Cardiology Flashcards
3 Is, 4 Ps, DTU
Causes of pericarditis
Infectious - usually viral (80% are viral or idiopathic)(coxsackie, COVID), can be bacterial, fungal, TB (poorer prognosis)
Immunological - SLE, rheumatic fever, vasculitis
Idiopathic
Post MI (Dressler’s syndrome)
Post cardiac surgery
Post RTx
Paraneoplastic
Trauma
Drug induced (isoniazid, cyclosporin)
Uraemia
ECG changes in pericarditis
Widespread concave STE (esp inferior and precordial) with reciprocal STD in aVR and V1
Widespread PR depression with reciprocal PR elevation in aVR and V1
Sinus tachycardia
Spodick’s sign
Differences between ECG for BER and pericarditis
Pericarditis:
-STE widespread in limb and precordial leads (BER pre cordial only)
-no “fish-hook” J point pattern (best seen in V4 in BER)
-ST/T wave ratio >0.25 (BER <0.25)
-presence of PR depression
-normal T wave amplitude
-dynamic ECG changes that evolve over time
Differences between ECG for STEMI and pericarditis
STEMI has reciprocal changes (pericarditis reciprocal only in aVR and V1)
Only STEMI causes convex or horizontal STE
STEMI causes STE > in III than II
PR depression in multiple leads is more likely pericarditis
Diagnosis of pericarditis
At least two of:
Chest pain (retrosternal, sharp, pleuritic, can radiate to L shoulder, better with leaning forward)
Pleural rub
Pericardial effusion
ECG changes of widespread STE and PR depression (<60% of patients)
NZ Criteria for Rheumatic Fever
2 major OR 1 major and 2 minor OR several minor
AND
Evidence of recent GAS infection (2-3 weeks)
Major:
Carditis (echo/new murmur)
Chorea (can be standalone diagnostic)
Polyarthritis (or aseptic mono arthritis)
Erythema marginatum
Subcutaneous nodules
Minor:
Fever
Raised ESR/CRP
Polyarthralgia
Prolonged PR interval on ECG
What is the OR of acute rheumatic fever in Maori and Pasifika cf other ethnicities?
> 20x more likely in Maori
40x more likely in Pasifika
Describe some key features of HFpEF
-EF >50%, LV normal volume
-usually females, older adults
-LV wall is thickened/stiff
-poorer prognosis/less amenable to drugs
List some causes of high output cardiac failure
Thyrotoxicosis
Obesity
Pregnancy
Anaemia
Shunting
Vit B1 deficiency
Describe the NYHA levels of HF
Class I - no limitation
Class II - ordinary activity causes SOB
Class III - less than ordinary activity causes SOB
Class IV - SOBAR
Hx and exam in HF
Hx:
Cough
SOB
Wheeze
Collapse
Palpitations
Decreased exercise tolerance
Orthopnoea/PND
Chest pain
Lethargy
Exam:
Elevated JVP
Tachycardia
Tachypnoea
Sweaty/clammy
Hypoxia
Hepatomegaly
Gallop rhythm/abnormal rhythm
Crackles
Oedema
Cyanosis
Treatment for acute HF
Oxygen
SL nitrates
Diuretics
Morphine
B blocker
ACE inhibiter/ARB
Aspirin
Risk factors for HF
IHD
Arrythmia
Smoking
HTN
High cholesterol
Increased age
Male
FHx heart disease
Treatment for chronic HF
If overloaded start with frusemide, add thiazide if required
Start ACE-i/ARB
Start B-blocker once fluid overload settled
If insufficient add spironolactone
If insufficient add entresto
If insufficient refer cardiology
Add SGLT2 inhibitor if diabetic
Digoxin if AF + consider anticoagulation
High risk features of syncope
Age >65
ANY ECG changes (esp ST/T changes, any conduction abnormalities, any QT prolongation or shortening, delta waves, brugada syndrome, LVH, RVH, bradycardia, abnormal Q waves, arrhythmia)
Palpitations
Dyspnoea
HCT <30
Abdo pain/back pain
Headache
Chest pain
SOB
Occurred while supine or exercising
No prodrome
Heart failure/IHD/structural heart disease/new murmur
Hypotension
Evidence of haemorrhage (malena)
Male
FHx sudden cardiac death <50yo
Low risk features of syncope
Provoking factors eg emotional stress/pain medical procedure
Postural
Prodrome
Age <40
Triggered by micturation/cough/defecation
Triggered by nausea/vomiting
Only while standing
ECG changes in STEMI
STE 1mm or greater in 2 or more limb leads
STE 2mm or greater in 2 or more precordial leads
STE 0.5mm or greater in posterior leads (if sig STD in V1-3) - always check for this in inferior or lateral STEMIs
New LBBB
Sgarbossa criteria
Fibrinolysis in STEMI
Tenecteplase:
<60kg = 30mg
60-69kg = 35mg
70-79kg = 40mg
80-89kg = 45mg
90kg+ = 50mg
Clexane 30mg IV (unless >75yo)
Clexane IM 1mg/kg (max 100mg) (unless >75yo then 0.75mg/kg, max 75mg)
Clopidogrel 300mg
Contraindications to fibrinolysis in STEMI
Dementia
Uncontrolled HTN
Non-compressible bleeding
Head trauma/brain surgery <6/12
Cerebral AVM/neoplasm/aneurysm
Possible aortic dissection
Ischaemic stroke <1 year
Non-compressible vascular punctures <24 hours
GI bleeding <1 year
Other internal bleeding <1 year
CPR <3 weeks
Infective Endocarditis diagnostic criteria
Dukes criteria:
Pathological Criteria:
+ve micro culture from vegetation or histology from vegetation indicating IE
OR
2 major OR
1 major, 3 minor OR
5 minor required
Major:
2x +ve BCs at least 12 hours apart (or 1x +ve coxiella burnetii culture)
New murmur/echo shows endocarditis
Minor
Vasc phenom eg Janeways lesions, emboli
Immunological phenom eg Oslers nodes/Roths spots/GMN
Predisposition eg IVDU/prev IE
Fever >38
Micro evidence not meeting major criteria
Risk factors for IE
IVDU
Unrepaired cyanotic congenital heart disease
Immunosuppressed
Prosthetic valves
Rheumatic heart disease
Prev IE
Surgical repair congenital heart disease <6 months
Bacterial causes of IE
Staph aureus
Coxiella burnetii
Strep viridans
GAS
Enterococcus
HACEK
-haemophilus
-aggregatibacter sp
-cardiobacterium hominis
-eikenella corrodes
-kingella sp
Strep gallolyticus/bovis
Risk factors/causes myocarditis
Viral illness
Peripartum or postpartum
HIV
Autoimmune disease
Hypersensitivity reactions
Toxins
ECG changes in myocarditis
QRS prolongation (poor prognosis)
ST/T diffuse elevation
AV block
Features of myocarditis
Chest pain
Arrhythmia
Heart failure
Posterior MI
-when to look
-how to identify
Look for posterior MI in inferior or lateral STEMI
ST depression in V1-3 suggests posterior MI
Other findings include:
-tall, broad dominant R waves in V2
-upright T waves
Obtain posterior leads to check for STE in V7-9
Posterior MI is confirmed by 0.5mm STE in posterior leads
What is Wellen’s Syndrome?
What are the features and the significance?
Wellen’s syndrome is a clinical syndrome involving BOTH chest pain that has now resolved AND either biphasic or deeply inverted T waves in leads V2 and V3
Highly specific for critical stenosis of the LAD
Likely will progress to significant anterior MI in the coming days
DO NOT stress test a Wellen’s
Features of the Marburg Score for chest pain?
Age (F >65, M >55)
Known CAD/CVD or PVD
Pain not reproducible with palpation
Patient assumes pain is cardiac
Pain worsened with exertion
Aortic dissection
Definition
A life threatening condition in which the intimal layer of the aorta tears, separating the intima from the media, creating a false lumen
Aortic dissection risk factors
Age
Hypertension
Smoking
Connective tissue disorder
Trauma
Iatrogenic (cardiac catheterisation)
Aortic dissection prognosis
20% die pre-hospital
33% die pre- or peri-operatively
Aortic dissection
Examination findings
May be nothing but look for:
Hypo or hypertension
Radial/radial or radial/femoral delay
Unequal pressures between arms
Diastolic murmur
Tachycardia
Abnormal pulse character
Abnormal neurological feature
Horner’s syndrome (rare but pathognomonic)
STEMI
Symptoms of myocarditis
Chest pain (commonly pleuritic)
Palpitations
SOB
Collapse
Orthopnoea
Fatigue
Fever
Decreased exercise tolerance
Associated viral illness
Death
Signs of myocarditis
Fever
Tachycardia
Hypotension progressing to cardiogenic shock
S3 gallop
Arrhythmia
Pericardial rub
Heart failure signs
ECG changes in myocarditis
Frequently variable/absent/unpredicatble but can include
Sinus tach (most common)
Non-specific ST and T wave changes
QRS prolongation
AV block
Ventricular arrhythmias
Risk and timeline of ARF post GAS
1-3% of untreated GAS will develop ARF in 2-3 weeks
Risk factors for AF
Advanced age
European
Male
Hypertension
IHD
Hyperthyroidism
Obesity
Sleep apnoea
Alcohol excess
Valvular heart disease
Cardiomyopathy
Acute infection
Diabetes
Heart failure
Caffeine excess
NYHA HF classes
I - no sx
II - ordinary exertion causes symptoms
III - less than ordinary exertion causes sx
IV - sx at rest
