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What is the common cause of angina pectoris?
Atheroma
What are the less common causes of angina pectoris? [5]
Anaemia, aortic stenosis, tachyarrythmias, hypertrophic obstructive cardiomyopathy, arteritis/small vessel disease
Name the types of angina [4]
Stable angina, unstable (crescendo) angina, decubitus angina, variant (Prinzmetal\\\'s) angina
How is stable angina induced?
Effort (relieved by rest)
What are the characteristics of unstable (crescendo) angina? [3]
Increasing frequency or severity, occurs in minimal exertion or rest, associated with ^^ risk of MI
What precipitates decubitus angina?
Lying flat
What is the cause of variant (Prinzmetal\\\'s angina)?
Coronary artery spasm
Angina - tests [2]
ECG, exercise ECG
How may angina present on ECG? [4]
May be normal, ST depession, flat/inverted T waves, signs of past MI
What precipitating factors may need to be excluded when investigating angina? [5]
Anaemia, diabetes, hyperlipidaemia, thyrotoxicosis, giant cell arteritis
What is the lifestyle management of angina? [3]
Stop smoking, encourage exercise, weight loss
Describe the drug management of stable angina [6]
Aspirin (75-150mg/24h), B-blockers (e.g. atenolol 50-100mg/24h po), nitrates (symptomatic spray, prophylaxis po), calcium antagonists (amlodipine 10mg/24h; diltiazem-MR 90-180mg/12h po), statin, K+ channel activator
List the treatment steps for acute coronary syndrome without ST-elevation (e.g. unstable angina, evolving MI [4]
MONA - morphine, oxygen, nitrate, aspirin
What is percutaneous transluminal coronary angioplasty (PTCA)?
Balloon dilation of a stenotic vessel
What are the indications for CABG? [8]
Left main stem disease, multi-vessel disease, multiple severe stenoses, distal vessel disease, failed/unsuitable for angioplasty, refractory angina, MI, pre-operative (valve/vascular surgery)
Acute coronary syndromes (unstable angina, evolving MI) - P [4]
Plaque rupture, thrombosis, and inflammation (rarely emboli, coronary spasm, or vasculitis)
What are the risk factors for ACS? [9]
Non-modifiable: age, male sex, family history of IHD; modifiable: smoking, hypertension, DM, hyperlipidaemia, obesity, sedentary lifestyle
What is the incidence of ACS?
5/1000 per annum (UK) for ST-segment elevation
What ECG changes are seen in ACS without ST-segment elevation? [4]
May show ST-depression, T-wave inversion, non-specific changes, or be normal
How is ACS diagnosed?
2/3 from: i) typical history, ii)ECG changes, iii) cardiac enzyme rise
What are the symptoms of ACS? [5]
Acute central chest pain lasting > 20 mins, sweatiness, dyspnoea, palpitations (elderly or diabetics may suffer \\\'silent\\\' infarct)
List the signs of ACS [6]
Distress and anxiety, pallor, sweatiness, pulse/BP high or low, 4th heart sound, may be signs of HF
What investigations are useful in ACS? [3]
ECG, CXR, bloods (FBC, U&E, ^glucose, low lipids, ^cardiac enzymes - CK, AST, LDH, troponin)
What are the differential diagnoses, for suspected ACS? [6]
Angina, pericarditis, myocarditis, aortic dissection, pulmonary embolism, oesophageal reflux/spasm
In ACS, what proportion of deaths occur in the first 2 hours?
50%
What are the CXR findings in ACS?
Cardiomegaly, pulmonary oedema, widened mediastinum (NB do not delay Rx waiting for CXR)
What are the classical ECG findings in ACS? [6]
Hyperacute T-waves, ST elevation or new LBBB occur within hours of acute Q-wave. T-wave inversion and pathological Q-waves follow after hours or days. (ECG initially normal in 20%)
Describe post-ACS management [8]
48h bed rest, daily 12-lead ECG U&E cardiac enzymes for 2-3d, prophylaxis for thromboembolism, oral B-blockers, continue ACE-i, statin, exercise ECG, modify risk factors
List the complications of MI [13]
Cardiac arrest, cardiogenic shock, unstable angina, bradycardias/heart block, tachyarrythmias, LVF, RVF/infarction, pericarditis, DVT/PE/systemic embolism, cardiac tamponade, mitral regurgitation, ventricular septal defect, Dressler\\\'s syndrome
List the cardiac causes of arrhythmia [8]
MI, coronary artery disease, LV aneurysm, MV disease, cardiomyopathy, pericarditis, myocarditis, aberrant conduction pathways
List the non-cardiac causes of arrhythmia [7]
Caffeine, smoking, alcohol, pneumonia, drugs, metabolic imbalance (K+, Ca2+, Mg2+, hypoxia, etc), phaeochromocytoma
How does arrhythmia present? [5]
Palpitation, chest pain, (pre)syncope, hypotension, or pulmonary oedema. (May be unsymptomatic)
What tests are indicated in arrhythmias? [8]
FBC, U&E, glucose, Ca2+, Mg2+, TSH, ECG (24h/exercise), echo
Bradycardia (<40 bpm or symptomatic) - Rx [4]
Treat cause (e.g. drugs, hypothyroidism), atropine 0.6 - 1.2 mg iv, temporary/permanent pacing wire, isoprenaline
How does sick sinus syndrome arise?
Sinus node dysfunction causes bradycardia +/- arrest, SA block, or tachy-brady syndrome (AF and thromboembolism may occur)
How is sick sinus syndrome treated? [1]
Pacing
What is SVT?
Narrow complex tachycardia (>100 bpm, QRS width <120 ms)
What is the acute management of SVT? [4]
Vagotonic manoeuvres, iv adenosine or verapamil (if not on B-blocker), DC shock if compromised
What is the maintenance management of SVT? [2]
B-blockers or verapamil
How is AF/flutter treated?
Digoxin loading dose (500 micrograms/12h x 2) then maintenance dose (0.125-0.25mg/24h)
How is VT defined?
Broad complex tachycardia (rate >100 bpm, QRS duration >120ms)
What is the acute management of VT?
iv lignocaine or amiodarone
Which drug is used in the maintenance management of VT?
Amiodarone
What is narrow complex tachycardia?
ECG shows rate of >100bpm and QRS complex duration of <120ms
What is the differential diagnosis of narrow complex tachycardia? [7]
Sinus tachycardia, SVT, AF, atrial flutter, atrial tachycardia, multifocal atrial tachycardia, junctional tachycardia
How does sinus tachycardia present on ECG?
Normal P wave followed by normal QRS
How does SVT present on ECG?
P wave absent or inverted after QRS
How does AF present on ECG?
Absent P wave, irregular QRS complexes
How does atrial flutter present on ECG?
Atrial rate usually 300 bpm (sawtooth baseline), ventricular rate often 150 bpm
How does atrial tachycardia present on ECG?
>100 bpm/QRS <120ms, abnormally shaped P waves, may outnumber QRS
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