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Phase2Karl Wild and Rowena Speak
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Stable Angina• Stable Angina - A retrosternal chest tightness or heaviness which is brought on by
exertion and relieved by rest.
• Symptoms – constricting discomfort in the front of the chest, arms, neck and jaw, Provoked by physical exertion, especially after meals and in cold, windy weather or excessive
emotion Relieved (within minutes) with rest or glyceryl trinitrite.
• Causes – Mostly Atheroma. Anaemia, Aortic Stenosis, Tachyarrhythmia, Hypertrophic Cardiomyopathy Arteritis.
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Unstable Angina – Angina of recent onset (<24hr) or a deterioration in stable angina with symptoms occurring at rest.
Refractory Angina – Refers to patients with severe coronary artery disease in whom revascularization is not possible and whose angina is not controlled by medical therapy.
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Angina Examination
Signs – AnaemiaThyrotoxicosisHyperlipidaemiaAortic Stenosis (Ejection Systolic murmur radiating to neck)Check blood pressure
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Angina Investigation
• 12 lead ECG -During an attack – Transient ST depression & T
wave inversion.• Cardiac Catheterization, CT Coronary
Angiography• Exclude anaemia, diabetes, hyperlipidaemia,
thyrotoxicosis and arteritis
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Angina Management
• Address risk factors• Aspirin 75mg daily• B-blocker/ Ca2+ – Atenolol/AmlodipineBoth if uncontrolled on one• Nitrates – GTN, Isosorbide Mononitrate bd• Ivabradine/Nicorandil
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Revascularisation
• PCI –Single vessel CAD and normal LV function
• CABG –Triple vessel disease and abnormal LV function
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Acute Coronary Syndromes
• ST Elevation Myocardial Infarction (STEMI)• Non ST Elevation Myocardial Infarction (NSTEMI)• Unstable Angina
• Causes –Plaque rupture Coronary SpasmThrombosis VasculitisEmboli
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NSTEMI
ECG changes -ST depressionT Wave inversion
Could be normal
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STEMI
• ECG changes –Tall T wavesST elevationNew LBBB
Later –T wave inversionPathological Q waves
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ACS symptoms -
• Acute central chest pain• Radiates neck and arm• Lasting >20 minutes• Nausea• Dyspnoea• Palpitations
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ACS Signs -
• Distress, anxiety, pallor, sweatiness• Tachy/bradycardia• Hyper/hypotension• 4th heart sound• Signs of HF and murmur• Later - Pericardial friction rub & peripheral
oedema
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ACS Investigations
• ECG• Bloods• Cardiac Enzymes –Cardiac Troponin (T & I) ^ 3 hours after onset
and peak at 24-48hrCreatine Kinase (CK-MB) ^ 3 hours after onset,
peak within 24hr
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ACS ManagementNSTEMI
OxygenMorphineGTNAspirin 300mg POClopidogrel 300mg POAtenolol PO / Verapamil POEnoxaparin
More Nitrate if in pain.High risk – GPIIb/Iia antagonist (tirofiban)Low risk – Discharge if 12hr Trop -ve
STEMIOxygenAspirin 300mg POMorphineGTN
PRIMARY PCI / ThrombolysisAtenolol
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ACS Pathology Cause ECG changes Cardiac enzymes
(Stable angina) (Narrowing lumen)
Unstable angina
Ischaemia Non-occlusive thrombus
No ST elevation
-ve troponin
NSTEMI Ischaemia/Infarction
Non-occlusive thrombus
No ST elevation
+ve troponin
STEMI Transmural infarction
Occlusive thrombus
ST elevation +ve troponin
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Hypertension (HTN)• Essential (primary) HTN
= idiopathic• Secondary HTN =
something is causing it
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HTN: causes of secondary• Renal disease: intrinsic, renovascular • Endocrine: Cushing’s, Conn’s, Phaeochromocytoma,
Acromegaly, Hyperparathyroidism• Coarctation of the aorta• Pre-eclampsia and HTN in pregnancy• Drugs and toxins: alcohol, cocaine, ciclosporin,
decongestants, adrenergic medications, oral contraceptives, corticosteroids, liquorice
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HTN: symptoms• Usually asymptomatic• Headaches, paroxysmal sweats or palpitations
= think phaeochromocytoma (tumour of the adrenal medulla)
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HTN: diagnosis• GP surgery BP measurements of adults at least every 5 yearsWhite coat syndrome = patients have elevated BP in a clinical setting but not
in other settings due to anxiety experienced during a clinic visit.
• ABPM = ambulatory blood pressure monitoring• HBPM = home blood pressure monitoring• Cardiovascular risk assessment• HTN retinopathy screening• ECG to look for LVH• Bloods: electrolytes, creatinine, eGFR, fasting glucose, lipids• Urinalysis: albuminuria, proteinuria or haematuria ± albumin:creatinine
ratio.
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HTN: stages• Stage 1 - BP in surgery/clinic is ≥140/90 mm
Hg and ABPM or HBPM is ≥135/85 mm Hg.
• Stage 2 - BP in surgery/clinic is ≥160/100 mm Hg and ABPM or HBPM is ≥150/95 mm Hg.
• Severe - BP in surgery/clinic is ≥180/110 mm Hg or higher.
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HTN: lifestyle interventions• Lower salt intake• Reduce alcohol consumption • Stop smoking• Do more exercise• Be less stressed
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HTN: initiation of treatment• Offer step 1 treatment to
people aged under 80 with stage 1 hypertension and one or more of:
a) target organ damageb) established cardiovascular
diseasec) renal diseased) diabetese) 10-year cardiovascular risk
equivalent to 20%
• Offer step 1 treatment to people of any age with stage 2 hypertension
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HTN: treatment
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Heart failure• A complex syndrome that can result from any
structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation.
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HF: aetiology• Ischaemic heart disease• Cardiomyopathy• HTN• Diseases of the heart
valves• Pericardial disease• Arrhythmias
• Alcohol• Cocaine• Chemo• Severe anaemia• Thyroid disease• Idiopathic
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HF: symptomsLeft• Exertional dyspnoea• Orthopnoea• Paroxysmal nocturnal
dyspnoea (PND)• Fatigue
Right• Swollen ankles• Fatigue• Anorexia
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HF: signsLeft• Cardiomegaly• Third and fourth heart
sounds• Tachycardia• Crepitations in lung bases
Right• Raised JVP• Hepatomegaly• Pitting oedema• Ascites
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HF Investigations
• Chest X ray• Bloods• B-type Natriuretic Peptide• ECG• Transthoracic echocardiogram
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Chronic HF Management
• Diuretics – Furosemide• ACE-I – Ramipril / ARB – Candesartan• B-Blocker – Atenolol• Spironolactone• Digoxin• Vasodilators – Hydralazine & Isosorbide
Dinitrate
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Acute HF Management
• Oxygen• Diamorphine IV• Furosemide IV• GTN spray• If systolic BP >100mmHg IV nitrate
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HF Question
A 75 year-old woman is brought to the Emergency Department by ambulance following an emergency call at 4 am. She is pain-free but very breathless. She has previously been diagnosed with congestive cardiac failure and is receiving drug treatment from her General Practitioner.
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GOOD LUCK!!!