Cardio

• Angina


  Symptomatic chest pain due to myocardial ischaemia
• Coronary circulation

  • Only allows blood filling during diastole
  • Coronary arteries become occluded over time due to atherosclerosis, impeding blood flow to the muscle
• Areas of myocardium become ischaemic

  Especially in times of greater oxygen demand, giving pain
• Body's response to angina

  1. Increases sympathetic stimulation to try to increase HR and force of contraction

  2. This only makes the problem worse as it increases O2 demand further
• Treating angina


  Try to relax heart giving it more time to fill and reduce oxygen demand
• Types of angina


  • Stable
  • Unstable
• Stable angina

  • Chronic condition which occurs when >70% of the vessel is occluded
  • Constricting discomfort in the front of the chest/neck/shoulders/arms
  • Precipitated by physical exertion
  • Relieved by rest or GTN spray in 5 minutes
• Typical angina


  Has all 3 features of stable angina
• Atypical angina


  Gives 2 of the 3 features of stable angina
• Unstable angina


  • Chest pain that occurs at rest
  • Treated as part of Acute coronary syndrome
  • Usually due to rupture of plaque which leads to incomplete occlusion of coronary artery
  • Relieved by nitroglycerin with ST-segment depression
  • High risk of progression to myocardial infarction (treated as ACS)
• Diagnosis of angina

  • CT coronary angiography (1st line)
  • Non-invasive functional imaging to look for reversible myocardial ischaemia (2nd line)
• Management of stable angina

  • Prophylaxis (Aspirin + Statin)
  • Symptom Relief (Glyceryl trinitrate spray)
  • Medical Therapy (B-blocker or Ca2+ channel blocker, dual therapy if still symptomatic)
• Myocardial Infarction

  Irreversible death of cardiac myocytes, due to ischaemia
• Causes of myocardial infarction

  • Rupture of a plaque leading to thrombosis and complete occlusion of the artery
• Types of myocardial infarction

  • ST-elevated Myocardial infarction (STEMI)
  • Non-elevated (NSTEMI)
• Risk factors for myocardial infarction


  • Older men
  • Hypertension
  • Diabetes
  • Smoking
• Symptoms of myocardial infarction

  • Acute crushing central chest pain that comes on at rest (maybe no pain in elderly and diabetics)
  • Pain radiates to jaw, neck, either/both Upper limb
  • Sweaty and clammy
  • Nausea, Vomiting and epigastric pain
• Blood Troponin test


  • Levels of troponin I indicate damage to myocardial cells
  • Two samples taken 3h apart and indicate possible infarction
  • Levels rise 2-4 hours and peak at 24 hours
• ECG findings in STEMI

  • >1mm ST elevation in at least 2 consecutive limb leads
  • >2mm ST elevation in at least 2 consecutive precordial leads
  • New onset left-bundle branch block
• ECG lead changes


  • Lead V1-V4 = anterior territory (LAD artery)
  • Leads I, V5, V6 = lateral territory (Circumflex artery)
  • Leads II, III, aVF = inferior territory (Right coronary artery)
• Acute management of myocardial infarction (MONA)

  1. Morphine (for pain relief + metoclopramide antiemetic)

  2. Oxygen (if SpO2 below 94%)

  3. Nitrates (GTN to vasodilate veins and reduce preload)

  4. Aspirin (loading dose of 300mg)
• Specific management for STEMI

  1. Give dual antiplatelet therapy (Clopidogrel)

  2. Give Primary PCI (1st choice) within 12 hours of symptom onset

  3. Fibrinolysis if PCI cannot be given within 120 minutes

  4. ECG 90 mins after fibrinolysis to check for >50% resolution in ST elevation

  5. Open heart surgery or emergency coronary bypass if very severe
• Specific management for NSTEMI

  1. Calculate GRACE score (6-month mortality indicator)

  2. If GRACE >1.5%, give 2nd antiplatelet clopidogrel

  3. If GRACE >3%, arrange coronary angiography within 96 hours
• Chronic management after myocardial infarction

  • Aspirin
  • Second antiplatelet (Clopidogrel, prasugrel or ticagrelor)
  • B-blocker
  • ACE inhibitor
  • Statin
• Heart Failure


  Condition where the cardiac output is inadequate to meet the body's requirements
• Types of heart failure

  • Systolic failure
  • Diastolic failure
• Systolic heart failure


  • Inability for the ventricle to contract properly, decreasing cardiac output
  • Ejection fraction (EF) is 40%
  • Due to conditions which weaken the heart muscle reducing contractility (e.g. ischaemic heart disease, myocardial infarction)
• Diastolic heart failure


  • Inability of ventricle to fill normally, causing increased filling pressure
  • Ejection fraction is >50%, but cardiac output is low
  • Due to constrictive causes (e.g. pericarditis, tamponade, hypertrophy)
• Left ventricular failure


  • Usually due to MI, cardiomyopathies and ischemia
  • Results in decreased forward perfusion and congestion of the pulmonary circulation
• Symptoms of left ventricular failure

  • Dyspnoea, paroxysmal nocturnal dyspnoea, orthopnoea (breathlessness lying down)
  • Polyphonic expiratory wheeze with bibasal crackles due to pulmonary oedema
  • 3rd heart sound
  • Weight loss and weight gain due to oedema
  • Pulsus alternans (alternation of force of arterial pulse: hard then soft)
• Right ventricular failure


  • Usually occurs after left-sided failure and pulmonary hypertension
  • Also due to left–>right shunts, which increases the pulmonary blood flow
  • Results in congestion of the peripheral venous circulation
• Symptoms of right ventricular failure

  • Raised JVP, pitting ankle oedema and ascites
  • Hepatosplenomegaly with a smooth "nutmeg" liver which is pulsatile
• Investigations for diagnosing heart failure

  • Blood tests (natriuretic peptides)
  • Echocardiogram
  • ECG
  • Chest X-ray
• Natriuretic peptides


  Get secreted when heart chambers get overloaded, carry a very important prognostic role
• Echocardiogram


  Used to assess the ventricular ejection fraction, medication commenced when EF <40%
• Management of acute heart failure

  • Early O2 to increase saturations
  • IV furosemide
  • Glyceryl trinitrate
  • IV nitrates
  • CPAP to drive out fluid from lungs
• Management of chronic heart failure

  • ACE inhibitor
  • Beta-blocker
  • Mineralocorticoid receptor antagonist
  • Diuretics
  • Vaccines (influenza and pneumococcal)
• Treatments that can worsen heart failure

  • Thiazide diuretic in diabetics
  • Calcium channel blockers (except dyhydropyridine)
  • NSAIDs and COX2 inhibitors
• Medications with no mortality benefit in ischemic heart failure

  • Furosemide
  • Statin
  • Digoxin
  • Ivabradine
• QRISK 3 score


  1. Calculate percentage risk of stroke or myocardial infarction in next 10 years

  2. Offer atorvastatin 20mg if risk >10%

  3. Check lipids at 3 months and increase dose to aim for >40% reduction in non-HDL cholesterol

  4. Check LFTs within 3 months and again at 12 months