Cardiology 1 Flashcards
ACS patho
- 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
ACS RFs
Unmodifiable
- Older age, male, FHx
Modifiable
- Smoking, DM, HTN, hypercholesterolaemia, obesity
ABCDEF
- Age, BP, cholesterol, diabetes, exercise, fags / fat / family
ACS Px
- > 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
STEMI ECG findings
- 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)
Unstable angina ECG
- normal
ACS general Mx
- 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
STEMI Dx criteria
- 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
Acute coronary syndrome (ACS)
Spectrum of acute conditions of ischaemic heart disease, inc:
- STEMI
- NSTEMI
- Unstable angina
Types of MI
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
ACS Ix
Bloods
- FBC, U/E, LFTs, lipids, glucose
- troponins - I/T - take at px, 3hrs, 6hrs
ECG
CXR
ECHO
Coronary angiography if indicated
NSTEMI ECG findings
- ST depression, T wave flattening / inversion
- normal ECG
ECG coronary territories
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
STEMI Mx
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…
NSTEMI / unstable angina Dx criteria
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
NSTEMI / unstable angina Mx
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
ACS secondary prevention
- 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)
ACS Cx
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
Stable angina
- 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
Angina Px
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
Angina Ix
- ECG
- Bloods - FBC, U/E, LFTs, lipids, TFTs, HbA1c, fasting glucose
- cardiac stress testing
- CT coronary angiography
- invasive coronary angiography
Angina Mx
- 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
Acute pericarditis
- inflammation of pericardial sac <4-6wks
- may lead to effusion/tamponade
Acute pericarditis causes
- viral - coxsackie, HIV, EBV
- TB
- uraemia
- post-MI - fibrinous / Dressler’s
- radiotherapy
- SLE, RA
- hypothyroid
- lung / breast Ca
- trauma
- methotrexate
Acute pericarditis Px
- chest pain, ?pleuritic, relieved by sitting forwards
- low grade fever
- cough (non-productive)
- SOB
- flu sx
- pericardial rub on ausc
- hiccups (phrenic)
Acute pericarditis Ix
- ECG - diffuse saddle-shaped ST elevation, PR depression
- ECHO - effusion- all patients
- Bloods - FBC, raised CRP/ESR, trops
Acute pericarditis Mx
- can tx as OP
- tx cause
- no strenuous activity until resolution
- NSAIDs + colchicine
- may need prednisolone
- pericardiocentesis if indicated
Constrictive pericarditis
- pericardium becomes rigid
- fibrosis, calcified, impairs diastolic filling of heart
- eg post-pericarditis, viral, TB, idiopathic
Constrictive pericarditis Px
- SOB
- RHF - elevated JVP, ascites, oedema, hepatomegaly
- pericardial knock - loud S3
- Kussmaul’s sign - rise in JVP on insp
Constrictive pericarditis Ix
- CXR - pericardial calcification
- ECG - low voltage QRS
- ECHO - thickened pericardium, small ventricles
- CT / MRI
Constrictive pericarditis Mx
pericardiectomy
Pericardial effusion
- fluid in pericardial sac
Cardiac tamponade
- pericardial effusion that constricts heart, drops CO
Pericardial effusion causes
- any cause of pericarditis
- myocardial rupture, aortic dissection, trauma, TB, malignancy
- post-cardiac surgery, central line insertion
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
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
Pericardial effusion Ix
CXR - large globular heart
- ECG - low voltage QRS, sinus tachy, electrical alternans
- ECHO
Pericardial effusion / tamponade Mx
Effusion
- spontaneously resolve
- pericardial fenestration
- pericardiocentesis
Tamponade
- Urgent pericardiocentesis
- cardiac surgery - midline sternotomy / thoracotomy
Myocarditis
- inflammation of myocardium- consider particularly in younger patients
Causes
- Viral – coxsackie B, HIV
- Bacteria – diphtheria, clostridia
- Lyme disease, Chagas, toxoplasmosis
- Autoimmune
- Drugs – doxorubicin
Myocarditis Px
- acute onset
- chest pain
- SOB
- arrhythmias, palpitations
- faint, dizzy
- recent flu-like sx
Myocarditis Ix
- bloods - raised CRP/ESR / trops / BNP
- ECG - tachycardia, arrhythmias, ST elevation, T wave inversion, other S/T changes
- CXR
- ECHO
Myocarditis Mx
- tx cause, eg abx if bacterial
- supportive tx - of HF / arrhythmias
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
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
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
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
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
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
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….
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
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
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
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….
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
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
HF Mx all pts
- diuretics - oral furosemide
- cardiac rehab
- stop smoking
- tx comorbidities
- consider statin
- consider antiplatelet
HF-pEF Mx
- manage comorbidities
- tx cause
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
HF Cx
- arrhythmias, depression, cachexia, CKD, sexual dysfunction, sudden cardiac death, VTE, hepatic dysfunction
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
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
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
AHF Ix
- A-E
- ECG
- Bloods - FBC, U/E, BNP, ?trop, ABG, Mg, Ca, TFTs
- CXR
- ECHO
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
HTN
- high BP
- clinic reading >140/90, 24hr BP avg >135/85
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
HTN RFs
- older, ethnicity, FHx, overweight, sedentary, smoking, alcohol, diabetes, stress
HTN Px
- asym
- headaches
- visual disturbance
- seizures
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
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
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
HTN Cx
- IHD, CVA, PAD, aortic dissection, AAA, atherosclerosis
- hypertensive retinopathy
- hypertensive nephropathy
- LVH
- HF
- malignant HTN / hypertensive emergency
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
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…
Hypertensive emergency Ix
- CT head
- fundoscopy
- ECG, urinalysis, U/E, CXR
- Ix for secondary causes
Hypertensive emergency Mx
- A-E
- IV Sodium nitroprusside
- IV labetalol
- IV GTN, nicardipine
- If asymptomatic - start chronic HTN mx
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
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
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
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
SVT Px
- chest pain, palpitations, sweaty/clammy, faint, dizzy, HF
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
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
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
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
AF Px
- Palpitations
- SOB
- Chest pain
- Syncope, dizziness
- Sx of associated condition, eg infection, stroke
- Irregularly irregular pulse
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
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
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
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
Paroxysmal AF
- may use pill-in-the-pocket approach
- flecainide / BB when sx of AF develop
AF reducing stroke risk
CHA2DS2-VASc
- risk of stroke with AF
ORBIT
- risk of bleeding
Mx
- DOAC
- warfarin 2nd line
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
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
AFl Px
- palpitations, SOB, chest pain, dizzy, syncope, fatigue, HF
AFl Ix
- ECG - sawtooth baseline, narrow complex tachy, regular QRSs
- Bloods - FBC, U/E, CRP, LFTs, TFTs, Mg, Ca
- CXR
- ECHO
AFl Mx
- rate / rhythm control
- lower energy levels for cardioversion
- radiofrequency ablation of tricuspid valve isthmus
Bradycardia causes
- HB
- Meds - BBs
- sick sinus syndrome - conditions which cause dysfunction in SAN -> sinus brady, sinus arrhythmias, prolonged pauses
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
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
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
BBB
block in lower conduction system
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
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
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
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
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
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
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
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
Prolonged QT Px
- syncope, palpitations…
- exertional syncope
- sudden cardiac death
Prolonged QT Ix
- ECG - prolonged QTc
- bloods
Prolonged QT Mx
- stop meds causing it
- correct electrolytes
- IV Mg
- BBs
- pacemaker / ICD
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
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
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
Assessing murmurs
see notes
Aortic stenosis (AS)
- narrowing of aortic valve
- calcification / congenital bicuspid valve
- reduced valve SA, increased afterload, LVH, LVF
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
AS Ix (and all valve diseases)
- ECHO
- ECG
- CXR
AS Mx
- aortic valve replacement - surgical / TAVI
- balloon valvuloplasty
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
MR Px
- SOBOE, fatigue
- palpitations
- signs of HF / pulm oedema
- pansystolic murmur - radiates to axilla
- thrill
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%
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
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
AR Mx
- medical mx of HF
- aortic valve replacement - if sx / LV systolic dysfunction
Mitral stenosis (MS)
- narrow mitral valve, restricting blood flow from LA -> LV
- increased pressure in LA, pulmonary vessels, R heart
- rheumatic fever, IE
MS Px
- SOBOE, oedema, angina etc
- haemoptysis
- mid-diastolic murmur, loud S1, opening snap after S2
- malar flush
MS Mx
- balloon valvuloplasty
- mitral valve replacement
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
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
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
HOCM Px
- asym
- SOBOE
- angina, syncope, dizziness, palpitations
- HF sx
- sudden death
- jerky carotid pulse
HOCM Ix
- ECG - LVH
- ECHO
- CXR
- cardiac MRI
- genetic testing
HOCM Mx
- BBs / verapamil
- amiodarone
- ICD
- surgical myomectomy
- alcohol septal ablation
- heart transplant
- avoid intense exercise, heavy lifting, dehydration
- avoid - ACEi, nitrates, inotropes
Arrhythmogenic right ventricular dysplasia / cardiomyopathy (ARVD/C)
- autosomal dominant - progressive fatty/fibrous replacement of ventricular myocardium
- arrhythmia risk
ARVD Px
- palpitations
- syncope
- sudden death
ARVD Ix
- ECG
- ECHO
- MRI
- genetic testing
ARVD Mx
- BB, amiodarone
- catheter ablation
- ICD
- heart transplant
Dilated cardiomyopathy
- thinning / dilatation of heart muscle
- genetic / secondary
- poorly contracts - systolic dysfunction
Causes
- idiopathic, myocarditis, IHD, peripartum, HTN, drugs, DMD, HHC, sarcoidosis….
Dilated cardiomyopathy Px
- HF sx
- systolic murmur
- S3
Dilated cardiomyopathy Ix
- CXR - balloon appearance of heart
- ECHO
- ECG
Dilated cardiomyopathy Mx
- medical mx of HF
Restrictive cardiomyopathy
- heart becomes rigid / stiff -> impaired ventricular filling during diastole
- genetic / secondary causes
- amyloidosis, sarcoidosis, post-radiotherapy…
Restrictive cardiomyopathy Px
- raised JVP, hepatomegaly, oedema, SOB, fatigue
Restrictive cardiomyopathy Ix
- CXR, ECHO, ECG
- cardiac catheterisation / MRI / heart imaging etc
Restrictive cardiomyopathy Mx
- poor prognosis
- heart transplant
- HF mx
Peripartum cardiomyopathy
- weakness of heart muscle that develops between last month pregnancy + 5mo post-partum
- more common older, higher G/P
- causes HF
Alcohol-induced cardiomyopathy
- type of dilated cardiomyopathy caused by long-term alcohol use
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
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
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
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
Shock
Circulatory failure leading to inadequate organ perfusion and tissue hypoxia
Shock causes
Hypovolaemic
Cardiogenic
Obstructive
Distributive - reduced SVR
- Septic shock
- Anaphylactic shock
- Neurogenic shock
Hypovolaemic shock
- shock due to low BV
- haemorrhage, D+V, burns, diuresis
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
Hypovolaemic shock Ix
- A-E
- bloods
- Ix for cause - CXR, ECG, ECHO, CT, FAST
Hypovolaemic shock Mx
- IV fluids
- blood - MHP etc
- tx cause
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
Obstructive shock
- shock due to obstruction of cardiac output
- tension PTX, massive PE, cardiac tamponade
Mx
- tx cause
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
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
Sepsis RFs
- <1yo / >75yo
- Chronic conditions
- Chemo, immunosuppressants, steroids
- Surgery, recent trauma, burns
- Pregnancy, childbirth
- Indwelling devices - catheters, central lines
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,
Sepsis Ix
- A-E, obs
- Bloods - FBC, U/E, LFTs, CRP, BMs, coag, cultures, VBG
- urine dip + culture
- CXR
- ECG
- CT / LP
Sepsis Mx
- O2
- Broad spec abx - eg tazocin / meropenem
- IV fluids
- Catheter + UO
- Blood cultures
- Serum lactate
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
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
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
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%)
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
ALS algorithms - cardiac arrest, tachy/brady arrhythmias
See notes
Post-MI complications?
- Death during/ immediately after MI = V-fib
- Pleuritic chest pain relieved by sitting forward days after MI = fibrinous pericarditis
- New pansystolic murmur + SOB days after MI = mitral regurgitation due to papillary muscle rupture
- Acute severe hypotension, raised JVP, muffled heart sounds days after MI = tamponade due to ventricular free wall rupture
- Harsh pansystolic murmur heard best in tricuspid area days after MI = ventricular septal rupture
- Persistent ST elevation weeks-months later + signs of LV dysfunction (poor CO, pulmonary oedema) = LV aneurysm
- Pleuritic chest pain relieved by sitting forward weeks after MI = Dressler’s syndrome
Ventricular tachycardia CI drug?
Verapamil should not be used in VT
Liver problems, psychiatric problems in non alcoholic disease?
Wilson’s disease
Also Kayser-Fleischer rings in the eyes
Hypothermia?
Mild hypothermia 32-35°C
Moderate or severe <32°C
