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Cardiology 1 Flashcards

1
Q

ACS patho

A
  • atherosclerotic plaque
  • gradual narrowing - less blood to myocardium - angina on exertion
  • sudden plaque rupture - sudden occlusion - MI

STEMI

  • full thickness damage to myocardium - complete occlusion major artery - ischaemia + infarction, troponin

NSTEMI

  • partial thickness damage - complete occlusion minor / partial major artery - ischaemia + infarction, troponin

Unstable angina

  • angina of increasing severity / frequency - minimal exertion/at rest - ischaemia, no troponin
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2
Q

ACS RFs

A

Unmodifiable

  • Older age, male, FHx

Modifiable

  • Smoking, DM, HTN, hypercholesterolaemia, obesity

ABCDEF

  • Age, BP, cholesterol, diabetes, exercise, fags / fat / family
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3
Q

ACS Px

A
  • > 20mins sx
  • chest pain - central/left side, may radiate to jaw/L arm, heavy, like dyspepsia
  • silent MI - diabetics/elderly
  • palpitations, SOB, sweaty, clammy, pale, faint
  • N+V
  • HF sx
  • tachycardia, hypotensive
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4
Q

STEMI ECG findings

A
  • ST elevation, tall/hyperacute T waves, new LBBB
  • pathological Q waves after >6hrs
  • long term - ST normal/depressed, T wave inversion, Q waves persist
  • inf MI - PR prolongation (RCA -> AVN)
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5
Q

Unstable angina ECG

A
  • normal
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6
Q

ACS general Mx

A
  • morphine
  • O2
  • nitrates - sublingual GTN
  • aspirin 300mg
  • insulin infusion to keep BM<11
  • cardiac rehab
  • stop smoking, drink less, healthy eating, regular exercise, lose weight
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7
Q

STEMI Dx criteria

A
  • Sx of ACS (>20mins) + ECG features in 2+ contiguous leads:
  • > 2.5mm (small squares) ST elevation V2-3 in M<40yo (>2mm M>40yo)
  • > 1.5mm ST elevation V2-3 women
  • > 1mm ST elevation in other leads
  • New LBBB
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8
Q

Acute coronary syndrome (ACS)

A

Spectrum of acute conditions of ischaemic heart disease, inc:
- STEMI
- NSTEMI
- Unstable angina

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9
Q

Types of MI

A

Type 1 – atherosclerotic plaque rupture

Type 2 – due to imbalance of blood supply to tissue demand, eg coronary artery vasospasm, hypotension, ongoing atherosclerosis, SCAD

Type 3 – death from MI and biomarkers were not collected prior

Type 4a – MI from PCI

Type 4b – MI from stent thrombosis

Type 5 – MI from CABG

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10
Q

ACS Ix

A

Bloods

  • FBC, U/E, LFTs, lipids, glucose
  • troponins - I/T - take at px, 3hrs, 6hrs

ECG

CXR

ECHO

Coronary angiography if indicated

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11
Q

NSTEMI ECG findings

A
  • ST depression, T wave flattening / inversion
  • normal ECG
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12
Q

ECG coronary territories

A

Anterior – V1-4 – LAD

Inferior – II, III, aVF – RCA (LCx in minority of pts)

Lateral – I, V5-6 – LCx

Posterior – horizontal ST depression in V1-3, STEMI V7-9 – RCA / LCx

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13
Q

STEMI Mx

A

PPCI

  • if px <12hrs onset of sx, and possible <2hrs
  • consider >12hrs if ongoing ischaemia
  • give DAPT - aspirin + prasugrel/ticagrelor/clopidogrel
  • during PCI - heparin + bailout IIbIIIa (eg tirofiban)
  • angioplasty + stent

Fibrinolysis

  • alteplase / streptokinase / tenecteplase
  • <12hrs sx onset if PPCI not possible <2hrs
  • also give antithrombin - heparin/fondaparinux
  • rpt ECG after 60-90mins
  • ticagrelor post-procedure

CABG

  • consider if multivessel coronary artery disease…
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14
Q

NSTEMI / unstable angina Dx criteria

A

NSTEMI

  • raised trop, may have normal ECG / ST depression / T wave inversion

Unstable angina

  • sx of ACS, normal trop, normal ECG / ST depression / T wave inversion
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15
Q

NSTEMI / unstable angina Mx

A

Antithrombins

  • no high bleeding risk / immediate PCI / angiography - fondaparinux
  • immediate angio - heparin

GRACE risk assessment

> 3% (intermediate, high, highest) - is high risk

Coronary angiography +/- PCI - for the following:

  • immediate - hypotensive
  • <72hrs - GRACE >3%
  • sx of ischaemia after admission

PCI - give:

  • heparin
  • DAPT

Conservative

  • DAPT
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16
Q

ACS secondary prevention

A
  • aspirin 75mg OD
  • DAPT for 12mo - clopidogrel / ticagrelor (post-medical) / prasugrel/ticagrelor (post-PCI)
  • BB - atenolol / bisoprolol
  • ACEi - ramipril
  • Statin - atorvastatin 80mg
  • HF - add aldosterone antagonist (eplerenone)
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17
Q

ACS Cx

A

Cardiac arrest

Cardiogenic shock

  • may need inotropes, aortic balloon pump

Chronic heart failure

  • persistent, oedema

Tachy/brady arrhythmias

  • eg VF/VT

Pericarditis

<48hrs - see on ECHO

Dressler’s syndrome

2-6wks - autoimmune reaction - fever, pleuritic pain, pericardial effusion, raised ESR/CRP, tx with NSAIDs/steroids

LV aneurysm

  • thrombus may also form

LV free wall rupture

  • px in acute HF, cardiac tamponade

VSD

Septum rupture - acute HF, murmur, see on ECHO, surgery to tx

Acute mitral regurg - ischaemia / rupture of papillary muscle - infero-posterior infarct - acute hypotension, pulm oedema - surgical repair

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18
Q

Stable angina

A
  • chest pain caused by insufficient blood supply to myocardium
  • atherosclerosis
  • demand for O2 greater than supply
  • stable - pain on exertion, relieved by rest/GTN
  • unstable - angina of increasing frequency/severity, present at rest
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19
Q

Angina Px

A

All 3 core features – typical angina, 2 features – atypical, 0-1 – non-anginal chest pain

Core features

  • constricting, heavy chest pain, radiation to jaw/neck/L arm
  • Sx on exertion
  • relieved by rest <5mins/GTN
  • sweaty, clammy, SOB, N+V, faint
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20
Q

Angina Ix

A
  • ECG
  • Bloods - FBC, U/E, LFTs, lipids, TFTs, HbA1c, fasting glucose
  • cardiac stress testing
  • CT coronary angiography
  • invasive coronary angiography
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21
Q

Angina Mx

A
  • refer to cardio - rapid access chest pain clinic
  • stop smoking, eat healthily, exercise, healthy weight, limit alcohol

Short-term

  • sublingual GTN

Long-term

  • BB - bisoprolol
  • CCB - diltiazem / verapamil (amlodipine if adding to BB)

Secondary care

  • isosorbide mononitrate
  • ivabradine (HCN channel blocker, slows HR)
  • nicorandil
  • ranolazine

Secondary prevention

  • aspirin 75mg OD
  • atorvastatin 80mg OD
  • ACEi
  • BB

Surgical

  • PCI - angioplasty + stent
  • CABG

admit if - pain at rest / minimal exertion

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22
Q

Acute pericarditis

A
  • inflammation of pericardial sac <4-6wks
  • may lead to effusion/tamponade
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23
Q

Acute pericarditis causes

A
  • viral - coxsackie, HIV, EBV
  • TB
  • uraemia
  • post-MI - fibrinous / Dressler’s
  • radiotherapy
  • SLE, RA
  • hypothyroid
  • lung / breast Ca
  • trauma
  • methotrexate
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24
Q

Acute pericarditis Px

A
  • chest pain, ?pleuritic, relieved by sitting forwards
  • low grade fever
  • cough (non-productive)
  • SOB
  • flu sx
  • pericardial rub on ausc
  • hiccups (phrenic)
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25
Acute pericarditis Ix
- ECG - diffuse saddle-shaped ST elevation, PR depression - ECHO - effusion- all patients - Bloods - FBC, raised CRP/ESR, trops
26
Acute pericarditis Mx
- can tx as OP - tx cause - no strenuous activity until resolution - NSAIDs + colchicine - may need prednisolone - pericardiocentesis if indicated
27
Constrictive pericarditis
- pericardium becomes rigid - fibrosis, calcified, impairs diastolic filling of heart - eg post-pericarditis, viral, TB, idiopathic
28
Constrictive pericarditis Px
- SOB - RHF - elevated JVP, ascites, oedema, hepatomegaly - pericardial knock - loud S3 - Kussmaul's sign - rise in JVP on insp
29
Constrictive pericarditis Ix
- CXR - pericardial calcification - ECG - low voltage QRS - ECHO - thickened pericardium, small ventricles - CT / MRI
30
Constrictive pericarditis Mx
pericardiectomy
31
Pericardial effusion
- fluid in pericardial sac
32
Cardiac tamponade
- pericardial effusion that constricts heart, drops CO
33
Pericardial effusion causes
- any cause of pericarditis - myocardial rupture, aortic dissection, trauma, TB, malignancy - post-cardiac surgery, central line insertion
34
Pericardial effusion Px
- muffled heart sounds - apex beat obscured - JVP raised - Ewart's sign - bronchial breathing at left base (compressed LL lobe) - SOB, chest pain, nausea, tachycardia
35
Cardiac tamponade px
Beck's - low BP - muffled HSs - raised JVP - Kussmaul's sign - rise in JVP with inspiration - Pulsus paradoxus - >10mmHG reduction in BP with inspiration SOB Tachycardia ECG: electrical alternans
36
Pericardial effusion Ix
CXR - large globular heart - ECG - low voltage QRS, sinus tachy, electrical alternans - ECHO
37
Pericardial effusion / tamponade Mx
Effusion - spontaneously resolve - pericardial fenestration - pericardiocentesis Tamponade - Urgent pericardiocentesis - cardiac surgery - midline sternotomy / thoracotomy
38
Myocarditis
- inflammation of myocardium- consider particularly in younger patients Causes - Viral – coxsackie B, HIV - Bacteria – diphtheria, clostridia - Lyme disease, Chagas, toxoplasmosis - Autoimmune - Drugs – doxorubicin
39
Myocarditis Px
- acute onset - chest pain - SOB - arrhythmias, palpitations - faint, dizzy - recent flu-like sx
40
Myocarditis Ix
- bloods - raised CRP/ESR / trops / BNP - ECG - tachycardia, arrhythmias, ST elevation, T wave inversion, other S/T changes - CXR - ECHO
41
Myocarditis Mx
- tx cause, eg abx if bacterial - supportive tx - of HF / arrhythmias
42
Infective endocarditis (IE)
- infection of endocardium, most commonly heart valves - mitral mostly, tricuspid in IVDU - valves have no direct blood supply - septic emboli / immune complexes thrown off
43
IE causes
- S aureus - most common- particularly acute/IVDU - Strep viridans - mouth/dental- poor dental hygeine or after procedure - Staph epidermidis - indwelling lines - Strep bovis - colorectal cancer - enterococcus - pseudomonas, HACEK, fungi - SLE, malignancy, CKD, malnutrition
44
IE RFs
- IVDU - Rheumatic valve disease - Hx of IE- strongest - CKD - immunocompromised - structural heart pathology - eg valvular disease, HOCM, prosthetic heart valves - recent piercings - dental procedures
45
IE Px
- fever, fatigue, night sweats, myalgia, anorexia - new/changing murmur - aortic root abscess -> long PR / AV block - splinter haemorrhages - petechiae - Osler's nodes - Roth spots - AKI / glomerulonephritis - Janeway lesions - Organ abscesses - splenomegaly / finger clubbing
46
IE Ix
- Bloods - FBC, U/E, CRP, cultures (3 sets from 3 sites at 3 different times >6hrs) - ECG - ?HB - CXR - urinalysis - haematuria - ECHO - TOE more accurate - CT - for emboli
47
IE Modified Duke Criteria - to dx
Dx requires pathology positive or either -2 major - 1 major + 3 minor - 5 minor Major criteria - Positive blood cultures on 2+ samples - Specific imaging findings – eg vegetation on ECHO Minor criteria - Predisposition – eg IVDU, valve pathology - Fever >38 - Vascular phenomena – splenic infarct, intracranial haemorrhage, Janeway lesions, petechiae, splinter haemorrhages - Immunological phenomena – Ostler’s nodes, Roth spots, glomerulonephritis - Microbiological phenomena – eg positive cultures 1x
48
IE Mx
IV abx Initial blind therapy - Amoxicillin + gentamicin (low-dose) - If pen allergic / MRSA / severe sepsis – vancomycin + gentamicin - If prosthetic valve – vancomycin + rifampicin + gentamicin Native valve, Staph - Flucloxacillin - If pen allergic / MRSA – vancomycin + rifampicin Prosthetic valve, Staph - Flucloxacillin + rifampicin + low-dose gentamicin - Pen allergic / MRSA – vancomycin + rifampicin + gent Fully sensitive Strep (ie viridans) - Benzylpenicillin - Vancomycin + gentamicin if pen allergic Less sensitive Strep - Benzylpenicillin + gentamicin - Vancomycin + gentamicin if pen allergic - narrow down once cultures back - continue for 4wks (6wks if prosthetic valves) Surgery - eg if severe valvular incompetence, resistant to tx, cardiac failure refractory to standard medical tx... - prophylaxis for at risk pts, valve replacement, previous IE....
49
Chronic heart failure
- heart unable to pump enough blood to meet metabolic demands of the body - cor pulmonale - right heart enlargement - from disease of lungs/pulmonary vessels - also RAAS activation and salt/fluid retention
50
HF patho
Key causes - IHD, valvular heart disease (AS), HTN, arrhythmias, cardiomyopathy HF-rEF - inability of ventricle to contract normally - reduced CO, EF<40% - systolic dysfunction - IHD, MI, dilated cardiomyopathy, arrhythmias, myocarditis, AS HF-pEF - inability of ventricle to relax + fill normally, SV decreased, EF>50% - diastolic dysfunction - HOCM, restrictive cardiomyopathy, tamponade, constrictive pericarditis LHF - eg HTN, AS, aortic regurg - pulm oedema, SOB, orthopnoea, PND RHF - pulm HTN, LVF, tricuspid regurg - peripheral oedema, raised JVP, hepatomegaly, wt gain, anorexia CCF - both sides of heart High-output HF - increased metabolic demands of body - anaemia, AV malformation, Paget's disease of bone, pregnancy, thyrotoxicosis Low-output HF - CO reduced, fails to increase normally with exertion
51
HF Px
- SOB - worse on exertion - cough - white/pink sputum - worse at night - orthopnoea - PND - ankle/sacral/leg oedema - fatigue - 3rd HS - bibasal creps on ausc - raised JVP - wheeze (cardiac wheeze) - hepatomegaly - wt loss - cardiac cachexia - wt gain - oedema
52
HF Ix
- bloods - FBC, U/E, LFTs, HbA1c, TFTs, lipids - NT-proBNP - normal<400, 400-2000 refer + ECHO <6wks, >2000 refer + ECHO<2wks - ECG - CXR - ECHO - urinalysis, peak flow, spirometry....
53
HF CXR findings
Alveolar oedema – ‘bat’s wing shadowing’ Kerley B lines – interstitial oedema Cardiomegaly – cardiothoracic ratio >50% Dilated prominent upper lobe veins (upper lobe diversion) Pleural Effusions
54
New York Heart Association (NYHA) classification
Class I – no symptoms on ordinary physical activity Class II – mild sx, slight limitation of physical activity Class III – moderate sx, comfortable at rest but less than ordinary activity leads to sx Class IV – severe sx, inability to carry out any activity without sx
55
HF Mx all pts
- diuretics - oral furosemide - cardiac rehab - stop smoking - tx comorbidities - consider statin - consider antiplatelet
56
HF-pEF Mx
- manage comorbidities - tx cause
57
HF-rEF Mx
1st line - ACEi (ramipril) + BB (bisoprolol) - ARB (candesartan) if not tolerating ACEi - hydralazine + nitrate if intolerant of ACEi/ARB - add MRA (spironolactone/eplerenone) if sx continue - check U/E (before/after each drug + dose change) Specialist mx if sx continue - replace ACEi/ARB with sacubitril valsartan if EF<35% - add ivabradine if sinus rhythm >75, EF<35% - add hydralazine + nitrate, esp if Afro-Caribbean - digoxin - SGLT2 inhibitor - dapagliflozin - amiodarone Specialist procedures - cardiac resynchronisation therapy (CRT) - triple chamber pacemaker - implantable cardioverter defibrillator (ICD) - heart transplant
58
HF Cx
- arrhythmias, depression, cachexia, CKD, sexual dysfunction, sudden cardiac death, VTE, hepatic dysfunction
59
Acute HF (AHF) / acute pulm oedema
- acute deterioration in cardiac function - LVF -> CO reduced, backlog of blood, excess fluid leaks -> pulm oedema - lung/alveoli filled with interstitial fluid - impaired gas exchange - De-novo AHF - AHF w/o hx of HF - eg ischaemia, viral, toxins, valvular
60
Causes of AHF / pulm oedema
Cardiac - acute LVF, ACS, arrhythmias, valvular heart disease, HTN, cardiomyopathy, tamponade Non-cardiac - fluid overload, high-output HF, ARDS, RAS Triggers - preload increase - eg IV fluids, retention - contractility decrease - ischaemia, infarction, arrhythmias, valvular, cardiomyopathy - afterload increase - HTN - direct lung damage
61
AHF Px
- acutely SOB - cough - frothy white / pink sputum - hypoxia, cyanosis, increased RR/HR - bibasal creps on ausc - peripheral oedema - fatigue, raised JVP - 3rd HS - chest pain, fever, palpitations (depends on cause) - BP normal / increased
62
AHF Ix
- A-E - ECG - Bloods - FBC, U/E, BNP, ?trop, ABG, Mg, Ca, TFTs - CXR - ECHO
63
AHF Mx
All patients: IV Loop Diuretics Possible additions: Oxygen to maintain 94-98% Vasodilators- nitrates- not given routinely, only if concomitant myocardial ischaemia, severe hypotension or regurgitant aortic or mitral disease- side effect/major contraindication is hypotension Patients with resp failure- CPAP Patients with hypotension/cardiogenic shock- Inotropic agents- dobutamine Vasopressor agents- norepinephrine Mechanical circulatory assistance Do not give opiates routinely Continue regular medication such as BB/ACEi BB only stopped if HR les than 50, atrioventricular block or shock
64
HTN
- high BP - clinic reading >140/90, 24hr BP avg >135/85
65
HTN causes
Primary / essential HTN - 90%, no cause Secondary - Renal - glomerulonephritis, chronic pyelo, PKD, RAS - Endocrine - hyperaldosteronism, phaeo, Cushing's, Liddle's, CAH, acromegaly - other - glucocorticoids, NSAIDs, pregnancy, coarctation of aorta, cOCP
66
HTN RFs
- older, ethnicity, FHx, overweight, sedentary, smoking, alcohol, diabetes, stress
67
HTN Px
- asym - headaches - visual disturbance - seizures
68
HTN Ix
- BP monitoring - clinic / 24hr ABPM / home BP monitoring - Stage 1 - >140/90 / >135/85 at home - Stage 2 - >160/100 / >150/95 at home - Stage 3 - >180/120 - BP both arms - urine albumin:creatinine ratio - urine dipstick - Bloods - HbA1c, U/E, lipids - fundoscopy - ECG - QRISK
69
HTN Mx overview
- healthy diet, stop smoking, reduce alcohol, lower caffeine/salt, exercise - <40yo, ?refer to r/o secondary causes BP targets <80yo - <140/90 in clinic, <135/85 at home >80yo - <150/90 in clinic, <145/85 at home - if stage 1 - tx if <80yo AND organ damage / CV disease / renal disease / DM / QRISK>10% - stage 2 - drug tx regardless of age - stage 3 - same day assessment for retinal haemorrhage / papilloedema / phaeo / life-threatening sx
70
HTN Mx algorithm
Step 1 <55yo / T2DM - ACEi (ramipril) - if T2DM Afro-Caribbean - ARB (candesartan) - change to ARB if ACEi not tolerated >55yo / Afro-Caribbean - CCB (amlodipine) Step 2 - if on ACEi/ARB - add CCB / thiazide-like (indapamide) - if on CCB - add ACEi/ARB / thiazide-like (ARB in Afro-Caribbean) Step 3 - add the 3rd drug left Step 4 - K<4.5 - low dose spironolactone - K>4.5 - add alpha/beta blocker - specialist review if still not controlled
71
HTN Cx
- IHD, CVA, PAD, aortic dissection, AAA, atherosclerosis - hypertensive retinopathy - hypertensive nephropathy - LVH - HF - malignant HTN / hypertensive emergency
72
Hypertensive emergency
Severe hypertension is SBP>200/ DPB>120 Hypertensive urgency – severe hypertension with no evidence of acute end organ damage Hypertensive emergency – severe hypertension with evidence of acute end organ damage Malignant/accelerated hypertension – a hypertensive emergency involving retinal vascular damage
73
Hypertensive emergency Px
- headache, visual disturbance, N+V, confusion, seizures, coma, drowsy - ischaemic chest pain, SOB, bibasal creps, raised JVP - focal neurology - tearing chest pain...
74
Hypertensive emergency Ix
- CT head - fundoscopy - ECG, urinalysis, U/E, CXR - Ix for secondary causes
75
Hypertensive emergency Mx
- A-E - IV Sodium nitroprusside - IV labetalol - IV GTN, nicardipine - If asymptomatic - start chronic HTN mx
76
Broad complex tachycardia
- QRS >120ms / 3 small squares VT - broad complex tachycardia originating from ventricles - monomorphic / polymorphic / Torsades de pointes (...long QT) - ALS guidelines to mx - synchronised DC cardioversion / IV amiodarone - Mg for Torsades de pointes AF with BBB - tx as AF SVT with BBB - tx as SVT VF - cardiac arrest rhythm
77
Narrow complex tachycardia
- high HR with QRS <120ms Sinus tachycardia - normal PQRST pattern - tx cause AF - technically an SVT AFl - technically an SVT SVT - tachycardia that originates from above the ventricles
78
SVT
- tachycardia that originates from above the ventricles - signal re-enters atria from ventricles, then goes through AVN to ventricles - loop - paroxysmal SVT - SVT reoccurs / remits - AVNRT - re-entry point through AVN - AVRT - re-entry point is accessory pathway - eg WPW - atrial tachycardia - signal from atria somewhere other than SAN - junctional tachycardia - impulse from AVN/junction - ECG narrow QRS, absent/inverted P waves
79
WPW syndrome
- congenital accessory pathway (bundles of Kent) between atria / ventricles - AVRT - L/R sided - pathway causes abnormal early depolarisation - if SAN delivers premature beat, signal travels down septum then back up accessory pathway - re-entry circuit - tachyarrhythmia Associations - HOCM, mitral valve prolapse, Ebstein's, thyrotoxicosis, secundum ASD ECG - Short PR - Wide QRS, slurred upstroke - delta wave - LAD if R sided pathway - RAD if L sided pathway
80
SVT Px
- chest pain, palpitations, sweaty/clammy, faint, dizzy, HF
81
SVT Mx
- ALS guidelines - synchronised DC cardioversion if unstable - modified valsalva - IV adenosine- 6mg, then 12mg, then 18mg - Electrical cardioversion - BBs / verapamil - long-term - BB / CCB / amiodarone - radiofrequency ablation - WPW + AF/AFl - use procainamide / electrical cardioversion
82
AF
- Disorganised electrical activity of atria leading to fibrillation and irregularly irregular ventricular contraction - type of SVT - blood can stagnate in atrial appendage - stroke risk - HF from impaired diastolic filling of ventricles - may go into AF wRVR - tachycardic ventricular rate
83
AF causes
- idiopathic - atrial damage - fibrosis - HTN - HF - coronary artery disease, IHD - valvular heart disease - eg mitral stenosis - cardiomyopathy - rheumatic heart disease - alcohol, caffeine - thyrotoxicosis - infection - anaemia
84
AF types
- first detected episode - recurrent - 2+ episodes - paroxysmal AF - terminates spontaneously, <7d, typically <24hrs - persistent AF - not self-terminating - >7d - permanent AF - continuous AF - rate control/anticoagulation goals
85
AF Px
- Palpitations - SOB - Chest pain - Syncope, dizziness - Sx of associated condition, eg infection, stroke - Irregularly irregular pulse
86
AF Ix
- Bloods - FBC, U/E, TFTs, LFTs, coag, Mg, Ca - ECG - absent P waves, irregularly irregular QRS, absence of isoelectric baseline, may be tachycardic - CXR - ECHO - 24hr ambulatory ECG (Holter) / cardiac event recorder - for paroxysmal AF - CHA2DSVASc / ORBIT
87
AF Mx overview
Unstable - synchronised DC cardioversion <48hrs of sx onset - rate / rhythm control >48hrs of sx onset / uncertain of onset - rate control - if ?long-term rhythm control - delay cardioversion until >3wks anticoagulation Catheter ablation - if no response to antiarrhythmics LAA occlusion - anticoagulate first - may insert catheter, place plug into LAA
88
AF rate control
Offer as first line apart from: - AF has reversible cause - HF primarily caused by AF - new onset <48hrs - AFl suitable for ablation - clinical judgement that rhythm control better - BB - bisoprolol / metoprolol - CCB - diltiazem (not in HF) - digoxin - eg if pt does no exercise
89
AF rhythm control
Offer to pts: - reversible cause for AF -new onset AF <48hrs - HF caused by AF - sx despite rate control <48hrs onset AF - immediate cardioversion - heparin - electrical - synchronised DC shock - pharm - flecainide / amiodarone >48hrs onset AF - delayed cardioversion - >3wks anticoagulation - TOE to exclude LA appendage thrombus - electrical cardioversion - 4wks amiodarone / sotalol before - anticoagulate >4wks after Long term rhythm control - BBs - dronedarone - amiodarone - esp if co-existing HF
90
Paroxysmal AF
- may use pill-in-the-pocket approach - flecainide / BB when sx of AF develop
91
AF reducing stroke risk
CHA2DS2-VASc - risk of stroke with AF ORBIT - risk of bleeding Mx - DOAC - warfarin 2nd line
92
AF when to refer to cardiology
- If rhythm control is appropriate - Rate control fails to control sx - <4wk referral - Valvular disease, LVF on ECHO - WPW or prolonged QT
93
AFl
- organised abnormal atrial rhythm, atrial rate 300 - re-entry circuit in RA - thrombus risk - pulse tends to be 150, 100, 75 - typical - rhythm origin in RA at level of tricuspid valve - atypical - origin from elsewhere Causes - idiopathic, coronary artery disease, HTN, HF, COPD, pericarditis, alcoholism, surgery
94
AFl Px
- palpitations, SOB, chest pain, dizzy, syncope, fatigue, HF
95
AFl Ix
- ECG - sawtooth baseline, narrow complex tachy, regular QRSs - Bloods - FBC, U/E, CRP, LFTs, TFTs, Mg, Ca - CXR - ECHO
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AFl Mx
- rate / rhythm control - lower energy levels for cardioversion - radiofrequency ablation of tricuspid valve isthmus
97
Bradycardia causes
- HB - Meds - BBs - sick sinus syndrome - conditions which cause dysfunction in SAN -> sinus brady, sinus arrhythmias, prolonged pauses
98
1st degree HB
- PR >0.2s (5 small squares) - delayed conduction at AVN, P wave precedes every QRS Causes - low K, myocarditis, inferior MI, IHD, BBs, CCBs, digoxin, rheumatic fever, IE, lyme disease, sarcoidosis Mx - normally no tx - tx cause if needed
99
2nd degree HB
Mobitz T1 (Wenkebach) - progressive PR prolongation, then P wave with no QRS, cycle restarts - regularly irregular pulse - causes - AVN blocking drugs, inferior MI, IHD - Px - light-headed, dizzy, syncope - Mx - maybe pacing / tx cause Mobitz T2 - PR interval constant, absence of QRS at regular intervals - regularly irregular pulse - causes - anterior MI, mitral valve surgery, SLE, lyme disease, IHD.... - Px - SOB, CP, light-headed etc
100
3rd degree HB
- complete dissociation between P waves + QRS complexes Causes - structural heart disease, IHD, HTN, endocarditis.... Px - syncope, HF, regular bradycardia, wide pulse pressure, variable S1 Mx - atropine - transcutaneous pacing / PPM
101
BBB
block in lower conduction system
102
RBBB
- lack of depolarisation down R branch - signal spreads from LV across septum, RV contraction delayed Causes - normal, RVH, cor pulmonale, PE, MI, ASD, IHD... - splitting of S2 on ausc ECG - Broad QRS >120ms - MARROW
103
LBBB
- lack of depolarisation down L branch - impulse spread from RV across septum to LV Causes - new LBBB always pathological - MI - Sgarbossa criteria - HTN, AS, cardiomyopathy, high K... - reverse splitting of S2 ECG - broad QRS >120ms - WILLIAM - associated with - LAD, poor R wave progression
104
Left anterior fascicular block (LAFB)
- Anterior fascicle inserts into upper lateral wall of LV - Left axis deviation - qR complexes in I, aVL - positive - rS complexes in II, III, aVF - negative - prolonged R wave peak time in aVL >45ms
105
Left posterior fascicular block (LPFB)
- Posterior fascicle inserts into inferoseptal wall of LV - Right axis deviation - rS complexes I, aVL - negative - qR complexes II, III, aVF - positive - Prolonged R wave peak time aVF
106
Bifascicular block
2/3 fascicles are blocked, so conduction is via single remaining fascicle, one of two patterns: - RBBB + LAFB, manifested as left axis deviation - RBBB + LPFB, manifested as right axis deviation
107
Trifascicular block
Conduction delay in all 3 fascicles below AVN (RBBB, LAFB, LPFB) Manifests as bifascicular block + 3rd degree AV block, one of two patterns: - 3rd degree AV block + RBBB + LAFB - 3rd degree AV block + RBBB + LPFB
108
Prolonged QT
- QT interval - from start of QRS to end of T wave - use QTc - >440ms (men), >460ms (women) is prolonged - prolonged repolarisation of myocytes - can lead to spontaneous depolarisation of myocytes -> Torsades de pointes, VT, arrest - Long QT syndrome - inherited condition causing prolonged QT - most commonly defects in K channels
109
Prolonged QT causes
ASTHMATIC - amiodarone - sotalol, SSRIs - terfenadine - haloperidol - methadone, macrolides - antiarrhythmics class Ia - TCAs - chloroquine - congenital - low Ca, low K, low Mg - acute MI, myocarditis, hypothermia, SAH
110
Prolonged QT Px
- syncope, palpitations... - exertional syncope - sudden cardiac death
111
Prolonged QT Ix
- ECG - prolonged QTc - bloods
112
Prolonged QT Mx
- stop meds causing it - correct electrolytes - IV Mg - BBs - pacemaker / ICD
113
Ventricular ectopics
- premature ventricular complexes (PVCs) - beats originate from ventricular myocardium - wide QRS - common, healthy - more common if IHD, HF, HTN, MI etc - bigeminy / trigeminy / quadrigeminy - every 2nd/3rd/4th beat is PVC Px - asym - cardiac sx - pulse irregular Ix - ECG - maybe ECHO Mx - reassure if healthy, infrequent - refer if concerning sx - BBs for sx
114
Junctional / ventricular escape rhythms
- abnormal heart rhythm with impulses originating from AVN / bundles of His at AV junction Types - Junctional bradycardia – <40BPM - Junctional escape rhythm – 40-60BPM - Accelerated junctional rhythm – 60-100BPM - Junctional tachycardia – >100BPM - ventricular escape rhythm - from ventricles Causes - anything that impairs SAN - sinus brady, sinus arrest, 3rd HB, high K, BBs, CCB, digoxin Px - asym / SOB, CP etc Ix ECG - P waves - absent / inverted before/after QRS - junctional escape - narrow QRS - ventricular escape - broad QRS
115
Heart sounds
S1 - Closing of tricuspid / mitral valves at start of ventricular systole - Loud in mitral stenosis S2 - Closing of pulmonary / aortic valves at end of ventricular systole - Soft (?) in aortic stenosis - Splitting during inspiration is normal S3 - After S2, tensioning of chordae tendineae with rapid ventricular filling at start of diastole - Can be normal in young people - Can indicate HF – ventricles / chordae are stiff / weak - Heard in LVF, mitral regurg S4 - Just before S1, atria contract and force blood against stiff / hypertrophic ventricle – sound is blood hitting ventricle wall - Always pathological - Heard in aortic stenosis, HOCM, HTN
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Assessing murmurs
see notes
117
Aortic stenosis (AS)
- narrowing of aortic valve - calcification / congenital bicuspid valve - reduced valve SA, increased afterload, LVH, LVF
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AS Px
- angina - syncope - HF - SOB - dizziness - sx worse on exertion - ejection systolic crescendo-decrescendo murmur - radiates to carotids - slow rising pulse, decreased pulse amplitude, narrow pulse pressure - thrill
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AS Ix (and all valve diseases)
- ECHO - ECG - CXR
120
AS Mx
- aortic valve replacement - surgical / TAVI - balloon valvuloplasty
121
Mitral regurg (MR)
- blood leaks back through incompetent mitral valve during systole - EF / SV reduced, LA enlargement, LVH, progressive heart failure Causes - mitral valve prolapse - coronary artery disease / post MI - IE - rheumatic fever - congenital - EDS / Marfan's
122
MR Px
- SOBOE, fatigue - palpitations - signs of HF / pulm oedema - pansystolic murmur - radiates to axilla - thrill
123
MR Mx
- drugs to increase CO in acute cases - nitrates, diuretics, inotropes, aortic balloon pump - HF - ACEi, BBs, spironolactone - surgery - repair/replacement - when sx / EF<60%
124
Aortic regurg (AR)
- incompetent aortic valve - blood leaks back into ventricle from aorta during diastole - increased preload, LV dilatation / hypertrophy -> LVF Causes - rheumatic fever, calcification, RA/SLE, bicuspid aortic valve, IE - ankylosing spondylitis, HTN, syphilis, Marfans, EDS, dissection
125
AR Px
- HF / pulm oedema sx - collapsing pulse - wide pulse pressure - early diastolic murmur - Quincke's sign - nailbed pulsation - De Musset's sign - head bobbing
126
AR Mx
- medical mx of HF - aortic valve replacement - if sx / LV systolic dysfunction
127
Mitral stenosis (MS)
- narrow mitral valve, restricting blood flow from LA -> LV - increased pressure in LA, pulmonary vessels, R heart - rheumatic fever, IE
128
MS Px
- SOBOE, oedema, angina etc - haemoptysis - mid-diastolic murmur, loud S1, opening snap after S2 - malar flush
129
MS Mx
- balloon valvuloplasty - mitral valve replacement
130
Prosthetic heart valves
Biological - cow/pig - deteriorate over time - replace in 10yrs - warfarin for first 3mo then aspirin Mechanical - last longer - life-long warfarin - metallic click on ausc Cx - thrombus, IE, haemolytic anaemia
131
Cardiomyopathy
- disorders of the heart muscle Primary - predominantly involving heart Genetic - HOCM - ARVD/C Mixed - dilated cardiomyopathy - restrictive Acquired - peripartum - Takotsubo Secondary - pathological myocardial involvement due to systemic disorder - eg coxsackie B, amyloidosis, HHC, alcohol, sarcoidosis, DM, thyrotoxicosis, acromegaly, DMD, thiamine, SLE
132
Hypertrophic obstructive cardiomyopathy (HOCM)
- autosomal dominant thickening/hypertrophy of LV - LV outflow blocked, thick wall poorly compliant, poor diastolic filling, reduced CO - increased arrhythmia/HF/MI risk
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HOCM Px
- asym - SOBOE - angina, syncope, dizziness, palpitations - HF sx - sudden death - jerky carotid pulse
134
HOCM Ix
- ECG - LVH - ECHO - CXR - cardiac MRI - genetic testing
135
HOCM Mx
- BBs / verapamil - amiodarone - ICD - surgical myomectomy - alcohol septal ablation - heart transplant - avoid intense exercise, heavy lifting, dehydration - avoid - ACEi, nitrates, inotropes
136
Arrhythmogenic right ventricular dysplasia / cardiomyopathy (ARVD/C)
- autosomal dominant - progressive fatty/fibrous replacement of ventricular myocardium - arrhythmia risk
137
ARVD Px
- palpitations - syncope - sudden death
138
ARVD Ix
- ECG - ECHO - MRI - genetic testing
139
ARVD Mx
- BB, amiodarone - catheter ablation - ICD - heart transplant
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Dilated cardiomyopathy
- thinning / dilatation of heart muscle - genetic / secondary - poorly contracts - systolic dysfunction Causes - idiopathic, myocarditis, IHD, peripartum, HTN, drugs, DMD, HHC, sarcoidosis....
141
Dilated cardiomyopathy Px
- HF sx - systolic murmur - S3
142
Dilated cardiomyopathy Ix
- CXR - balloon appearance of heart - ECHO - ECG
143
Dilated cardiomyopathy Mx
- medical mx of HF
144
Restrictive cardiomyopathy
- heart becomes rigid / stiff -> impaired ventricular filling during diastole - genetic / secondary causes - amyloidosis, sarcoidosis, post-radiotherapy...
145
Restrictive cardiomyopathy Px
- raised JVP, hepatomegaly, oedema, SOB, fatigue
146
Restrictive cardiomyopathy Ix
- CXR, ECHO, ECG - cardiac catheterisation / MRI / heart imaging etc
147
Restrictive cardiomyopathy Mx
- poor prognosis - heart transplant - HF mx
148
Peripartum cardiomyopathy
- weakness of heart muscle that develops between last month pregnancy + 5mo post-partum - more common older, higher G/P - causes HF
149
Alcohol-induced cardiomyopathy
- type of dilated cardiomyopathy caused by long-term alcohol use
150
Takotsubo cardiomyopathy
- Stress-induced cardiomyopathy - rapid onset of LV dysfunction / weakness - Broken heart syndrome - Chest pain, HF sx - Transient apical ballooning of myocardium - Supportive tx, sx resolve with time
151
Pacemakers
- Pulse generator + pacing leads – carry electrical impulses to heart to improve function Indications - Bradycardia with sx - Mobitz T2 - 3rd degree block - AVN ablation for AF - Severe HF – biventricular pacemakers Single chamber - RA/RV Dual chamber - both RA/RV Biventricular (triple chamber) pacemaker - RA,RV,LV - CRT ICDs - shock if VF/VT ECG changes - sharp vertical line Indications for temporary pacemaker - sx/unstable bradycardia, unresponsive to atropine - post-anterior MI - trifascicular block prior to surgery
152
Atrial myxoma
- most common primary cardiac tumour - 75% in LA, attached to fossa ovalis Px - SOB, fatigue, wt loss, fever, clubbing - emboli - AF - mid-diastolic murmur Ix - ECHO - pedunculated heterogenous mass Mx - surgical removal by median sternotomy
153
Brugada syndrome
- autosomal dominant condition causing arrhythmia - can cause tachycardia Px - dizzy, syncope, SOB, palpitations Ix ECG - Downward sloping ST segment, inverted T wave, incomplete RBBB – in V1-3 - Changes more apparent after flecainide Mx - ICD
154
Shock
Circulatory failure leading to inadequate organ perfusion and tissue hypoxia
155
Shock causes
Hypovolaemic Cardiogenic Obstructive Distributive - reduced SVR - Septic shock - Anaphylactic shock - Neurogenic shock
156
Hypovolaemic shock
- shock due to low BV - haemorrhage, D+V, burns, diuresis
157
Hypovolaemic shock Px
- Reduced GCS, agitation, confusion - Skin pale, cold, sweaty, vasoconstricted - Cool peripheries - Tachycardia - Tachypnoea - Oliguria - reduced urine output - Increased cap refill time (CRT) - Weak, rapid pulse - Reduced pulse pressure
158
Hypovolaemic shock Ix
- A-E - bloods - Ix for cause - CXR, ECG, ECHO, CT, FAST
159
Hypovolaemic shock Mx
- IV fluids - blood - MHP etc - tx cause
160
Cardiogenic shock
- shock due to cardiac dysfunction / failure of the pump action of heart Causes - MI, myocardial contusion, myocarditis, cardiac arrhythmias, BBs, CCBs Px - signs of heart disease - signs of shock Ix - for cause - ECG / ECHO Mx - tx cause
161
Obstructive shock
- shock due to obstruction of cardiac output - tension PTX, massive PE, cardiac tamponade Mx - tx cause
162
Neurogenic shock
- spinal cord injury above T6 - loss of sympathetic outflow, decreased SVR, decreased preload/CO Px - Instant hypotension - Warm, flushed peripheries - Priapism - Bradycardia - Flaccid paralysis, loss of reflexes - Loss of bladder / bowel control Mx - IV fluids - adrenaline infusion
163
Sepsis
- body launches large immune response to infection, causing systemic inflammation + organ dysfunction - cytokine/interleukin/TNF release -> systemic inflammation, release of vasodilators - SOFA score to assess severity of organ dysfunction
164
Sepsis RFs
- <1yo / >75yo - Chronic conditions - Chemo, immunosuppressants, steroids - Surgery, recent trauma, burns - Pregnancy, childbirth - Indwelling devices - catheters, central lines
165
Sepsis Px
- sx of infection source - cough, SOB, dysuria, N+V, abdo pain, cellulitis.... - reduced UO - mottled skin, cyanosis - warm peripheries, clammy skin - bounding pulse - confusion, drowsy, off legs - high HR/RR/temp, low BP,
166
Sepsis Ix
- A-E, obs - Bloods - FBC, U/E, LFTs, CRP, BMs, coag, cultures, VBG - urine dip + culture - CXR - ECG - CT / LP
167
Sepsis Mx
- O2 - Broad spec abx - eg tazocin / meropenem - IV fluids - Catheter + UO - Blood cultures - Serum lactate
168
Anaphylaxis
- severe life-threatening T1 hypersensitivity reaction - allergen reacts with IgE ABs on mast cells/basophils - rapid histamine release - capillary leakage, mucosal oedema, shock, airway compromise - anaphylaxis - ABC compromise
169
Anaphylaxis Px
Hx of exposure to allergen, rapid onset sx A – swelling of tongue/throat (angioedema) -> hoarse voice + stridor B – wheeze, SOB, fatigue, cyanosis, low sats C – hypotension, tachycardia, shock, confusion, reduced consciousness D – confusion… E – urticarial rash, pruritis
170
Anaphylaxis Mx
- IM adrenaline - 500mcg (>12yo), 300mcg (6-12yo), 150mcg (6mo-6yrs), 100-150mcg (<6mo) - IV fluids Refractory anaphylaxis - IV adrenaline infusion - IV fluids - consider salbutamol nebs + ipratropium
171
Anaphylaxis Mx post-stabilisation
- Non-sedating oral antihistamine (chlorphenamine is sedating) - Serum mast cell tryptase - measure <6hrs of event - confirm dx - Refer to specialist allergy clinic - Prescribe 2 adrenaline auto-injectors - Beware biphasic reactions (20%)
172
Anaphylaxis approach to discharge
Fast-track discharge (>2hrs of sx resolution) - Good response to single dose adrenaline - Complete resolution of sx - Has epipen, trained on how to use - Adequate supervision following discharge >6hrs sx resolution - 2 doses IM adrenaline needed - Or previous biphasic reaction >12hrs after sx resolution - Severe reaction requiring 2 doses IM adrenaline - Severe asthma - Possibility of ongoing reaction (eg slow release medication) - Pt presents late at night - Patient in area where access to emergency care difficult
173
ALS algorithms - cardiac arrest, tachy/brady arrhythmias
See notes
174
Post-MI complications?
1. Death during/ immediately after MI = V-fib 2. Pleuritic chest pain relieved by sitting forward days after MI = fibrinous pericarditis 2. New pansystolic murmur + SOB days after MI = mitral regurgitation due to papillary muscle rupture 3. Acute severe hypotension, raised JVP, muffled heart sounds days after MI = tamponade due to ventricular free wall rupture 4. Harsh pansystolic murmur heard best in tricuspid area days after MI = ventricular septal rupture 5. Persistent ST elevation weeks-months later + signs of LV dysfunction (poor CO, pulmonary oedema) = LV aneurysm 6. Pleuritic chest pain relieved by sitting forward weeks after MI = Dressler's syndrome
175
Ventricular tachycardia CI drug?
Verapamil should not be used in VT
176
Liver problems, psychiatric problems in non alcoholic disease?
Wilson's disease Also Kayser-Fleischer rings in the eyes
177
Hypothermia?
Mild hypothermia 32-35°C Moderate or severe <32°C

Phase 4 Question Knowledge (36 decks)

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