Cardiology Flashcards
What are the clinical features of Myocarditis?
Usually young patient with acute history (recent flu like illness)
- Preceeding Viral Syndrome → fever, myalgia, URTI symptoms around 2-3 weeks before initial presentation
- Chest Pain → indicates perimyocarditis
- Cardiac Arrhythmias → palpitations
- Dyspnoea
What are the investigations for Myocarditis?
- Endomyocardial Biopsy- Gold standard
- 12-Lead ECG → ordered immediately in anyone with chest pain or cardiac symptoms. May see ST elevation and T wave inversion.
- Bloods → increased cardiac enzymes (CK, CK-MB, Troponin), increased ESR, increased BNP
- CXR → cardiac enlargement, pleural effusions, bilateral pulmonary infiltrates (pulmonary oedema)
What is Myocarditis?
Inflammation of the myocardium in the absence of the predominant acute or chronic ischaemia characteristic of coronary artery disease
What is Chronic Pericarditis?
Lasts >3 months. Leads to constrictive pericarditis (raised JVP)
Constrictive Pericarditis ⇒ dyspnoea, right heart failure (peripheral oedema), raised JVP
Positive Kussmaul’s sign (paradoxical rise in JVP on inspiration)
pulsus paradoxus (large drop in BP during inspiration - sign of tamponade).
CXR may show pericardial calcification.
Kussmaul’s Sign = differentiates constrictive pericarditis and cardiac tamponade.
What is Dressler’s Syndrome ?
pericarditis several weeks after an MI
What are the clinical features of Pericarditis?
Clinical Features:
Chest Pain → acute in onset, sharp & pleuritic. -
- May be stabbing or aching.
- Relieved when sitting up or leaning forwards (hence also worse when lying down).
- Can radiate to neck and shoulders (typically left side)
Pericardial Rub → occurs in 1/3 of cases.
-Superficial scratchy or squeaking sound
-best heard with the diaphragm of the stethoscope over the left sternal border.
-Heard best at the left sternal edge with the patient leaning forward at end-expiration.
May also have fever & myalgia
Cardiac Tamponade ⇒ Beck’s Triad = raised JVP, decreased BP, muffled heart sounds
- Pulsus Paradoxus → abnormally large drop in BP during inspiration
What constitutes under Beck’s Triad and what is this indicative of?
raised JVP, decreased BP, muffled heart sounds
cardiac tamponade
What is the ECG finding of Pericarditis?
saddle shaped ST elevation (IN ALL LEADS) + PR depression
Widespread ST elevation (as oppose to STEMI, which will only cause ST elevation in leads corresponding to territory)
What are the investigations for Pericarditis?
- Transthoracic Echocardiography → pericardial effusion (cardiac tamponade) may be present
- CXR → pericardial effusion
- Troponin → elevation indicates myopericarditis or other aetiologies such as ACS
- U&Es → elevated urea suggests a uraemic cause
- Blood Culture → positive if infective cause
What is the management for Pericarditis?
- Often self-limiting → NSAIDs (Can also give PPI prophylaxis to protect against effects of high doses of NSAIDs)
- If the patient has idiopathic or viral pericarditis, add Colchicine and continue it for 3 months.
- Main side effect is diarrhoea
- Surgical:
- If Tamponade → Pericardiocentesis
- If Recurrent → Pericardiectomy (complete removal of the pericardium)
What is the management for Vasovagal Syncope?
Patient education + avoiding triggers
Volume expansion → increased dietary salt and electrolyte-rich sports drinks
Fludrocortisone
What 4 specific cardiac arrhythmias can cause cardiac arrest?
ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electrical activity (PEA), and asystole
Which out of the 4 specific cardiac arrhythmias can cause cardiac arrest are shockable and non shockable?
shockable rhythm (VT/VF)
non-shockable rhythm (asystole/PEA)
What is the management plan for Shockable Rhythms (Pulseless VT or VF)?
CPR (30:2 ratio) and Defibrillation + Adrenaline.
May also use anti-arrhythmic such as amiodarone.
If due to Torsade de Pointes, give magnesium.
What is the management plan for Non-Shockable Rhythms (PEA or Asystole)?
CPR and Adrenaline. No defibrillation.
Atropine (once) if rate <60bpm
What is Cardiac Arrest?
Sudden state of circulatory failure due to a loss of cardiac systolic function
What is the Secondary Prevention of MI (long-term management) ?
Dual Antiplatelet Therapy (aspirin + ticagrelor/clopidogrel)
ACEi (ramipril), Beta Blocker (bisoprolol)
Statin (atorvastatin 80mg - secondary prevention dose)
What is the initial management for Acute ACS?
MOAN
- Morphine (patients with severe pain)
- Oxygen (only if sats <94%)
- Aspirin (300mg)
- Nitrates (contraindicated if hypotensive, <90mmHg)
What is the management for STEMI?
- Aspirin 300mg and continue indefinitely
-
Symptoms <12h and PCI possible in 2h → Angiography + PCI
- Also give Prasugrel
- Symptoms <12h and PCI not possible in 2h → Thrombolysis (alteplase + antithrombin)
If present >12h after symptoms, manage pharmacologically.
What is Supra-Ventricular Tachycardia?
A regular, narrow-complex tachycardia with no P waves and a supraventricular origin. (regular = distinguishing feature from AF which is irregular)
How does Wolf-Parkinson-White Syndrome present on an ECG?
Delta waves (slurred upstroke in QRS) after SVT termination
What is the management for Supra-Ventricular Tachycardia?
Haemodynamically Stable
- 1st Line → **Vagal Manouveres** (eg. carotid sinus massage or valsalva manoeuvre - exhalation against closed airway/blowing into syringe)
- 2nd Line (chemical cardioversion) → **IV Adenosine** (6mg then 12mg then 12mg) (Adenosine is contraindicated in asthma patients ⇒ use **Verapamil**)
- MOA ⇒ causes transient heart block in the AV node (makes patient feel like they’re about to die). Short acting (half life <10secs).
- Side Effects of Adenosine ⇒ chest pain (brief + intense), bronchospasm, flushing
- If Haemodynamically Unstable (Systolic BP <90mmHg) → DC Cardioversion
What is the management for AF and when is rhythm control preferred over rate control?
Rate Control → 1st line = beta-blocker (propanolol) or rate-limiting CCB (diltiazem** or verapamil).
-2nd line = **digoxin** (**if patients sedentary** or other drugs unsuitable, eg. avoid propanolol in asthmatics) - Don’t use beta blocker and verapamil together ⇒ can lead to heart block
- Rhythm Control (1st line over rate control if clear reversible cause for AF) **→ DC cardioversion (give LMWH prior) **or Amiodarone/Flecainide
What is VT and how does it present on an ECG
A regular broad-complex tachycardia originating from a ventricular ectopic focus. The rate is usually >120 bpm.
ECG → rate >100bpm, broad QRS complexes, no P waves, AV dissociation
SVT = QRS <120ms (narrow-complex). VT = QRS >120ms (broad-complex).
How does Torsades de Pointes present on an ECG
Polymorphic VT - VT with varying amplitude → associated with long QT interval. Corkscrew appearance
May deteriorate into VF and cause sudden death.
What is the management for Ventricular Tachycardia?
ABC approach, check whether patient has pulse or not (if in cardiac arrest may require defibrillation).
Stable VT (Haemodynamically Stable) → IV Amiodarone 300mg (chemical conversion)
- Verapamil is contraindicated in VT
- Amiodarone ⇒ can cause hypo or hyperthyroidism
If Haemodynamically Unstable (ie. tachycardic and hypotensive - systolic BP <90mmHg) → DC Cardioversion
Torsades de Pointes → IV magnesium sulfate (if stable, if unstable DC cardiovert)
How does an VF ECG present?
Not Regular (as opposed to VT)
VT = Very Tidy. VF = Very Funny.
Irregular broad-complex tachycardia that can cause cardiac arrest and sudden cardiac death
What is the management for Ventricular Fibrillation?
Check if patient has a pulse → Initiate ALS
Urgent Defibrillation and Cardioversion (and CPR)
Survivors will need an Implantable Cardioverter Defibrillator (ICD)
What are the ECG presentations for the different types of Heart Block
First Degree → fixed prolonged PR interval (>0.2s/200ms = 1 large square)
- Normal variant in athlete (asymptomatic), hence doesn’t require tx in that case (as is mobitz I)
Mobitz Type I → progressively prolonged PR interval, then eventually dropped beat
Mobitz Type II → intermittently a P wave is not followed by a QRS (PR interval is constant)
Complete Heart Block → no relationship between P waves and QRS complexes (complete AV dissociation)
What is the management for Heart block?
Chronic Block (definitive management) → permanent pacemaker
Acute Block → IV atropine (may need temporary (transcutaneous) pacing if this does not work)
- Atropine = used for bradycardias to speed up heart
