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32 Cards in this Set
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Chest pain differentials include: (MI) |
1. Acute coronary syndrome 2. PE 3. Aortic dissection 4. GERD 5. Pneumothorax 6. Anxiety 7. Myocarditis/tamponade/pericarditis 8. MSK injury/Costochondritis |
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Investigations for MI + why: |
1. Serial ECG (every 10-15 mins) - ST elevation, LBBB, compare to old one 2. Bloods - glucose, FBC, CHEM20, troponin (repeat after 3-6 hours) - rule out type 2 MI causes, myocardial ischemia 3. Chest x-ray - rule out respiratory source 4. CT coronary angiogram - if nstemi, will inform PCI/CABG |
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Initial management of MI includes: (STEMI and NSTEMI) |
M - morphine + metoclopramide O - O2 if sats below 94% N - GTN A - DAPT PO STAT aspirin 300 mg + Clopidogrel 600 mg if PCI 300 mg if thrombolysis |
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Initial management after MONA for STEMI: |
Within 90 mins - Cath Lab for PCI - start anticoagulation (unfractionated heparin) >90 mins - thrombolysis within 30 mins - unfractionated heparin or clexane - tPA eg. Alteplase 15 mg iv bolus 50 mg iv over 30 mins then 35 mg IV over 60 mins |
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Initial management after MONA for NSTEMI: |
1. Beta blocker - eg. Atenolol 25 mg OD Metoprolol 25 mg BID 2. Anticoagulation - if indicated by patient risk eg. Enoxaparin (clexane) 1mg/kg subcu BID Unfractionated heparin if renal impairment or high risk of bleeding 3. PCI - within 2-72 hours depending on risk *No thrombolysis* |
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Absolute contraindications for thrombolysis: |
- recent (3 months) intracranial hemorrhage or head trauma - known cerebrovascular lesions - recent ischemia stroke - active bleeding anywhere - suspected aortic dissection - patient in cardiogenic shock: unlikely to be very effective (if at all) |
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Long-term management of STEMI/NSTEMI: |
PHARMACOLOGICAL 1. DAPT: aspirin 100 mg OD Clopidogrel 75 mg OD - continue clopidogrel 1 year, aspirin lifelong 2. Reduce cardiac mortality: statin, ACEi/ARB, beta blocker 3. GTN prn if appropriate, cease PDE5i's NON PHARMACOLOGICAL 1. Cardiac rehab program + patient education 2. Lifestyle optimization: diet, weight loss, stop smoking, exercise, reduce stress 3. Optimize comorbidities: diabetes, HTN, cholesterol, CKD, arrhythmias 4. TTE: wall motion abnormalities, heart failure |
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CHADSVASC Score includes: |
+1 point for each... - age 65-75 (+2 points for 75+) - female - hx of CHF - hx of HTN - hx of stroke/TIA/any thromboembolic event - vascular disease (past MI, PAD) - diabetes [Score 2+ should anticoagulate] |
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Shortness of breath + edema differentials include: (Heart failure) |
1. Decompensated heart failure (hfpef vs hfref) 2. Fluid overload of other cause 3. COPD 4. PE 5. Pneumonia |
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Causes of fluid overload other than heart failure : |
1. Renal failure 2. Nephrotic syndrome 3. Liver failure 4. Endocrine/metabolic disturbances including thyroid, ADH/renin, estrogen, steroids |
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Investigations for heart failure + why: |
1. ECG - arrhythmias 2. Bloods - FBC, CHEM20, CRP, thyroid, troponin, digoxin level, BNP<50 = NOT heart failure: electrolytes, liver/renal function, concurrent MI 3. Chest x-ray - cardiomegaly, fluid overload (congestion, fluid in fissures, Kerley b lines) 4. Echo - assess LV ejection fraction, valvular function, wall motion abnormalities 5. Cardiac MRI - investigate valvular disease if present |
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New York Heart Association (NYHA) classes = |
Class I - able to do full physical activities, no symptoms Class II - symptomatic with regular physical activity, slightly limited by this Class III - symptomatic with minimal physical activity, significantly limited by this Class IV - symptomatic at rest, very significant limitation to ADLs |
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Initial management of decompensated heart failure includes: |
1. O2 if sats below 94%, more invasive ventilation is necessary (bipap, cpap), sit upright 2. Diuretics - 40-80 mg frusemide IV stat 3. GTN - reduces LV filling + therefore workload of heart 4. Salt + fluid restrictions + monitoring 5. Daily weights 6. VTE prophylaxis 7. Monitor renal function 8. Identify precipitating factors 9. Cease nephrotoxic drugs 10. If AF: digoxin or amiodarone, anticoagulation as per CHADSVASC *Do not start beta blocker* |
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Precipitating factors of decompensated heart failure include: |
- medication nonadherence - fluid/salt/alcohol restriction nonadherence - AF - MI - PE - infection - iron deficiency anemia - hyperthyroid - any arrhythmias - medications: verapamil, diltiazem, NSAIDs, corticosteroids, some chemotherapies |
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Long-term management for heart failure (both hfref and hfpef): |
LIFESTYLE 1. Heart failure program + patient education 2. Importance of adherence to salt/fluid restrictions, dietician 3. Plan with GP for medication adjustments and decompensation 4. Optimize comorbidities: stop smoking, regular exercise, weight loss, diet, mental health, diabetes 5. Arrhythmia management 6. Yearly vaccinations 7. Symptomatic behaviour education: raise head of bed eg. |
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Long-term pharmalogical management for HFpEF: |
HFpEF = LVEJ > 40%, "diastolic HF" There is no evidence medications reduce mortality, treatment is only symptomatic: Frusemide 20-40 mg OD (These patients more sensitive to diuretics - use lower doses) |
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Long-term pharmalogical management of HFrEF: |
HFrEF = LVEJ <40%, "systolic HF" Pharmacological management reduces mortality: 1. Beta blockers - eg. Bisoprolol 1.25 mg OD (titrate up to 10 mg) 2. ACEi/ARB/ARNI - eg. Ramipril 2.5 mg BID (titrate up to 5 mg BID) 3. Spironolactone 25 mg OD PLUS 4. Frusemide 40-80 mg OD (Frusemide no mortality benefit, just symptomatic) |
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3 most common causes of heart failure: |
1. Ischemic heart disease 2. Dilated cardiomyopathy 3. Hypertension |
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Causes of secondary hypertension: |
1. Renal causes - renal artery stenosis - CKD - AKI - diabetic nephropathy - PKD - glomerulonephritis 2. Endocrine causes - hyperthroid - hyperparathyroid - hyperaldosteronism - Cushing's - phaeochromocytoma 3. Obstructive sleep apnea = SNS activation 4. Anxiety = SNS activation 5. Pre-eclampsia 6. Malignant HTN 7. Drugs: smoking, alcohol, amphetamines, steroids, estrogens, NSAIDs, MAOi's, clozapine, appetite suppressants, chemotherapy |
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Investigations for hypertension + why: |
- renal + adrenal ultrasound - urinalysis - blood, protein, K - sleep study - bloods - CK and urea up/eGFR down, TFT, PTH, aldosteron:renin- sleep study- dexamethasone suppression test- urinary metanephrines- HbA1c, bgl, fundoscopy - dexamethasone suppression test - urinary metanephrines - HbA1c, bgl, fundoscopy |
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Initial management for asymptomatic hypertension: |
1. Observe for short time to see if it comes down (white coat) 2. Begin antihypertensives if not already on them |
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Initial management for hypertensive urgency: |
Hypertensive urgency = >180/110 and symptomatic 1. Give regular antihypertensives if a dose has been missed 2. Nifedipine 10mg PO or Prazosin 2 mg PO STAT 3. Adjust antihypertensives once resolved |
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Initial management for hypertensive emergency: |
Hypertensive emergency = >220/140 1. Arterial line for BP monitoring if possible 2. Hydralazine 1mg IV bolus (up to 5x in 5 mins if no IV infusion available) or Sodium nitroprusside 0.3mcg/kg/min every 5 mins with increasing doses |
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Long-term management of hypertension: |
NON PHARM 1. Lifestyle management: diet, weight loss, stop smoking, limit alcohol/drugs/stress/anxiety 2. Optimizing comorbidities: cholesterol, diabetes PHARM 1. One drug - ACEi or ARB titrated to max 2. Two drugs, low dose - add CCB 3. Increase dose of one then the other to max 4. Three drug combo - once all three are at max dose "treatment resistant htn" 5. Add/change combo to include beta blocker |
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What is the main risk of uncontrolled, extreme hypertension? |
End organ damage |
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What are the differentials for shortness of breath (PE): |
1. PE: sudden onset SOB, central pleuritic chest/back pain, tachycardia. If massive: syncope, shock, hemoptysis 2. ACS 3. Acute decomp. heart failure 4. Pneumothorax 5. Pneumonia 6. Pericarditis 7. Cardiac tamponade 8. Panic attack 9. COPD exacerbation |
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What investigations will you do for suspected PE and why: |
TAKE BLOODS, SEND FOR CTPA 1. ECG: sinus tachycardia, RBBB/r-axis deviation, rule out MI 2. Bloods: negative d-dimer=not PE, elevated BNP and troponin=poor outcome, FBC, CHEM20, coagulation profile, need eGFR 3. CTPA: gold standard PE diagnosis 4. ABG: hypoxemia (resp alkalosis in PE) 5. Chest x-ray: rule out other resp sources 6. Doppler ultrasound if DVT suspected |
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Describe Well's score: |
Increased likelihood it's a PE if... - history of DVT/PE - heart rate >100 - hemoptysis - clinical signs of a DVT - active cancer - surgery/immobilization in the last month - alternative diagnoses are less likely |
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Initial management of a PE includes: |
1. O2: high flow unless contraindicated 2. Obtain IV access: only if very severe, fluids and inotropic agents (digoxin, epinephrine) 3a. Anticoagulation: HEMODYNAMICALLY STABLE: apixaban 10 mg PO BID for 7 days or Rivaroxaban 15 mg PO BID for 21 days or UFH or dalteparin if eGFR<30 3b. Thrombolysis: HEMODYNAMICALLY UNSTABLE: alteplase 10 mg IV bolus then 90 mg infusion over 2 hours or tenecteplase 40 mg IV bolus Followed by UFH and referral to specialists for embolectomy/IVC filter if anticoagulation is contraindicated |
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Initial management for a hemodynamically stable PE includes: |
3a. Anticoagulation: HEMODYNAMICALLY STABLE: apixaban 10 mg PO BID for 7 days or Rivaroxaban 15 mg PO BID for 21 days or UFH or dalteparin if eGFR<30 |
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Initial management of a hemodynamically unstable PE includes: |
3b. Thrombolysis:HEMODYNAMICALLY UNSTABLE: alteplase 10 mg IV bolus then 90 mg infusion over 2 hours or tenecteplase 40 mg IV bolusFollowed by UFH and referral to specialists for embolectomy/IVC filter if anticoagulation is contraindicated |
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Long-term management of a PE: |
1. Anticoagulation: Provoked PE: continue for 3-6 months Unprovoked PE: continue 3 months to maybe indefinitely (patient preference) apixaban 5mg PO BID or rivaroxaban 20 mg PO OD Then continue aspirin 100 mg OD indefinitely 2. Lifestyle: education about immobilization, stop smoking, diet, weight, stop hypercoaguable drugs (ocp, hrt), graduated compression stockings 3. Consider investigating: malignancy, inherited thrombophilias (what caused the PE) |
