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Flashcards

5 - ACS and HF

lw409 Clinical Masters English 186 cards

draw the ECG of an ischaemic heart

Cards in this deck (186)

  1. 1what is HFc complex syndrome that can occur from any structural/functional cardiac disorder that impairs the ability of the heart to fill with and eject blood
  2. 2what dysfunction do you get in HF?LV dysfunction
  3. 3what are symptoms of HFfatigue, breathlessness/SOB, malaise and fluid retention e.g. ankles
  4. 4what do patients report feeling with chronic HFprogressive loss of ability e.g. stubble getting upstairs
    wake up at night feeling like you're drowning
  5. 5what is orthopnoea?cant lie flat - get a feeling of filling up - often use 3-4 pillows
  6. 6where does fluid sit at night?bottom of back - sacral oedema
    and abdo swelling
  7. 7what does the heart sound like in HF? why?gallop rhythm - cant deal with the amount of volume
  8. 8what do you hear when you listen to the lungs in HFpulmonary oedema - crackles on inspiration
  9. 9what do HCPs mean by the 'revolving door'they stabilise and are ok - get sent home - destabilise so come back into hospital
    loads of readmissions
  10. 10what tool is used to classify heart failure?NYHA
  11. 11describe each class of NYHA1 - no limitations on physical activity
    2- slight limitation, comfort at rest but ordinary physical activity causes symptoms
    3 - marked limitation of activity, comfort at rest but less than ordinary activity causes symptoms
    4 - unable to carry out any physical activity without discomfort, symptoms at rest
  12. 12what is the most common cause of HF?coronary artery disease e.g. MI/angina
  13. 13what causes the symptoms of HF?muscle damaged due to MI = fine at rest but haven't got capability to maintain extra volume demand of exercise = symptomatic
  14. 14is HF a disease by itself?NO - it occurs as a consequence of some other disease process
  15. 15list the most common causes of HFcoronary artery disease
    hypertension
    smoking
    high cholesterol
    drugs/toxins e.g. alcohol, cocaine + cytotoxics
    endocrine e.g. diabetes +thyroid
    thiamine deficiency
    obesity
    cardiomyopthay due to viruses
    hiv
    renal failure
  16. 16how is HF diagnosed?echocardiography - looks at heart/valve functions
    ECG shows heart rhythm e.g. AF and damage from previous MI
    CXR shows signs of pulmonary oedema and size of heart
    lab tests pick up anaemia, under active thyroid which causes SOB
    presence of nature tic peptides - reflects fluid retention
  17. 17what is an echo?ultrasound combined with doppler - allows imaging of the heart in particular valves and muscle, and assessment of function
  18. 18what can an echo measureejection fraction
    size of chambers (esp LV)
    regional wall abnormalities
  19. 19can LVSD be asymptomatic?yes - feel fine then do echo and see ventricle is barely pumping, heart quivers instead
    don't notice it as its happened slowly - then when theyre treated they feel great
  20. 20what are the aims of HF treatment?improve quality of life and life expectancy
  21. 21what are non pharmacological treatments for HFexercise
    diet
    lose weight
    decrease alcohol and smoking
  22. 22what drugs are used in HF - 8 of them1 - ACEI/ARB
    2 - B blocker
    3 - aldosterone antagonists
    4 - digoxin
    5 - hydralazine and nitrate combos
    6 - anticoagulants in AF
    7 - anti platelets
    8 - statins
  23. 23why do we use ACEI/ ARB in HFvasodilate arteries to reduce preload
  24. 24why do we use beta blockers in HFstabilise membranes and reduce arrythmias
  25. 25why do we use aldosterone antagonists in HFsymptom control
  26. 26why do we use digoxin in HFreduce heart rate
  27. 27what is eplerenonenew aldosterone antagonist - expensive
  28. 28what is ivabradineSA node blocker = for people with HF who cant tolerate beta blockers
  29. 29what invasive treatments can be used in HFcoronary revascularisation
    cardiac resynchronisation therapy
    intra-cardiac defibrillators
    cardiac transplant
  30. 30what monitoring do we need to do with ACEIrenal function and K
  31. 31what do we use to get rid of fluid acutely?loop/thiazide diuretic
  32. 32why aren't loop/thiazide diuretics good long term?they cause high aldosterone levels - bad for HF
  33. 33how do patients use diuretics in HFuse them short term, then educate them to medicate themselves only when they need them
  34. 34what do you need to monitor with spironolactonecan cause high K = rhythmic problems (also causes gynacomastea)
  35. 35what causes diastolic dysfunction?respiratory conditions e.g. COPD
    obesity
    lack of fitness
    angina
  36. 36whats the treatment for diastolic dysfunction?only diuretics in fluid overload
  37. 37what is ACSdescribes the clinical presentation of ischaemic heart disease
  38. 38what are initial signs of ACSchest pain, increased cardiac markers and ECG changes
  39. 39how is ACS classifiedSTEMI
    NSTEMI
    unstable angina
  40. 40what is it called if ST segment is permanently elevatedSTEMI
  41. 41what is it called if the ST segment is abnormal?could be NSTEMI or angina - need to check biomarkers
  42. 42what biomarkers show an NSTEMItroponin rise/fall
  43. 43what biomarkers show unstable anginatroponin normal
  44. 44what initiates ACSthe disruption/rupture of an athersclerotic plaque - exposure of unstable core gauss generation of thrombin and deposition of fibrin = platelet aggregation = clot
  45. 45what type of clot are NSTEMI and unstable angina associated withpartially occlusive thrombus
  46. 46what type of clot is STEMI associated withocclusive thrombus
  47. 47how long does it take to make a thrombusover hours - very quickly aggregate
  48. 48which type of ACS needs to be treated ASAP? whySTEMI is urgent - need to treat quickly to prevent ischaemic damage
  49. 49how is unstable angina described?chest pain when they exert themselves, but OK at rest
  50. 50which cardiac markers are specific for myocardial damage?troponin (TnT and TnI)
  51. 51when are troponin levels takenat 4 and 12 hours
  52. 52whats the problem with troponin levelscant tell exactly when the pt had an infarct
  53. 53whats the problem with taking creatinine kinase levels?not selective for myocardial damage - also found in skeletal muscle so can be raised in exercise etc
  54. 54why do we take creatinine kinase levelsto tell when someone had the infarct - rises 6hrs post infarction and falls >36hrs
  55. 55when is troponin released from cells?when myocardial cells die
  56. 56draw the ECG of an ischaemic heartA = starts normal
    B = ST segment gradually raises up
    D = tissue is ischaemic = dies
    F = goes back to normal after 24-48hrs    draw the ECG of an ischaemic heart
  57. 57what do you see on an ECG if an artery is partially occludeda 'squared off' ST = NSTEMI
  58. 58which types of ACS are troponin positiveNSTEMI and STEMI
  59. 59what does an ST segment in a NSTEMI look likeST depression/ T inversion
  60. 60what happens if ST is elevated in 2 or more leadsTREATED AS EMERGENCY - STEMI
  61. 61what drugs are given in a STEMI - 6 thingsaspirin 300mg STAT
    prasugrel 60mg stat (unless previous TIA or CVA then give clopidogrel 600mg STAT instead)
    oxygen
    morphine, metoclopramide, nitrates
  62. 62what happens after drugs are given in a STEMIsend for primary angioplasty - balloon to widen vessels
  63. 63if a pt comes in with an NSTEMI/ unstable angina, what do you do first?check ECG
    do TIMI risk scoring
  64. 64what is TIMI risk scoring?age >65 = 1
    >3 CAD risk factors = 1
    known CAD stenosis >50% = 1
    aspirin use in past week = 1
    recent severe angina = 1
    troponin positive = 1
    ST deviation >0.5mm = 1
  65. 65what is low risk TIMI? whats the treatment?LOW RISK = 0-2 TIMI points
    - aspirin 300mg STAT
    - trial of GTN
  66. 66what is intermediate risk TIMI? whats the treatment?INTERMEDIATE = 3-4 TIMI points
    - aspirin 300mg and clopidogrel 600mg
    - fondaparinux 2/5mg OD s/c
    - beta blocker
    - ACEI
    - statin
    - IV nitrates if ongoing pain
    - morphine and metoclopramide prn
  67. 67what is high risk TIMI? whats the treatment?HIGH RISK = 5-7 TIMI points
    - aspirin 300mg and clopidogrel 600mg
    - fondaparinux 2.5mg
    - tirofiban (anti platelet)
    - beta blocker
    - ACEI
    - statin
    - Iv nitrates if ongoing pain
    - morphine and metoclopramide prn
    - LIKELY EARLY INVASIVE THERAPY
  68. 68what anti platelet is given to STEMI ptsprasugrel whilst in hospital then clopidogrel for 1 yr on discharge
  69. 69what anti platelet is given to NSTEMI ptsclopidogrel for 1yr
  70. 70what drugs are ALL ACS PTS given- aspirin
    - atenolol
    - ramipril
    - simvastatin OR atorvastatin
  71. 71what drug is given if pt has LVDeplenerone
  72. 72what does daughter needle time mean?time they present to A+E to getting thrombolysed
  73. 73what does daughter balloon time meanfrom when they enter A+E into cath lab getting balloon in artery to heart
  74. 74what is the GRACE score used forassess risk of going on to developing infarcts
  75. 75what is coronary angiographylook at narrowing/stenosis/blockages of coronary vessels under x-ray fluoroscopy
  76. 76what is percutaneous coronary intervention / PCI?therapeutic intervention to open up narrowed/blocked vessels using balloons and small stents
  77. 77what is PCI used forSTEMI - occluded artery
  78. 78what is a stent?mesh wire tube put in coronary artery, inflated to right size with balloon then left there = compressed plaque and therefore widens artery
  79. 79what is thrombolysis? what 2 drugs are usedpharmacological treatment to disperse/dissolve thrombi
    - streptokinase
    - rt-PA e.g. alteplase/tencteplase
  80. 80whats the disadvantage of streptokinaseolder drug with risk of anaphylaxis
  81. 81what is better - thrombolysis or angioplasty?ANGIOPLASTY
    thrombolysis doesn't always work and pts might need angioplasty afterwards!
  82. 82in what instance does thrombolysis decrease mortalityin STEMI, but not NSTEMI
  83. 83when should thrombolysis be givenideally within 1hr of onset of symptoms
  84. 84when is thrombolysis normally used now?if theres a long wait to get into the cath lab e.g. thrombolyse then transfer for balloon
  85. 85name the 2 types of glycoprotein inhibitors and name examples- mAb e.g. abciximab
    - small molecules e.g. tirofiban
  86. 86when are glycoprotein inhibitors useful?in NSTEMI and unstable angina pts, with high risk of progression to further infarction
    also used in PCI to decrease thrombotic complications due to plaque disruptions
  87. 87why aren't glycoprotein inhibitors used in STEMIthey don't work on already formed thrombi - no benefit when already occluded
  88. 88whats the risk of glycoprotein inhibitorsyou're inhibiting platelet function, therefore at risk of bleeding - need to balance risks and benefits
  89. 89what is coronary artery bypass surgery / CABGtake vessels from leg/arm/chest wall and graft them to bypass around the narrowed/blocked areas
  90. 90when is CABG usedno longer treatment of choice for single vessel or simple lesions
    still treatment of choice for pts with multi-vessel disease or with co-morbities e.g. diabetes
  91. 91whats the problem with CABGmajor surgery = 3-4%mortality, long recovery and high complications e.g. stroke/infarction/renal impairment
  92. 92what is double and triple bypass?theres 3 coronary arteries - can bypass them all
  93. 93what should pts be offered after an ACS eventcardiac rehabilitation programme - lifestyle advice, exercise programme, stopping smoking an support from others
  94. 94what are the 4 main drugs used in ACS1 - anti platelet (typically 75mg aspirin)
    2 - statin
    3 - ACEI
    4 - B blocker
  95. 95whats the problem with patients and ACS secondary preventiontheyre all long term preventative meds = won't feel better from taking them = compliance issues
  96. 96how long do patients take 75mg aspirinusually lifelong
  97. 97what do they take alongside aspirin after a STEMI or PCIa second anti platelet for 12 months (combination)
  98. 98whats the problem with clopidogreleffect varies person to person as its a prodrug metabolised into active form = 75% don't activate it fully
  99. 99what anti platelets can be used in dual therapyaspirin +
    clopidogrel/ticagrelor/prasugrel
  100. 100who is offered a statineveryone post MI regardless of starting lipid levels
  101. 101what dose statin should ACS pts receivehigh doses e.g. atorvastatin 80mg
  102. 102what is the cholesterol target in ACS?<3.5
  103. 103what are the benefits of taking a beta blocker post MIreduce myocardial activity and stress on heart
    reduce BP by vasodilation
    reduce risk of arrhythmia
  104. 104what is perfusion arrhythmia? how can it be prevented?no oxygen in MI = cells shut down, can get arrhythmias when oxygen is available and cells start to work again
    prevent this by doing PCI quickly
  105. 105what do ACEI do to the heartreduce arterial pressure and cardiac load
  106. 106when are ACEI really importantin LVD
  107. 107which ACEI should be used in ACSno preference - give most cost effective
  108. 108what should you do if the pt gets a cough from ACEIgive an ARB
  109. 109who should receive an aldosterone antagonistpts with evidence of HF post MI = ejection fraction <40%
  110. 110when should an aldosterone antagonist be started?within 3-14 days of an event
  111. 111what aldosterone is licenced in ACSonly eplenerone
  112. 112what should you do is a pt is already taking spironolactione for pre-existing LVD?don't switch - stay with spironolactone
  113. 113what causes dysfunction of the heart in HF?muscle damage, valvular dysfunction or arrythmias
  114. 114how do you diagnose acute HFbistro
    clinical examination
    ECG, CXR, blood tests
    test naturetic peptides
  115. 115what should you do if naturetic peptides are highdo doppler 2d echo
  116. 116when should a beta blocker be startedonce the pts condition has stabilised
  117. 117when should you check beta blocker?after 48 hrs before theyre discharged
  118. 118how do you monitor fluid overload in HFweight and urine output
  119. 119what are risk factors for HFhistory of angina/MI
    hypertension
    valvular heart disease
    AF
    diabetes
    smoking/alcohol
    coronary heart disease
  120. 120what drugs can cause HFNSAIDs
    steroids
    diltiazem/ verapamil
  121. 121what are the differential diagnoses for breathlessnessPE
    lung malignancy
    COPD
    chest infection
  122. 122what clinical examinations should be performedpulse and rhythm - tachycardia or AF?
    BP
    listen for murmurs - valvular heart disease?
    reap rate - crepitations?
    oedema
  123. 123what level of naturetic peptide is normal<100
  124. 124what blood tests should be done in HFnaturetic peptides
    FBC and TFTs to exclude anaemia and thyroid problems
    rentals and liver function tests - could cause oedema
    lipid profile and fasting HbA1c to assess CV risk
  125. 125what gain of weight is worrying and pts should report?gaining >2kg in 3days
  126. 126which pts need urgent specialist assessment within 2 weeks?previous MI
    NYHA class 4
    valvular heart disease
    naturetic peptide >400
    baseline creatinine >250
  127. 127who gets acute HF?people with no known cardiac dysfunction
    OR people with chronic HF having an acute decompensation
  128. 128what are the 3 main symptoms of HFSOB
    ankle or foot swelling
    tiredness
  129. 129what other symptoms are also present in HFraised JVP
    tachycardia
    crepitations
  130. 130what caused LVDdecreased cardiac output and pulmonary congestion
  131. 131how do you differentiate between acute and chronic HFchronic = symptoms for longer than 4 weeks
  132. 132when are naturetic peptides released?as a result of myocardial damage or excess strain on cardiac chambers
  133. 133what other diseases will affect naturetic peptidesCOPD and renal dysfunction will increase bNP
    obesity and diuretics will decrease bNP
  134. 134why should o2 sats be monitored in acute HFto prevent hypoxaemia
  135. 135whats the disadvantage of the NYHA classificationsits subjective - people see different things as 'normal'
  136. 136whats the prognosis of HF30-40% die within 1yr
  137. 137what is HFREF/HFPEFHFREF = HF with REDUCED ejection fraction
    HFPEF = HF with preserved ejection fraction
  138. 138what needs to be monitored whilst on diureticsrenal function and electrolytes - Na, creatinine and K
  139. 139what are symptoms of over-diuresis?thirsty
    increased creatinine and urea
  140. 140what should be monitored on ACEIrenal function, K and serum creatinine
  141. 141which HF pts should be given beta blockers?all classes 1-4
  142. 142what is monitored with beta blockersHR and BP
    echo done to exclude heart block in pts with HR<60
  143. 143when is hydrazine and nitrate combination used?NYHA class 3-4
  144. 144when is ivabradine usedif pt cant take beta blocker - e.g. in asthma
  145. 145what should be monitored with ivabradinebradycardia and visual disturbances
  146. 146what 2 drugs are used 1st line in HF1 - ACEI
    2 - B blocker
  147. 147what vaccines should be offered to HF ptsannual flu vaccine and one off pneumococcal
  148. 148what OTC meds should be avoided in HFantacids - high Na content
  149. 149do you use anti platelets routinely in HF?no - only if pt has atherosclerotic arterial disease
  150. 150what meds should be avoided in HFNSAIDs
    steroids
    verapamil and diltiazem
    antiarrhythmics e.g. flecianide
    pioglitazone and metformin
  151. 151when should a PCI be given to a STEMI ptwithin 12 hrs after onset of symptoms
  152. 152when should fibrinolysis be offered to STEMI pt?<12hrs onset but cannot get to PCI within 120mins
  153. 153what should you check after fibrinolysisdo ECG 60-90mins after
  154. 154what 2 anti platelets are given after STEMIaspirin and ticagrelor for 12 months
  155. 155what 3 drugs are given to STEMI pts undergoing PCIaspirin, clopidogrel and prasugrel
  156. 156what normally causes MIblockage = tissue death = symptoms of chest pain
  157. 157how long should an ACEI be continued for after an ACS eventindefinitely
  158. 158how should an ACEI be dosedstart low and titrate up slowly
  159. 159how long should aspirin be continued for after an ACS event?indefinitely (unless its not tolerated or they have an indication for anticoagulation)
  160. 160what should be offered to pts with a NSTEMI/STEMI and a stent?clopidogrel alone for 12 months
  161. 161what should be offered to pts with a STEMI and fibrinolytic treatmentclopdogrel for 1 month and consider for up to 12 months
  162. 162what should be offered to pts with STEMI treated with CABGaspirin and 2nd antiplatelt continued for 12 months
  163. 163how long should a beta blocker be continued for after an ACS event?with LVD = indefinitely
    without LVD = at least 12 months
  164. 164why do we need to give anti platelets during PCI treatmentsto prevent in-stent thrombosis because trauma to the artery walls can cause further blockages
  165. 165in pts with UA/NSTEMI and a high risk GRACE score - when should they be offered angiography?within 96hrs
  166. 166how is aspirin dosed in ACS300mg STAT
    75mg indefinitely
  167. 167what general things should you do if someone presents with chest painECG
    monitor o2 sats
    pain relief - GTn or IV morphine
    300mg STAT aspirin
    test for troponin
    look for pulmonary oedema
    take detailed clinical history
  168. 168when should you NOT test for naturetic peptides?in ACS - only in HF
  169. 169how long should it take for GTN to relieve anginal pain5mins
  170. 170what are essential pt education topics in HF- what is hF and CV risk
    - cardiac rehab
    - recognise signs of deterioration
    - use diuretics flexibly
    - depression at end of life
    - medicine SEs
    - digoxin toxicity signs
    - vaccines
    -lifestyle e.g. smoking and diet
    - adherence - need to understand they wont see a benefit
    - avoid NSAIDs as they increase fluid retention
    - beta blockers may mask diabetic hypos
    - weight gain and BP control
  171. 171list all the meds used in HF1st line - ACEI and B blocker (ARB/ Hydralazine and nitrate if ACE not tolerated) - alongside statin and anti platelets
    2nd line - aldosterone antagonist
    3rd line - digoxin if they have AF or ivabradine
  172. 172what does GRACE estimateestimates risk of ACS pts experiencing future CV events
    (low risk = <3%, high risk >6%)
  173. 173what is the step by step management of a STEMI1 - oxygen
    2 - pain relief (morphine needs metoclopramide)
    3 - IV beta blocker e.g. motoprolol
    4 - aspirin 300mg STAT (or ticagrelor/prasugrel)
    5 - check ST on ECG - reperfuse pt using thrombolysis or PCI if within 2hrs
  174. 174why don't we give clopidogrel as an anti platelet in STEMI75% pts don't metabolise it - too risky! give more expensive prasugrel
  175. 175when do we need heparinalongside theombolysis and PCI
  176. 176what secondary preventions need to be put in place after a STEMIstop smoking
    aspirin for life
    dual anti platelet for 12 months
    b blocker
    statin
    ACEI/ARB
  177. 177what does a strongly positive exercise tolerance test meantheyre used to diagnose CHD and arrythmias
    strongly positive = likely to have ischaemic heart disease
  178. 178what GRACE scoring system should we use to calculate the risk of future CV eventsGRACE2 - more up to date
  179. 179what beta blocker is normally used in acute ACS ptsatenolol
  180. 180how long is heparin given for in PCI pts3-8 days to stop further occlusion
  181. 181what HR should we aim for with a beta blocker?50-60bpm - to reduce heart load
  182. 182when should ACEI be titrated up?after 3 days - monitor BP once beta blocker has been added
  183. 183what is target BP140/90
  184. 184when should atorvastatin be takenits long acting = can be taken anytime of day (statins usually at night)
  185. 185what is target cholesterol<4 or 20% reduction
  186. 186what do pts often need to help with aspirin symptomsa PPI - give lansoprazole because omeprazole and clopidogrel interact

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Masters Clinical Flashcards on 5 - ACS and HF, created by lw409 on 25/04/2015.
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