CVS

• Atrial fibrillation


  Superventricular arrythmia
• Atrial fibrillation pathophysiology


  • Activation of the RAAS pathway
  • Structural changes to the atria
  • Tachyarrithymia
• Atrial fibrillation risks


  • Predisposed factors
  • Infection
• Atrial fibrillation symptoms


  • SoB
  • Palpitations
  • Chest pain
  • Fatigue
• Atrial fibrillation classification


  • First diagnosed
  • Paroxysmal- goes within 7 days
  • Persistent- more than 7 days
  • Long standing- more than 12 months
  • Permanent- no further attempts to restore sinus rhythm
• Atrial fibrillation management


  1. Stroke risk (CHA-DS-VAS)

  2. Symptom severity

  3. Severity of AF burden

  4. Substrate severity
• Rate control


  Control ventricular rate (less than 110bpm)
• Rate control first line


  • Beta-blocker (NOT sotalol)
  • Digoxin (if immobile with non-proximal AF)
• Rate control second line


  • Rate-limiting CCB (verapamil/diltiazem)
• Stable angina has no necrosis
• Stable angina symptoms


  • Heaviness/pain that radiates to the neck, jaw, left arm
  • Bought on by stress
  • Rest fixes
• Stable angina investigations


  • Resting 12-lead ECG
  • FBC
  • LFTs
  • HbA1c
  • Lipids
  • Troponin
• Stable angina management of symptoms


  • 1st line= lifestyle
  • 2nd line= GTN (short acting nitrate)
• Stable angina treatment


  • 1st line= B-blocker/ CCB
  • 2nd line= long acting nitrate—ivabradine
  • 3rd line= surgery
• STEMI symptoms


  • Crushing pain
  • N&V
  • SoB
  • Sweating
• STEMI investigations


  • ECG
  • HR
  • BP
  • History
  • Troponin
• STEMI immediate offer


  1. 300mg asprin

  2. Pain= i.v. morphine/diamorphine

  3. N&V= prochlorpromazine

  4. Oxygen if below 94%

  5. Sublingual GTN
• STEMI stent post-op meds


  • If not on anticoagulant= prasugrel and aspirin
  • If on anticoagulant= clopidogrel and aspirin
  • If radial access needed= unfractionated heparin
  • If femoral access needed= bivalirudin
• STEMI fibrinolysis


  • Ticagrelor with aspirin
  • Clopidogrel with aspirin
  • Aspirin
• NSTEMI fibrinolytic therapy never indicated
• NSTEMI immediate offer


  1. 300mg asprin

  2. Pain= i.v. morphine/diamorphine

  3. N&V= prochlorpromazine

  4. Oxygen if below 94%

  5. Sublingual GTN
• NSTEMI normal patient


  • Fondaparinux after loading dose of aspirin
• NSTEMI high bleeding risk, renal problems or low weight

  • Unfractionated heparin
• NSTEMI risk below 3% (low risk)


  • Ticagrelor/ clopidogrel with aspirin
  • Aspirin
• NSTEMI risk above 3% (high risk)


  • Angiography
• Stroke pathophysiology


  • Na+/K+ channel failure
  • Cytotoxic oedema- water in intracellular compartment= narrowing of extra cellular matrix
  • Penumbra- tissue that may be at risk of death
• Stroke types


  • Haemorrhagic stroke
  • Ischaemic stroke
  • Transient ischaemic attack (TIA)
• Haemorrhagic stroke


  • Rupture of cerebral artery
  • Around brain= SAH
  • Inside brain= ICH or IVH
  • DO NOT give LMWH for VTE prophylaxis
  • Stockings instead
• Ischaemic stroke


  • Episode of neurological dysfunction caused by focal cerebral, spinal or retinal infarction
  • Embolic- AF
  • Thrombotic- small vessel disease
• Transient ischaemic attack (TIA)


  Transient episode of neurological dysfunction caused by focal cerebral, spinal or retinal infarction without acute infarction
• Causes of strokes


  • Arterial embolism from another site
  • Arterial thrombus
  • Haemorrhage
• Stroke risk factors


  • predisposed factors
  • AF
  • Diabetes
• Stroke symptoms


  • Negative symptoms: Loss of sensation, Weakness, Speech impairment
  • Positive symptoms: Shaking limbs, Tingling sensation, Flashing lights
  • FAST
  • ROSIER
• BP tends to rise after stroke
• Ischaemic stroke management


  1. i.v. thrombolysis with fibrinolytic agent: Alteplase, Tenecteplase

  2. Anti-platelets: Aspirin 300mg daily for 2 weeks, then long term antithrombotic: Aspirin 75mg, Clopidogrel 75mg

  3. Anti-coagulants: 1st line= DOAC, 2nd line= warfarin

  4. Thrombectomy (surgery): Mechanical clot retrieval within 6 hours of onset
• Stroke treatment for patients aged 55+ or of African/Caribbean origin


  • Long acting dihydropyridine CCB
  • Thiazide like diuretic
  • If BP target not reached= ACEi or ARB
• Stroke treatment for patients younger than 55 or not of African/Caribbean origin


  • ACEi or ARB
• Stroke statin treatment


  • 1st line= Atorvastatin 80mg OD
  • 2nd line= ezetimibe 10mg OD
• Stroke antiplatelet therapy for TIA onset within 24 hours or minor ischaemic stroke AND low bleeding risk


  • Option 1: Clopidogrel loading dose 300mg then 75mg OD AND aspirin loading dose 300mg then 75mg OD for 21 days, THEN Clopidogrel monotherapy 75mg OD
  • Option 2: Ticagrelor initial dose 180mg then 90mg BD AND aspirin loading dose 300mg then 75mg OD for 30 days, THEN Ticagrelor 90mg BD or clopidogrel 75mg OD
• If antiplatelet therapy not indicated for stroke= clopidogrel 300mg loading dose then 75mg OD