1. Clinical presentation - Case Histories Flashcards
IV Drug use cardiac complication
Infective endocarditis affecting right side of heart
30 yr old woman
Upper Resp Tract Infection
Pleuritic chest pain
Better leaning forward
Pericarditis
Differentiate between split S2 and S3
S3 better heard with Bell of stethoscope
Raised JVP DDx
R heart failure
Tricuspid regurgitation
Constrictive Pericarditis
Acute Fast AF
BP 120/80
Management
Rhythm Control:
-if onset more than 48hrs ago, anticoagulate for 3-4wks before cardioversion
Rate Control:
- beta blocker
- digoxin
(Treat underlying cause and manage complications)
ECG: Fast, No P waves, Regular
SVT
60 yr old Chest Pain Tight 4hrs Nausea Sweating Breathlessness HTN DH: Amlodipine
Myocardial Infarction
Slow rising pulse
Felt in carotid, like a thrill in neck.
3rd Degree Heart Block
Complete Dissociation P/QRS
P not followed by QRS
2nd Degree Heart Block
or 3rd
Congestive Cardiac Failure
R failure secondary to L failure
Pericarditis ECG
ST elevation in all leads
STEMI treatment?
Aspirin, Clopidogrel, Percutaneous Coronary Intervention
```
MONABASH:
Morphine
Oxygen
NTG PRN chest pain
Aspirin
Beta blocker
ACE inhibitor
Statin
Heparin
~~~
Broad QRS, Fast
VT unless proven otherwise
Palpitations/Tachycardia diagnoses (by ECG)
Sinus Tachycardia SVT Atrial Fibrillation Atrial Flutter VT (VF)
Cardiac Arrest Reversible Causes
Four H’s Four T’s:
Hyper/Hypokalaemia Hypoxia Hypothermia Hypovolaemia Thromboembolism Tension Pneumothorax Toxicity Cardiac Tamponade
Examination Aortic Dissection
Difference BP two arms;
Early diastolic murmur (aortic regurgitation)
Coronary Artery
ECG changes in Inferior MI
RC artery
II, III, aVF
Adenosine Contraindication
Asthmatics
ECG: Fast, No P waves, irregular
AF
Gold standard LVH
Echocardiogram
Acute Fast AF
BP 60/30
Cardioversion
Be aware of clots having formed
Features of seizures
Aura, Stereotypical Movements, Tongue Biting, Incontinence
Pan Systolic Murmur DDx
Mitral regurgitation
Tricuspid Regurgitation
VSD
Constrictive Pericarditis
Fibrosis of pericardium e.g. TB. Raised JVP, hepatomegaly, calcification of pericardium on CXR
PE Risk Factors
Immobility, malignancy, smoking, birth control, pregnancy, prior DVT
Postural Hypotension Investigations
Lying/Standing BP
65 yr old woman Breathlessness Onset few hours Orthopnoea PMHx: 2 MIs DH: Aspirin, Simvastatin, Ramipril, Bisoprolol Temp 36.5 Raised JVP S1+S2+S3 Fine Crackles Peripheral Oedema
Cause + Management
Heart Failure
Sit her up and 60-100% O2
S1
Closure of Mitral Valve
30 yr old man Collapse HPC: no warning no tongue biting not confused FH brother died at young age HS S1+S2 BP 120/80 lying 115/75 standing Vesicular breath sounds Abdomen SNT
Tachyarrhythmia - Ventricular Tachycardia
Common cause of gastritis
Excessive Alcohol intake
VT Management
IV Amiodarone
Cause and Complications
Think about ICD (implantable cardiac defibrillator)
Pulseless VT -> Defibrillate
Outflow Obstruction O/E and Investigations
(L: Aortic Stenosis, HOCM R: PE) Low Volume/Slow rising pulse Ejection Systolic Murmur Echocardiogram
Fixed wide splitting of S2
Atrial Septal Defect
Oesophageal Infection during immunosuppression
Oesophageal Candidiasis
Long QT Syndrome
Abnormal Ventricular Repolarisation
Congenital e.g. mutations in K+ channels
Acquired: Low K+/Mg2+, drugs
FH of sudden death
2nd Degree Heart Block
P not followed by QRS
Delta waves
AVRT ECG finding in sinus rhythm
Coronary Artery and ECG changes in Anterior MI
LAD artery
V1-V4
ALS algorithm
VF/Pulseless VT: Shock CPR 2mins Assess rhythm Adrenaline every 3-5mins Correct reversible causes
Asystole/Pulseless electrical activity:
CPR
Correct reversible causes
Pericarditis characteristic pain
Pleuritic Chest Pain (worse on inspiration) - better by leaning forward.
Also maybe preceding flu-like illness
Chest Pain Investigations
- ECG
- Troponin
+ve: coronary angiography and PCI
-ve: Exercise Tolerance Test - Echocardiography
SVT, BP 120/80 Management
Valsava Manoeuvre
Adenosine
Systolic Murmur DDx
Aortic Stenosis
Mitral regurgitation
Tricuspid Regurgitation
VSD
Differentiate by where loudest, radiation, associated features
Displaced apex beat in which cardiac condition
Mitral regurgitation
Prolonged PR interval
>0.2s
1st Degree Heart Block
Acute Heart Failure Managment
Sit up Oxygen Furosemide (IV) GTN infusion Diamorphine
(all venodilators - reduce preload of heart)
Treat underlying cause
S4
Associated with ventricular filling
Caused by atria contracting forcefully to overcome stiff/hypertrophic ventricle
Sinus Tachycardia DDx
Sepsis, Hypovolaemia, Endocrine (thyrotoxicosis, phaeochromocytoma)
Anxiety
Tricuspid regurgitation causes
Valve leaflet defects
R ventricle dilatation
PE timing
Sudden onset pain
60 yr old man Chest Pain Tight 2hrs Nausea and Sweating PMH HTN DH amlodipine Temp 37.0 HS S1+S2 BP: 120/80L 118/75R Chest Clear Abdomen SNT
Most appropriate investigation?
ECG (STEMI/NSTEMI?)
Then serial Troponin, then Echocardiogram
SVT subtypes
AVNRT
AVRT
-> ECG in sinus rhythm has short PR and Delta wave
Chest Pain DDx
Cardiac: IHD, Aortic Dissection, Pericarditis
Resp: PE, Pneumonia, Pneumothorax
GI: Oesophageal spasm, Oesophagitis, Gastritis
Musc: Costochondritis, Rib Fracture
R heart failure causes
Secondary to L failure Pulmonary HTN (PE, COPD etc)
Collapse DDx
- Hypoglycaemia
- Cardiac:
Vasovagal
Arrhythmia
Outflow obstruction
Postural Hypotension - Neurological - Seizure
1st Degree Heart Block
Prolonged PR interval
>0.2s
Ventricular Tachycardia DDx
Ischaemia, Electrolyte abnormality, long QT
45 yr old man Fever Malaise IV drug use Temp 38 Raised JVP to earlobes S1+S2+PSM louder on inspiration Hepatomegaly
Tricuspid Regurgitation
PSM louder inspiration due to increased venous return
Hepatomegaly due to back pressure - hepatic congestion.
Risk Factors Aortic Dissection
HTN
NSTEMI treatment?
Aspirin, Clopidogrel, Fondaparinux
Why need to take serial troponins?
Rapid increase to peak after MI, then slower decrease after peak is reached - need to know where on graph you are for timing.
S2
Closure of Aortic Valve
LVH DDx
Aortic Stenosis
HTN
Bundle of Kent
Accessory pathway in AVRT (SVT)
Arrhythmia O/E and Investigations
(Tachycardia/Bradycardia)
ECG (?Long QT - predisposes to VT)
Cardiac Monitor
24hr tape
LVH by VC
LVH by Voltage Criteria
Deep S in V1/V2
Tall R in V5/V6
S in V1 + R in V5/V6 (whichever is bigger) greater or equal than 7 large squares
Risk Factors IHD
Smoking
HTN
Diabetic
Pathologies suggested by ECG
Ischaemia:
ST elevation
T inversion
Q waves
Arrhythmia/Conduction Defects: Rate/Rhythm PR long Broad QRS QT
Ventricular Strain/Hypertrophy:
Axis
65 yr old man Breathlessness Palpitations PMH: HTN DH Bendroflumethiazide Temp 38 PR 160, irregular BP 110/80 Dull percussion note and coarse crackles L base
Atrial Fibrillation
Caused by Pneumonia
Features Aortic Dissection
Pain radiating to back;
Sudden onset
Complete Dissociation P/QRS
3rd Degree Heart Block
SVT and BP 60/30 Management
Cardioversion
Adenosine
Constrictive pericarditis causes
Infection e.g. TB
Inflammation e.g. CTD
Malignancy
Features IHD
Tight
Nausea
Sweating
etc
Atrial Fibrillation DDx
Thyrotoxicosis, Alcohol
Heart: Pericariditis, IHD, Rheumatic Heart disease, Endocarditis
(Remember layers: Heart, Valve, Pericardium)
Lungs: Pneumonia, PE, cancer
Pleuritic Chest Pain DDx
Pericarditis Pneumothorax PE Pneumonia Pleural Pathology
Sub-diaphragmatic pathology
Coronary Artery and ECG changes in Lateral MI
Circumflex artery
V5, V6, I, aVL
