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Phase 4 Question Knowledge > Cardiology 1 > Flashcards

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
Q

Acute pericarditis Ix

A
  • ECG - diffuse saddle-shaped ST elevation, PR depression
  • ECHO - effusion- all patients
  • Bloods - FBC, raised CRP/ESR, trops
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26
Q

Acute pericarditis Mx

A
  • can tx as OP
  • tx cause
  • no strenuous activity until resolution
  • NSAIDs + colchicine
  • may need prednisolone
  • pericardiocentesis if indicated
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27
Q

Constrictive pericarditis

A
  • pericardium becomes rigid
  • fibrosis, calcified, impairs diastolic filling of heart
  • eg post-pericarditis, viral, TB, idiopathic
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28
Q

Constrictive pericarditis Px

A
  • SOB
  • RHF - elevated JVP, ascites, oedema, hepatomegaly
  • pericardial knock - loud S3
  • Kussmaul’s sign - rise in JVP on insp
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29
Q

Constrictive pericarditis Ix

A
  • CXR - pericardial calcification
  • ECG - low voltage QRS
  • ECHO - thickened pericardium, small ventricles
  • CT / MRI
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30
Q

Constrictive pericarditis Mx

A

pericardiectomy

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31
Q

Pericardial effusion

A
  • fluid in pericardial sac
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32
Q

Cardiac tamponade

A
  • pericardial effusion that constricts heart, drops CO
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33
Q

Pericardial effusion causes

A
  • any cause of pericarditis
  • myocardial rupture, aortic dissection, trauma, TB, malignancy
  • post-cardiac surgery, central line insertion
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34
Q

Pericardial effusion Px

A
  • muffled heart sounds
  • apex beat obscured
  • JVP raised
  • Ewart’s sign - bronchial breathing at left base (compressed LL lobe)
  • SOB, chest pain, nausea, tachycardia
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35
Q

Cardiac tamponade px

A

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
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36
Q

Pericardial effusion Ix

A

CXR - large globular heart
- ECG - low voltage QRS, sinus tachy, electrical alternans
- ECHO

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37
Q

Pericardial effusion / tamponade Mx

A

Effusion

  • spontaneously resolve
  • pericardial fenestration
  • pericardiocentesis

Tamponade

  • Urgent pericardiocentesis
  • cardiac surgery - midline sternotomy / thoracotomy
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38
Q

Myocarditis

A
  • inflammation of myocardium- consider particularly in younger patients

Causes

  • Viral – coxsackie B, HIV
  • Bacteria – diphtheria, clostridia
  • Lyme disease, Chagas, toxoplasmosis
  • Autoimmune
  • Drugs – doxorubicin
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39
Q

Myocarditis Px

A
  • acute onset
  • chest pain
  • SOB
  • arrhythmias, palpitations
  • faint, dizzy
  • recent flu-like sx
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40
Q

Myocarditis Ix

A
  • bloods - raised CRP/ESR / trops / BNP
  • ECG - tachycardia, arrhythmias, ST elevation, T wave inversion, other S/T changes
  • CXR
  • ECHO
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41
Q

Myocarditis Mx

A
  • tx cause, eg abx if bacterial
  • supportive tx - of HF / arrhythmias
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42
Q

Infective endocarditis (IE)

A
  • infection of endocardium, most commonly heart valves
  • mitral mostly, tricuspid in IVDU
  • valves have no direct blood supply
  • septic emboli / immune complexes thrown off
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43
Q

IE causes

A
  • 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
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44
Q

IE RFs

A
  • IVDU
  • Rheumatic valve disease
  • Hx of IE- strongest
  • CKD
  • immunocompromised
  • structural heart pathology - eg valvular disease, HOCM, prosthetic heart valves
  • recent piercings
  • dental procedures
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45
Q

IE Px

A
  • 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
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46
Q

IE Ix

A
  • 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
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47
Q

IE Modified Duke Criteria - to dx

A

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
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48
Q

IE Mx

A

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….
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49
Q

Chronic heart failure

A
  • 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
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50
Q

HF patho

A

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

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51
Q

HF Px

A
  • 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
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52
Q

HF Ix

A
  • 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….
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53
Q

HF CXR findings

A

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

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54
Q

New York Heart Association (NYHA) classification

A

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

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55
Q

HF Mx all pts

A
  • diuretics - oral furosemide
  • cardiac rehab
  • stop smoking
  • tx comorbidities
  • consider statin
  • consider antiplatelet
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56
Q

HF-pEF Mx

A
  • manage comorbidities
  • tx cause
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57
Q

HF-rEF Mx

A

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
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58
Q

HF Cx

A
  • arrhythmias, depression, cachexia, CKD, sexual dysfunction, sudden cardiac death, VTE, hepatic dysfunction
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59
Q

Acute HF (AHF) / acute pulm oedema

A
  • 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
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60
Q

Causes of AHF / pulm oedema

A

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
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61
Q

AHF Px

A
  • 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
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62
Q

AHF Ix

A
  • A-E
  • ECG
  • Bloods - FBC, U/E, BNP, ?trop, ABG, Mg, Ca, TFTs
  • CXR
  • ECHO
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63
Q

AHF Mx

A

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

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64
Q

HTN

A
  • high BP
  • clinic reading >140/90, 24hr BP avg >135/85
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65
Q

HTN causes

A

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
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66
Q

HTN RFs

A
  • older, ethnicity, FHx, overweight, sedentary, smoking, alcohol, diabetes, stress
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67
Q

HTN Px

A
  • asym
  • headaches
  • visual disturbance
  • seizures
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68
Q

HTN Ix

A
  • 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
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69
Q

HTN Mx overview

A
  • 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
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70
Q

HTN Mx algorithm

A

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
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71
Q

HTN Cx

A
  • IHD, CVA, PAD, aortic dissection, AAA, atherosclerosis
  • hypertensive retinopathy
  • hypertensive nephropathy
  • LVH
  • HF
  • malignant HTN / hypertensive emergency
72
Q

Hypertensive emergency

A

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
Q

Hypertensive emergency Px

A
  • headache, visual disturbance, N+V, confusion, seizures, coma, drowsy
  • ischaemic chest pain, SOB, bibasal creps, raised JVP
  • focal neurology
  • tearing chest pain…
74
Q

Hypertensive emergency Ix

A
  • CT head
  • fundoscopy
  • ECG, urinalysis, U/E, CXR
  • Ix for secondary causes
75
Q

Hypertensive emergency Mx

A
  • A-E
  • IV Sodium nitroprusside
  • IV labetalol
  • IV GTN, nicardipine
  • If asymptomatic - start chronic HTN mx
76
Q

Broad complex tachycardia

A
  • 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
Q

Narrow complex tachycardia

A
  • 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
Q

SVT

A
  • 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
Q

WPW syndrome

A
  • 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
Q

SVT Px

A
  • chest pain, palpitations, sweaty/clammy, faint, dizzy, HF
81
Q

SVT Mx

A
  • 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
Q

AF

A
  • 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
Q

AF causes

A
  • 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
Q

AF types

A
  • 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
Q

AF Px

A
  • Palpitations
  • SOB
  • Chest pain
  • Syncope, dizziness
  • Sx of associated condition, eg infection, stroke
  • Irregularly irregular pulse
86
Q

AF Ix

A
  • 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
Q

AF Mx overview

A

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
Q

AF rate control

A

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
Q

AF rhythm control

A

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
Q

Paroxysmal AF

A
  • may use pill-in-the-pocket approach
  • flecainide / BB when sx of AF develop
91
Q

AF reducing stroke risk

A

CHA2DS2-VASc

  • risk of stroke with AF

ORBIT

  • risk of bleeding

Mx

  • DOAC
  • warfarin 2nd line
92
Q

AF when to refer to cardiology

A
  • If rhythm control is appropriate
  • Rate control fails to control sx - <4wk referral
  • Valvular disease, LVF on ECHO
  • WPW or prolonged QT
93
Q

AFl

A
  • 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
Q

AFl Px

A
  • palpitations, SOB, chest pain, dizzy, syncope, fatigue, HF
95
Q

AFl Ix

A
  • ECG - sawtooth baseline, narrow complex tachy, regular QRSs
  • Bloods - FBC, U/E, CRP, LFTs, TFTs, Mg, Ca
  • CXR
  • ECHO
96
Q

AFl Mx

A
  • rate / rhythm control
  • lower energy levels for cardioversion
  • radiofrequency ablation of tricuspid valve isthmus
97
Q

Bradycardia causes

A
  • HB
  • Meds - BBs
  • sick sinus syndrome - conditions which cause dysfunction in SAN -> sinus brady, sinus arrhythmias, prolonged pauses
98
Q

1st degree HB

A
  • 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
Q

2nd degree HB

A

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
Q

3rd degree HB

A
  • 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
Q

BBB

A

block in lower conduction system

102
Q

RBBB

A
  • 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
Q

LBBB

A
  • 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
Q

Left anterior fascicular block (LAFB)

A
  • 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
Q

Left posterior fascicular block (LPFB)

A
  • 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
Q

Bifascicular block

A

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
Q

Trifascicular block

A

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
Q

Prolonged QT

A
  • 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
Q

Prolonged QT causes

A

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
Q

Prolonged QT Px

A
  • syncope, palpitations…
  • exertional syncope
  • sudden cardiac death
111
Q

Prolonged QT Ix

A
  • ECG - prolonged QTc
  • bloods
112
Q

Prolonged QT Mx

A
  • stop meds causing it
  • correct electrolytes
  • IV Mg
  • BBs
  • pacemaker / ICD
113
Q

Ventricular ectopics

A
  • 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
Q

Junctional / ventricular escape rhythms

A
  • 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
Q

Heart sounds

A

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
116
Q

Assessing murmurs

A

see notes

117
Q

Aortic stenosis (AS)

A
  • narrowing of aortic valve
  • calcification / congenital bicuspid valve
  • reduced valve SA, increased afterload, LVH, LVF
118
Q

AS Px

A
  • 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
119
Q

AS Ix (and all valve diseases)

A
  • ECHO
  • ECG
  • CXR
120
Q

AS Mx

A
  • aortic valve replacement - surgical / TAVI
  • balloon valvuloplasty
121
Q

Mitral regurg (MR)

A
  • 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
Q

MR Px

A
  • SOBOE, fatigue
  • palpitations
  • signs of HF / pulm oedema
  • pansystolic murmur - radiates to axilla
  • thrill
123
Q

MR Mx

A
  • 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
Q

Aortic regurg (AR)

A
  • 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
Q

AR Px

A
  • HF / pulm oedema sx
  • collapsing pulse
  • wide pulse pressure
  • early diastolic murmur
  • Quincke’s sign - nailbed pulsation
  • De Musset’s sign - head bobbing
126
Q

AR Mx

A
  • medical mx of HF
  • aortic valve replacement - if sx / LV systolic dysfunction
127
Q

Mitral stenosis (MS)

A
  • narrow mitral valve, restricting blood flow from LA -> LV
  • increased pressure in LA, pulmonary vessels, R heart
  • rheumatic fever, IE
128
Q

MS Px

A
  • SOBOE, oedema, angina etc
  • haemoptysis
  • mid-diastolic murmur, loud S1, opening snap after S2
  • malar flush
129
Q

MS Mx

A
  • balloon valvuloplasty
  • mitral valve replacement
130
Q

Prosthetic heart valves

A

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
Q

Cardiomyopathy

A
  • 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
Q

Hypertrophic obstructive cardiomyopathy (HOCM)

A
  • autosomal dominant thickening/hypertrophy of LV
  • LV outflow blocked, thick wall poorly compliant, poor diastolic filling, reduced CO
  • increased arrhythmia/HF/MI risk
133
Q

HOCM Px

A
  • asym
  • SOBOE
  • angina, syncope, dizziness, palpitations
  • HF sx
  • sudden death
  • jerky carotid pulse
134
Q

HOCM Ix

A
  • ECG - LVH
  • ECHO
  • CXR
  • cardiac MRI
  • genetic testing
135
Q

HOCM Mx

A
  • BBs / verapamil
  • amiodarone
  • ICD
  • surgical myomectomy
  • alcohol septal ablation
  • heart transplant
  • avoid intense exercise, heavy lifting, dehydration
  • avoid - ACEi, nitrates, inotropes
136
Q

Arrhythmogenic right ventricular dysplasia / cardiomyopathy (ARVD/C)

A
  • autosomal dominant - progressive fatty/fibrous replacement of ventricular myocardium
  • arrhythmia risk
137
Q

ARVD Px

A
  • palpitations
  • syncope
  • sudden death
138
Q

ARVD Ix

A
  • ECG
  • ECHO
  • MRI
  • genetic testing
139
Q

ARVD Mx

A
  • BB, amiodarone
  • catheter ablation
  • ICD
  • heart transplant
140
Q

Dilated cardiomyopathy

A
  • thinning / dilatation of heart muscle
  • genetic / secondary
  • poorly contracts - systolic dysfunction

Causes

  • idiopathic, myocarditis, IHD, peripartum, HTN, drugs, DMD, HHC, sarcoidosis….
141
Q

Dilated cardiomyopathy Px

A
  • HF sx
  • systolic murmur
  • S3
142
Q

Dilated cardiomyopathy Ix

A
  • CXR - balloon appearance of heart
  • ECHO
  • ECG
143
Q

Dilated cardiomyopathy Mx

A
  • medical mx of HF
144
Q

Restrictive cardiomyopathy

A
  • heart becomes rigid / stiff -> impaired ventricular filling during diastole
  • genetic / secondary causes
  • amyloidosis, sarcoidosis, post-radiotherapy…
145
Q

Restrictive cardiomyopathy Px

A
  • raised JVP, hepatomegaly, oedema, SOB, fatigue
146
Q

Restrictive cardiomyopathy Ix

A
  • CXR, ECHO, ECG
  • cardiac catheterisation / MRI / heart imaging etc
147
Q

Restrictive cardiomyopathy Mx

A
  • poor prognosis
  • heart transplant
  • HF mx
148
Q

Peripartum cardiomyopathy

A
  • weakness of heart muscle that develops between last month pregnancy + 5mo post-partum
  • more common older, higher G/P
  • causes HF
149
Q

Alcohol-induced cardiomyopathy

A
  • type of dilated cardiomyopathy caused by long-term alcohol use
150
Q

Takotsubo cardiomyopathy

A
  • 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
Q

Pacemakers

A
  • 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
Q

Atrial myxoma

A
  • 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
Q

Brugada syndrome

A
  • 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
Q

Shock

A

Circulatory failure leading to inadequate organ perfusion and tissue hypoxia

155
Q

Shock causes

A

Hypovolaemic
Cardiogenic
Obstructive
Distributive - reduced SVR
- Septic shock
- Anaphylactic shock
- Neurogenic shock

156
Q

Hypovolaemic shock

A
  • shock due to low BV
  • haemorrhage, D+V, burns, diuresis
157
Q

Hypovolaemic shock Px

A
  • 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
Q

Hypovolaemic shock Ix

A
  • A-E
  • bloods
  • Ix for cause - CXR, ECG, ECHO, CT, FAST
159
Q

Hypovolaemic shock Mx

A
  • IV fluids
  • blood - MHP etc
  • tx cause
160
Q

Cardiogenic shock

A
  • 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
Q

Obstructive shock

A
  • shock due to obstruction of cardiac output
  • tension PTX, massive PE, cardiac tamponade

Mx

  • tx cause
162
Q

Neurogenic shock

A
  • 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
Q

Sepsis

A
  • 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
Q

Sepsis RFs

A
  • <1yo / >75yo
  • Chronic conditions
  • Chemo, immunosuppressants, steroids
  • Surgery, recent trauma, burns
  • Pregnancy, childbirth
  • Indwelling devices - catheters, central lines
165
Q

Sepsis Px

A
  • 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
Q

Sepsis Ix

A
  • A-E, obs
  • Bloods - FBC, U/E, LFTs, CRP, BMs, coag, cultures, VBG
  • urine dip + culture
  • CXR
  • ECG
  • CT / LP
167
Q

Sepsis Mx

A
  • O2
  • Broad spec abx - eg tazocin / meropenem
  • IV fluids
  • Catheter + UO
  • Blood cultures
  • Serum lactate
168
Q

Anaphylaxis

A
  • 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
Q

Anaphylaxis Px

A

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
Q

Anaphylaxis Mx

A
  • 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
Q

Anaphylaxis Mx post-stabilisation

A
  • 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
Q

Anaphylaxis approach to discharge

A

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
Q

ALS algorithms - cardiac arrest, tachy/brady arrhythmias

A

See notes

174
Q

Post-MI complications?

A
  1. Death during/ immediately after MI = V-fib
  2. Pleuritic chest pain relieved by sitting forward days after MI = fibrinous pericarditis
  3. New pansystolic murmur + SOB days after MI = mitral regurgitation due to papillary muscle rupture
  4. Acute severe hypotension, raised JVP, muffled heart sounds days after MI = tamponade due to ventricular free wall rupture
  5. Harsh pansystolic murmur heard best in tricuspid area days after MI = ventricular septal rupture
  6. Persistent ST elevation weeks-months later + signs of LV dysfunction (poor CO, pulmonary oedema) = LV aneurysm
  7. Pleuritic chest pain relieved by sitting forward weeks after MI = Dressler’s syndrome
175
Q

Ventricular tachycardia CI drug?

A

Verapamil should not be used in VT

176
Q

Liver problems, psychiatric problems in non alcoholic disease?

A

Wilson’s disease

Also Kayser-Fleischer rings in the eyes

177
Q

Hypothermia?

A

Mild hypothermia 32-35°C
Moderate or severe <32°C

Phase 4 Question Knowledge (30 decks)

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