Cardio Flashcards
Native valve empirical IE abx
Amox / benpen + gent
Vanc + gent if penicillin allergic / MRSA / severe sepsis
Prosthetic valve empirical IE abx
Vanc + gent + rifampicin
Native valve + staph IE abx
Fluclox
Vanc + rifampicin - MRSA or penicillin allergic
Prosthetic valve staph IE abx
Fluclox (or vanc) + rifampicin + gent
Fully sensitive strep viridans IE mx
Benzylpenicillin
Vanc + gent - penicillin allergic
Less sensitive strep viridans IE Mx
Benzylpenicillin + gent
Vanc + gent - penicillin allergic
Permanent pacemaker indications
- persistent symptomatic bradycardia e.g. sick sinus syndrome
- AV pauses >3s when awake
- AV pauses <3s when awake with symptoms
- mobitz 2
- complete heart block
- persistent AV block post MI
Normal AV gradient
25mmHg
MV gradient calculation
capillary wedge pressure - LV diastolic pressure
Normal MV gradient
<5mmHg
Arrhythmogenic right ventricular dysplasia features
- AD inheritance
- palpitations, syncope, sudden death
- V1-3 TWI
- epsilon wave (positive depolarisation after QRS)
Mx
- sotalol / catheter ablation (VT) / ICD
Indications for surgical prophylaxis for IE
- Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- Previous infective endocarditis
- Cardiac transplantation with the subsequent development of cardiac valvulopathy
Congenital heart disease but only if it involves:
- Unrepaired cyanotic defects, including palliative shunts and conduits
- Completely repaired defects with prosthetic material or devices whether placed by surgery or catheter intervention, during the first 6 months after the procedure (after which the prosthetic material is likely to have been endothelialised)
- Repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation)
WPW type / side differentiation
Type 1 - right axis deviation, left sided pathway
Type 2- left axis deviation, right sided pathway
AF + WPW mx
1) Flecainide
2) Amiodarone if structural heart disease
Angina management
All: aspirin, statin, SL GTN
Long term
1) B blocker / CCB
2) + CCB / B blocker
3) ISMN
Alternatives:
- ivabradine: HR>70
- nicorandil: avoid in hypotension
- ranolazine: avoid in severe liver / renal dysfunction
Trifascicular block
1) prolonged PR
2) RBBB
3) LAFB (LAD)
OR
LPFB (RAD)
Cardiac amyloidosis ECG
Low voltage QRS
Poor R wave progression
LAD MI ECG changes
V1-4
Right coronary ECG changes and territory
II, III, avF
Inferior
Anterolateral vessels and ECG changes
LAD OR left circumflex
V4-6, I, aVL
Lateral vessel & ECG changes
I, aVL +/- V-6
Posterior vessel & ECG changes
Tall R waves V1-2
Usually left circumflex
Sometimes right coronary
(NB: may have inferior ECG changes as well if RCA involved OR lateral changes if LCirc involved)
Peripartum cardiomyopathy definition
- HF towards the end of pregnancy / within 5 months postpartum
- no other cause of HF
- LVEF <45% or 45-50% if classical HF symptoms
Peripartum cardimyopathy treatment
- salt and fluid restriction
- diuresis
- consider digoxin if AF co-existing
- anticoagulate with heparins
- avoid ACEi / ARB / mineralocorticoids
- beta blockers when stable
Hypertension - stages / values in clinic and ambulatory
Stage 1
- ≥140/90 in clinic and ≥135/85 ambulatory
Stage 2
- ≥160/100 in clinic and ≥150/95
Stage 3
- ≥180 systolic or ≥110 diastolic
Hypertension: when to treat and targets
Treat stage 1 (≥140/90 clinic / ≥135/85 ambulatory) if <80 yrs old AND - hypertensive retinopathy - ACR >2.5 men / >3.5 women - CKD - DM - other CV disease - Qrisk ≥10%
Treat all stage 2 hypertension (≥160/100 in clinic and ≥150/95 ambulatory)
Target bp <80: 140/90 clinic AND 135/85 ambulatory
Target bp >80 150/90 clinic AND 145/85 ambulatory
Uncomplicated DM 140/90 clinic and 135/85 home
DM with end organ damage 130/80 clinic AND 125/80 home
CKD: higher target if uncomplicated
CKD + DM2 OR ACR >70: lower target
Hypertensive encephalopathy management
- IV mx e.g. sodium nitroprusside, labetalol
- aim 10-15% decrease MAP w/i few hours, 25% decrease within 1 day
Causes qt prolongation
- hypokalaemia
- hypomagnesaemia
- hypocalcaemia
- hypothermia
- MI
- raised ICP
- congenital
- > Jervell-Lange-Nielson syndrome (deafness)
- > Romano ward (no deafness)
- drugs: antipsychotics, TCAs, amiodarone, macrolides e.g. erythromycin, abx e.g. chloroquine, hydroxychloroquine
NB: females are more likely to have torsades as a result
Investigating aortic stenosis in association with left ventricular dysfunction
Dobutamine stress echo OR cardiac catheterisation with dobutamine distinguishes between true severe AS and apparent severe AS in the context of LV failure
True severe AS: dobutamine -> increased transvalvular pressure with the same valve area
Apparent /pseudo-severe AS: dobutamine -> increased valve area
Duke’s criteria infective endocarditis
Diagnosis definite if:
- 2 major
- 1 major + 3 minor
- 5 minor
Diagnosis possible if:
- 1 maj + 1 minor
- 3 minor
Major criteria
- 2x positive blood cultures for typical organisms: S aureus, S viridans, Streptococcus bovis/gallolyticus, HACEK organisms
- 3+ +ve blood cultures of skin contaminant organisms
- positive echo findings: vegetation / abscess / valve dehiscence
- new valvular regurgitation
Minor criteria
- predisposition e.g. IVDU, prosthetic valve, other cardiac lesion -> turbulence
- fever >38C
- vascular phenomena e.g. septic emboli, splinter haemorrhages, janeway lesions
- immunological phenomena: GN, roth spots, osler nodes, RF +ve
- micro/serological evidence of infection not meeting major criteria
Chemical cardioversion in AF
1) Flecainide - unless structural heart disease. Best chance of cardioversion
2) Amiodarone if structural heart disease
Heart failure and new pansystolic murmur after inferior MI
- 30% inferior MI -> right ventricular wall involvement -> RV failure +/- VSD/TR
Management of familial hypercholesterolaemia
1) high dose statin
2) ezetimibe (can be added to statin)
3) evolucumab - if LDL peristently >3.5
Management of hypertriglyceridaemia
Fenofibrate
Nicotinic acid can also be used
Statins and pregnancy
Discontinue 3 months prior to conception
Viral myocarditis
Features: chest pain with or without heart failure, arrhythmias
Ix: elevated trop, elevated crp, non specific ECG changes, bnp may be elevated
Mx:
1) Diuresis
2) CV support as required - inotropes / IABP
3) Early ACE
4) Beta blocker when no longer in acute heart failure
AVOID
- NSAIDs
- heavy etoh
- exercise
Pulmonary hypertension and pregnancy
- high mortality risk -> give advice and consider termination
- if they want to keep: anticoagulation, prostacyclin, close monitoring
VT/VF following full thickness MI (q waves)
day 1 - no significance
delayed VT/VF -> ICD
Causes of reverse split S2
(AV closure after PV)
- LBBB
- severe AS
S2 in normal individuals
Expiration - single sound
Inspiration - 1) AV 2) PV
Louder P2 than A2
Pulmonary hypertension
ASD
Wide split S2
- RBBB
- Pulmonary stenosis
Fixed split S2
- ASD
- RV failure
U waves
- follow T waves
- hypoK/Ca/Mg
- hypothermia
- digoxin, amiodarone, sotalol, procainamide, TCAs
ECG features in severe hypoK
- Increased p wave width/amplitude
- PR prolongation
- St depression
- T wave flattening/inversion
Ebstein anomaly
- assoc w/ maternal lithium usage
- assoc w/ WPW syndrome
- TV anomalies
- ASD
- atrialisation of RV
- may present late with reduced exercise tolerance, cyanosis, AF, right heart failure
- ECG: RBBB, small R waves V1-2
WPW + FAF mx
- DO NOT GIVE: verapamil, metoprolol, digoxin, sotalol, adenosine (blocks AV conduction -> VF)
- GIVE: flecainide / amiodarone / procainamide
Posterior STEMI ECG
V1-4 st depression
upright t waves
prominent r wave
pAF mx
Bisoprolol > digoxin in prophylaxis
Chronic aortic regurgitation managment
All
- yearly follow up with echo at least every 2 years
- 3-6 monthly follow up if rapidly deteriorating or approaching surgery criterial
In general:
- ACEi -> prolongs deterioration into LV dysfunction
- Bblockers - if heart failure
- Mineralocorticoids esp if heart failure
Surgery should be considered if
- asymptomatic with
- LVEF <50%
- LV external diastolic diameter > 70mm
- LVESD > 50mm
- all symptomatic patients
- significant ascending aorta enlargement
When to use thallium myocardial perfusion imaging vs dobutamine stress echo vs CT calcium scoring in stable angina ix
CAD consortium score
- high risk (61-90%) -> invasive coronary angiogram
- intermediate (30-60%) -> non-invasive evaluation (thallium / dobutamine)
- low (10-29%) -> CT calcium scoring
- thallium has greater sensitivity
- dobutamine has greater specificity
- therefore use thallium in intermediate risk CAD cases
- never use dobutamine in WPW cases / other conduction abnormalities
JVP: causes of prominent a waves
Any cause of RV hypertrophy e.g. pulmonary stenosis, tricuspid stenosis
JVP: causes of cannon a waves
AV dissociation - atria contracting against closed tricuspid
Endocarditis associated with bowel cancer
Strep bovis, bacterioides fragilis
Digoxin toxicity management
1) Activated charcoal
2) Measure levels
3) Digibind
4) If VT develops - IV lignocaine / procainamide can be used
5) IV phenytoin is also an option
Anticoagulation with DC cardioversion
- start anticoagulation prior to cardioversion
- review anticoagulation at 1 month post procedure -> still in sinus? any symptoms suggestive of interim AF?
- consider stopping anticoagulation if nad
Indications for surgery in infective endocarditis
- congestive cardiac failure e.g. acute valvular regurgitation or obstruction by vegetation
- peri-annular extension - abscess formation
- recurrent systemic embolism
- large vegetations >10mm with systemic embolism
Dominant v waves
Tricuspid regurgitation
Right heart failure
Management of severe symptomatic mitral stenosis
Percutaneous balloon valvotomy, unless
- mod-sev MR
- LA thrombus
- heavily calcified MV
- other valve disease / coronary artery disease requiring surgery
IN WHICH CASE
- mitral valve replacement
Type of lipid abnormality with palmar xanthomas
dysbetaliporoteinaemia (type III hyperlipoproteinaemia)
Drugs for primary pulmonary hypertension
AIM: pulmonary vasculature vasodilation
1) CCBs
Later stage options: sildenafil, endothelin receptor antagonists (beware hepatotoxicity), prostacyclin infusions
Goals of statin therapy
If high CV risk patient
- LDL <1.8
- or decrease by 50% if baseline 1.8-3.5
Stable patient with regular tachycardia where unsure if ventricular or SVT - which drug?
Adenosine - no effect on VT so it is safe
Management of prosthetic valve thrombosis
Critically unwell?
- thrombolysis
- surgery in select cases
Stable?
- heparin infusion
- surgery in select cases
HOCM ECG features
- LVH -> non specific ST / T wave abnormalities
- RBBB
- inferolateral Q waves
- P mitrale due to LV diastolic dysfunction
Indications for anticoagulation in very low EF
- previous thromboembolism
- intracardiac thrombus
- LV aneurysm
High altitude pulmonary oedma mx
Prophylaxis = acetazolamide
Acute treatment
- high flow oxygen
nifedipine if unavailable
- descent
Indications for myomectomy in HOCM
- symptomatic HOCM despite beta blockers
- LVOT >50
Heyde syndrome
Triad
- calcific aortic stenosis
- anaemia
- acquired coagulopathy
vW factor is depleted by passing through calcific AS -> acquired vW syndrome and anaemia secondary to GI bleeding from any angiodysplasia
Mx: aortic valve replacement
Long QT mx
- reduce symptoms associated with non-sustained arrhythmias - bblocker e.g. metoprolol
- reduce sudden death from VT - ICD
Familial hypercholesterolaemia
- total chol >7.5 and LDL >4.9
AND
- tendon xanthomata (or in 1st/2nd degree relative)
OR
- LDL receptor mutation, apo-B or PCSK9 mutations
homozygotes present before 20
heterozygotes present after 30
Digoxin in amyloidosis patients
use with caution as it irreversibly binds to amyloid fibrils
1st line drug for vasoreactive pulmonary hypertension
Non-cardioselective CCBs e.g. amlodipine
Drug treatment of PVEs causing symptoms
Bblocker
Becker’s muscular dystrophy cardiac features
Dilated cardiomyopathy
May present ages 5-15, but sometimes later
Cardiac features may be in presentation
Less significant proximal muscle weakness vs Duchenne’s
Factors to differentiate VT from broad complex SVT…
VT is more likely if:
- no typical LBBB / RBBB morphology
- extreme NW axis deviation
- complexes >160ms
- fusion / capture beats
- positive or negative concordance i.e. chest leads all show either negative or positive deflections, no combination
- left rabbit ear of RSR’ complex is taller (right ear taler in RBBB)
Isoprenaline in complete heart block secondary to MI
Contraindicated!
Driving post ACS
- cars: drive after 1 week if free of symptoms
- lorry: stop driving, inform DVLA, in 6 weeks he must pass exercise tolerance test (stop beta blockers 48hrs before)
CRT-P vs CRT-D in heart failure patients
- LVEF <35% required for either
- NYHA IV AND QRS >120ms -> CRT-P
- NYHA II or below -> CRT-D if LBBB or QRS >150ms
- NYHA III CRT-P or D
