Cardiology Flashcards
Modified Duke Criteria
> Major criteria
- Positive blood culture:
(Typical organism in 2 separate culture OR
Persistently +ve blood culture, eg: 3 >12 hours apart OR
Single positive blood culture for Coxiella burnetti)
- Endocardium involved:
(Positive echocardiogram OR
Abnormal activity around prosthetic valve on PET/CT or SPECT/CT OR
Paravulvular lesion on cardiac CT)
> Minor criteria
- Predisposition (IV drug abuse)
- Fever >38’C
- Vascular phenomena (emboli, Janeway’s lesion)
- Immunological phenomena (glomerulonephritis, Osler’s nodes)
- Positive blood culture that do not meet major criteria
> How to diagnose
- 2 major OR
- 1 major and 3 minor OR
- All 5 minor criteria
Management of infective endocarditis**
○ Empirical antibiotics
- Generally: ampicillin + gentamycin
○ Surgery
- Indication
□ Severe valvular regurgitation/ heart failure
□ Persistent infection/ uncontrolled sepsis
□ Fungal endocarditis
□ Very large vegetation (>10mm)
○ Monitoring of treatment response
- FBC - total WBC
- Inflammatory markers - CRP/ ESR
- Blood C&S - 3 to 4 days after antibiotics
Complication of infective endocarditis*
- Cardiac: heart failure, perivalvular abscess, pericarditis
- Neurologic: stroke, brain abscess, meningitis
- Renal: renal infarction or abscess (following septic embolization), glomerulonephritis (due to deposition of immunoglobulin and complement in glomerular membrane)
Revised Jones Criteria
" JONES PEACE" > Major - Joints (polyarthritis) - Heart (carditis, valve damage) - Nodule (subcutaneous) - Erythema marginatum (painless rash) - Sydenham chorea (flinching movement disorder)
> Minor
- Previous rheumatic fever
- ECG with PR prolongation
- Arthralgias
- CRP and ESR elevated
- Elevated temperature
> Diagnosis
- Evidence of recent strep infection + 2 major/ 1 major + 2 minor criteria
Secondary prophylaxis for rheumatic fever
> Penicillin V 250mg/12h PO; Alternative: erythromycin 250mg BD
- Carditis + persistent valvular disease -> at least until age 40
- Carditis without valvular disease -> continue for 10 years
- No carditis -> 5 years prophylaxis (until age of 21) is sufficient
Framingham criteria
> Major criteria
- Acute pulmonary edema
- Cardiomegaly
- Hepatojugular reflux
- Neck vein distension
- Paroxysmal nocturnal dyspnea
> Minor criteria
- Ankle edema
- Dyspnea on exertion
- Hepatomegaly
- Nocturnal cough
- Pleural effusion
- Tachycardia (pulse >120)
> Note
- HF present in patient with at least 2 major criteria/ 1 major + 2 minor criteria
New York classification of heart failure
I: Heart disease present, but no undue dyspnea from ordinary activity
II: Comfortable at rest; dyspnea during ordinary activity
III: Less than ordinary activity cause dyspnea, which is limiting
IV: Dyspnea present at rest; all activity cause discomfort
ECG features of hyperkalemia***
- > 5.5 mmol/L: peaked T waves
- > 6.5: widening of P waves, PR segment lengthening
- > 7.0: prolonged QRS interval, bradycardia
- > 9.0: VF, asystole
Treatment for hyperkalemia**
“Lytic cocktail”
- 10ml of 10% calcium gluconate given over 10 minutes
- 50ml of 50% dextrose
- 10 unit IV Actrapid
Physical signs in heart failure
General:
- Use of accessory muscles
- Cyanosis
- Hand: cold periphery, CRT >2 sec
- Face: pallor
- Neck: raised JVP, hepatojugular reflux
- Back and lower limb: edema
> Cardiovascular
- Displaced apex beat
- Parasternal heave
- Murmur
> Other
- Lung crepitation
- Hepatomegaly
- Ascites
Investigation for heart failure**
- FBC
- BUSE/ Cr
- B-type natriuretic peptide
- Liver function test: congestive hepatomegaly
- ABG: hypoxemia, hypercapnia, acidosis
- ECG: exclude arrhythmia, ACS, evidence of LVH
- CXR: ABCDE
- Echocardiography
Acute management of heart failure**
> Stabilization
- Supplemental O2: keep >95%
- Diuretic: IV frusemide - reduce fluid overload
- Vasodilators: IV nitrate - concurrent ACS
- Inotropes: IV noradrenaline, dopamine - if SBP <100mmHg at initial presentation
- IV morphine - reduce pulmonary venous congestion
> Treat underlying causes > Continuous assessment - Vital signs - Urine output - Weight - Respiratory distress - Cold/ warm periphery
> DVT prophylaxis
Physical sign of ACS**
- Hand: tendon xanthoma
- Face: pallor, xanthelasma
- Chest: scars (median sternotomy, CABG)
- CVS: apex beat, murmur, carotid bruit
- Lower limb arterial: bypass scar, trophic changes, delayed CRT
Immediate management of ACS**
“MONAC”
- Morphine
- Oxygen if <90%
- Nitrates
- Aspirin 300mg
- Clopidogrel 300mg
Definitive, subsequent and long term management for STEMI***
> Definitive
- Depends on time from symptoms onset: PCI/ FT (eg: IV tenecteplase)
> Subsequent
- Admit to CCU
- Supportive: IV opioids, O2 keep >95%, dual antiplatelet therapy, anticoagulation (for patient received fibrinolytic)
- Drugs with positive impact on survival: ACE-I/ ARB, beta blocker, mineralocorticoid receptor antagonist, statins
> Long term
- Smoking cessation
- Diet modification
- Weight control
- Physical exercise
- Optimize BP, glucose
Definitive management for NSTEMI**
- Initial management at ED: ECG and cardiac troponin to establish diagnosis, urgent medication (MONAC), supportive treatment (O2 when <90%, IV morphine)
- Risk stratify patient: TIMI/ GRACE
- Subsequent management
- Depends of risk group: ischemic guided strategy (risk reduction + medical treatment) vs invasive strategy (coronary angiography + PCI, CABG)
- Start medication: dual antiplatelet, anticoagulation, beta blocker, ACE inhibitor, high intensity statin
- Discharge
Investigation for ACS***
- ECG
- Cardiac troponin
- FBC, RP
- Glucose, lipid profile
Investigation for infective endocarditis**
○ Diagnosis - Blood C&S □ At least 3 sets of sample, each taken at least 30 minutes apart - Echocardiography □ Vegetation □ Abscess
○ Support diagnosis - FBC □ Leukocytosis □ Anemia - Inflammatory markers □ Raised ESR/ CRP - Urinalysis (UFEME) □ Microscopic hematuria
○ Monitor treatment response
- Repeated blood culture
- FBC: WCC trend
- Inflammatory markers
Causes of AF**
- Valvular heart disease: especially MS
- Ischemic heart disease
- Hypertension
- Congenital heart disease: ASD, VSD
- Secondary causes: thyrotoxicosis, medication-induced
CHA2DS2VA risk score
Assess stroke risk
- C: Congestive HF
- H: history of HPT
- A: Age >=75
- D: DM
- S: history of Stroke
- V: Vascular ds
- A: Age 65-74
0: OAC for 4 weeks
1: consider OAC long term
2 or more: OAC long term
Long term management of heart failure
> Non-pharmaco
- Exercise: 30min, 5 times/ week
- Dietary
- Fluid restriction: 1.5L/day
- No alcohol, smoking
> Pharmaco
- ACE-I
- B blocker
- Spironolactone
- Diuretics
Cardiac biomarker
- CK-MB: good to detect reinfarction due to presence for only 1-2 days
- Troponin is investigation of choice due to high specificity
- Others: CK, Myoglobin
Management of SVT***
> Acute
- Unstable -> Immediate synchronized cardioversion
- Stable -> carotid sinus massage
- If not terminate by vagal maneuver -> IV adenosine or CCB (eg: verapamil or diltiazem)
> Prophylaxis against recurrence
- Beta blocker or CCB
- Radiofrequency ablation (in hemodynamically unstable attack, pre-excitation on ECG)
5 life threatening condition of chest pain
- Acute coronary syndrome
- Aortic dissection
- Pulmonary embolism
- Pneumothorax
- Oesophageal tear
ECG features of ACS*
> STEMI
□ Within hours: tall T waves, ST elevation
□ Hours to days: T wave inversion and pathological Q waves
> NSTEMI/ UA
□ ST depression
□ T wave inversion
□ Normal
Management of AF*
> Immediate
○ Assessment
□ Hemodynamic status
□ Immediate ECG: look for pre-excited AF
○ Management
□ Unstable: urgent synchronized electrical cardioversion
□ Stable: rate control with IV beta blocker/ non-dihydropyridine CCB (no structural heart disease); IV amiodarone (CCF)
□ If suboptimal control/ contraindicated -> Digoxin
> Subsequent
- Assess stroke risk: CHA2DS2VA
- Long term rate control: beta blocker, non-dihydropyridine CCB
ECG changes in AF*
- Irregular rhythm
- Tachycardia
- Absence of P wave
- Fibrillatory waves
- Loss of isoelectric baseline
- Narrow QRS complex
Investigation for AF
> Confirm diagnosis
- 12-lead ECG
> Others
- Serum electrolyte
- Thyroid function test
- Transthoracic echocardiography
What is Dabigatran and its indication
- Direct thrombin inhibitor
> Indication
- Non-valvular AF
- DVT
- Pulmonary embolism
- Postoperative DVT prophylaxis
Target INR in AF
2 to 3
Investigation for myocarditis
○ ECG
- ST changes
- T waves inversion
- Atrial arrhythmia
- QT prolongation
○ CRP, ESR, Troponin
- May be raised
○ Echo
- Diastolic dysfunction
- Reginal wall abnormalities
Management for myocarditis
- Supportive
- Treat underlying cause
- Treat arrhythmia and heart failure
Definition of metabolic syndrome**
> Central obesity (BMI >30) plus 2 of:
- BP >= 130/85
- Triglyceride >=1.7mmol/L
- HDL <= 1.03 (male)/ 1.29 (female) mmol/L
- Fasting glucose >=5.6 mmol/L
- Type 2 DM
How IHD cause MR
- Myocardial infarction can lead to LV dilation
- > dilation of the MV annulus
- > tethering of the chordae tendineae
How to diagnosed DVT
- Calculate Well’s score (determine probability)
- If <= 1 points, DVT unlikely and perform a D dimer test
Negative -> exclude DVT
Positive -> ultrasound to confirm - In high probability patient -> whole leg ultrasound (D dimer cannot be reliably used to exclude DVT)
Example of non-ischemic cardiomyopathy
- Hypertrophic CM
- Restrictive CM
- Dilated CM
- Myocarditis
Degree of AV block
- 1st: PR interval is longer than normal (>0.2 sec)
- 2nd - MB1: PR interval progressively lengthens with each beat until the atrial impulse is not conducted and the QRS complex is dropped
- 2nd - MB2: beats are intermittently non-conducted and QRS complex dropped, usually in repeating cycle of every 3rd (3:1 block) or 4th (4:1 block) P waves
- 3rd: AV dissociation
Complication of prosthetic heart valve
> From the valve
- Hemolysis
- Valve dysfunction: leaking, dehiscence, thrombosis
- Thromboembolism
- Endocarditis
> From treatment
- Overwarfarinization (bleeding)
Type (+ cause, management) of heart failure
> Dilated cardiomyopathy
- Cause: IHD, HPT
- Mx: anticoagulation
> Hypertrophic CM
- Cause: hereditary (autosomal dominant HOCM)
- Mx: beta blocker, implantable defibrillator
> Restrictive CM
- Cause: infiltrative ds (amyloidosis, sarcoidosis, hemochromatosis)
- Mx: anticoagulation, heart transplant
