic angina disqualifies truck drivers. True or false?True.
Which vessels can be used as a graft in CABGs?The internal mammary arteries, radial arteries or reversed segments of the patient's own saphenous vein.
In what type of angina patients in whom symptoms are not controlled by medications are CABGs undertaken?Diabetics, those over the age of 65, or those who have anatomically complex multi-vessel disease (three-vessel disease – LAD, circumflex, RCA) with or without the involvement of the left main stem.


Question Answer
How would a patient with an MI typically present?Acute central chest pain lasting >20minutes, often associated with nausea, sweatiness, dyspnoea, palpitations. The pain does not usually respond to sublingual GTN, and opiate analgesia is required. The pain may radiate to the left arm, neck, or jaw.
How is an MI diagnosed?In the first 6 hours, ECG is the gold standard. ECG changes can include ST elevation (transmural infarct), ST depression (subendocardial infarct), and pathological Q waves (transmural infarct). Cardiac troponin I and T also rise after 4 hours and are elevated for 7-10 days.
What is the characteristic ECG change in the hyperacute stage of a STEMI?Hyperacute (very peaked) T waves.
What is the sequence of ECG changes seen in an MI?Peaked T waves, ST-segment elevation, pathological Q waves, T-wave inversion, ST-segment normalisation, T-wave normalisation.
What should one suspect if there is persistent ST-segment elevation following an acute MI?Left ventricular wall aneurysm.
An inferior MI (RCA) will show ST-segment elevations in which leads?II, III, and aVF.
An anterior MI (LAD) will show ST-segment elevations in which leads?In the anterior leads – V1-V4.
A lateral MI (circumflex) will show ST-segment elevations in which leads?I, aVL, and V5-V6.
An anterolateral MI (LAD) will show ST-segment elevations in which leads?V1-V6 (and sometimes I and aVL)
ST depression in leads V1-V3 indicates what?True posterior wall infarct (often associated with dominant R waves in V1 and V2).
What are the complications of an MI?DARTH VADER. Death, Arrhythmia, Rupture (either of septum or outer walls), Tamponade, Heart failure, Valve disease, Aneurysm, Dressler’s syndrome, Embolism, Re-infarction.


Question Answer
What is cardiac tamponade?Also known as pericardial tamponade, this is a type of pericardial effusion (accumulation of fluid in the pericardial cavity) in which fluid, pus, blood, clots, or gas accumulate in the pericardium, resulting in slow or rapid compression of the heart.
What is Dressler’s syndrome?A secondary form of pericarditis that is thought to result from an autoimmune inflammatory reaction to myocardial neo-antigens formed as a result of an MI. It normally occurs 2-6 weeks following an MI.
What is the ECG criteria for ST elevation?ST elevation >1mm in 2 or more limb leads or >2mm in 2 or more chest leads.
How is a STEMI managed?Sublingual GTN and IV morphine + metoclopramide 10mg should be given to help relieve the symptoms. Then give 150-300mg of aspirin. Oxygen should only be given if the oxygen saturations are <94%. Beta blocker (if no contraindication) for ongoing chest pain, hypertension, and tachycardia. Following these initial steps there is a large amount of variation in practice in terms of which other medications are given prior to PCI. A second antiplatelet is normally given, usually ticagrelor, clopidogrel or prasurgel (all are antagonists of the P2Y12 adenosine diphosphate receptor). Offer primary PCI to patients who present within 12 hours of onset of symptoms, although PCI performed within 90 minutes is the preferred reperfusion therapy in interventional cardiology centres that have the expertise available.
How is a NSTEMI managed?All patients should receive aspirin 300mg (loading dose, lower to 75mg afterwards), nitrates or morphine to relieve chest pain if required, clopidogrel 300mg for 12 months, fondaparinux. Coronary angiography should be considered within 96 hours of first admission to hospital to patients who have a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in patients who are clinically unstable.
What can aspirin toxicity result in?Gastric ulceration, bleeding, hyperventilation, Reye’s syndrome, tinnitus (CN VIII).
What can ticlopidine toxicity result in (note that ticlopidine is no longer used)?Neutropenia.
What is the most common cause of death following an MI?Ventricular fibrillation (leading to cardiac arrest).
How can an MI lead to left ventricular aneurysm?The ischaemic damage sustained may weaken the myocardium resulting in aneurysm formation. This is typically associated with persistent ST elevation and left ventricular failure.


Question Answer
What is heart failure?A complex clinical syndrome, resulting from almost any cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. In other words, it is the inability of the heart to pump sufficiently enough to maintain blood flow to meet the body’s needs.
What are the symptoms of heart failure?Exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, fatigue.
What are the signs of heart failure?Many, including cardiomegaly, displaced apex beat, third and fourth heart sounds, elevated JVP, tachycardia, hypotension, bi-basal crackles, pleural effusion, ankle oedema, ascites, tender hepatomegaly.
What is forward heart failure?When the heart is unable to maintain adequate cardiac output to meet demand or is able to do so only by elevating filling pressure.
What is backward heart failure?When the heart is unable to accommodate venous return resulting in elevated filling pressures and vascular congestion (systemic or pulmonary).
What is diastolic dysfunction?This refers to an abnormality in how the heart fills with blood during diastole. The ventricle(s) do not relax in a normal manner and the heart may fill too slowly, asynchronously, or with an elevation in filling pressure only. It can be a component of heart failure.
What is systolic dysfunction?LVEF<40%; i.e. when the ventricles do not contract with enough force. It can be a component of heart failure.
What is high-output heart failure?A heart condition that occurs when the cardiac output is higher than normal due to increased demand. With time, this overload causes systolic failure, and cardiac outputs can be reduced to very low levels.
Name some of the causes of high-output heart failure.Paget’s disease of bone, chronic and severe anaemia, hyperthyroidism, large arteriovenous fistulae, sepsis (particularly when caused by gram-negative bacteria).


Question Answer
What is the Killip classification of heart failure and how are they interpreted?A classification used to assess patients with heart failure post-MI. Killip I = no crackles and no third heart sound. Killip II = crackles in <50% of the lung fields or a third heart sound. Killip III = crackles in >50% of the lung fields. Killip IV = cardiogenic shock.
With regards to the New York Heart Association’s classification of heart failure, what is class I?No limitation. Normal physical exercise does not cause fatigue, dyspnoea, or palpitations.
With regards to the New York Heart Association’s classification of heart failure, what is class II?Mild limitation. Comfortable at rest but normal physical activity produces fatigue, dyspnoea, or palpitations.
With regards to the New York Heart Association’s classification of heart failure, what is class III?Marked limitation. Comfortable at rest but gentle physical activity produces marked symptoms of heart failure.
With regards to the New York Heart Association’s classification of heart failure, what is class IV?Symptoms of heart failure occur at rest and are exacerbated by any physical activity.
What should be done with patients with suspected heart failure with history of MI?Urgent referral to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks.


Question Answer
How is heart failure diagnosed?If heart failure is suspected (from signs and symptoms), first assess the presence of cardiac disease by ECG, chest x-ray, or B-type natriuretic peptides. If these are normal, heart failure is unlikely. Otherwise, if abnormal then do imaging by echocardiography. If normal, heart failure is unlikely. Otherwise, if abnormal, assess the aetiology, degree, precipitating factors, and type of cardiac dysfunction, and carry out additional diagnostic tests where appropriate.
How are levels of B-type natriuretic peptides interpreted?Normal = <100pg/ml. BNP levels from 100-300pg/mL suggest heart failure is present. BNP levels >300pg/mL indicate mild heart failure. BNP levels >600pg/ml indicate moderate heart failure.
What is the prognosis of heart failure?Poor. 25% of patients die within 5 years of diagnosis.
Symptomatic heart failure disqualifies patients from driving large lorries and buses. True or false?True.
Patients with heart failure should be offered what vaccinations?An annual vaccination against influenza, and vaccination against pneumococcal disease (only required once).
Is air travel possible in heart failure patients?Air travel will be possible for the majority of patients with heart failure, depending on their clinical condition at the time of travel.
What would you look for in a chest x-ray in heart failure patients?ABCDE. Alveolar oedema (bat’s wings), Kerley B lines (short parallel lines in lung periphery), Cardiomegaly, Dilated prominent upper lobe vessels, pleural Effusion.
What is the pharmacological management in patients with (non-acute) heart failure?ACE inhibitors are first line. Angiotensin II receptor antagonists (ARA) are second-line in patients intolerant of ACE inhibitors. Beta-blockers have been shown to improve functional status and reduce cardiovascular morbidity and mortality and can therefore also be given. If symptoms persist then give an aldosterone antagonist (spironolactone), hydralazine in combination with nitrate (especially in those of African descent), or an ARB. If symptoms persist, consider digoxin (indicated in patients with AF and heart failure). Therapies to consider include CRT (cardiac resynchronisation therapy), and an implantable cardioverter defibrillator.
What is acute decompensated heart failure (ADHF)?A sudden worsening of the signs and symptoms of heart failure, which typically includes dyspnoea, leg or feet swelling, and fatigue. ADHF is a common and potentially serious cause of acute respiratory distress syndrome.
When would IV inotropic agents (such as dobutamine) be considered for the treatment of heart failure?Short-term treatment of acute decompensation of chronic heart failure.
What are the effects of spironolactone toxicity?Hyperkalaemia (can lead to arrhythmias), endocrine effects (e.g. gynaecomastia, anti-androgen effects).
How is digoxin poisoning treated?The primary treatment is “digoxin immune Fab”, which is an antibody made up of anti-digoxin immunoglobulin fragments. This antidote has been shown to be highly effective in treating life-threatening signs of digoxin toxicity such as hyperkalaemia, haemodynamic instability, and arrhythmias.
What is the leading cause of hospital admissions in above 65s?Acute heart failure.
How is acute heart failure managed?Give the following: oxygen, furosemide (if already on diuretic, then up the dose), GTN, diamorphine (if there is chest pain), inotropic agents (can be given if BP is low). Note that nitrates, opiates, and inotropes should not be routinely offered. Also note that if the patient is already on beta-blockers, then continue them until the HR is <50.

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