Cardiology

Question 1

What are the clinical features of Myocarditis?

Answer 1

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

Question 2

What are the investigations for Myocarditis?

Answer 2

• 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)

Question 3

What is Myocarditis?

Answer 3

Inflammation of the myocardium in the absence of the predominant acute or chronic ischaemia characteristic of coronary artery disease

Question 4

What is Chronic Pericarditis?

Answer 4

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.

Question 5

What is Dressler’s Syndrome ?

Answer 5

pericarditis several weeks after an MI

Question 6

What are the clinical features of Pericarditis?

Answer 6

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

Question 7

What constitutes under Beck’s Triad and what is this indicative of?

Answer 7

raised JVP, decreased BP, muffled heart sounds

cardiac tamponade

Question 8

What is the ECG finding of Pericarditis?

Answer 8

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)

Question 9

What are the investigations for Pericarditis?

Answer 9

• 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

Question 10

What is the management for Pericarditis?

Answer 10

• 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)

Question 11

What is the management for Vasovagal Syncope?

Answer 11

Patient education + avoiding triggers

Volume expansion → increased dietary salt and electrolyte-rich sports drinks

Fludrocortisone

Question 12

What 4 specific cardiac arrhythmias can cause cardiac arrest?

Answer 12

ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electrical activity (PEA), and asystole

Question 13

Which out of the 4 specific cardiac arrhythmias can cause cardiac arrest are shockable and non shockable?

Answer 13

shockable rhythm (VT/VF)
non-shockable rhythm (asystole/PEA)

Question 14

What is the management plan for Shockable Rhythms (Pulseless VT or VF)?

Answer 14

CPR (30:2 ratio) and Defibrillation + Adrenaline.

May also use anti-arrhythmic such as amiodarone.

If due to Torsade de Pointes, give magnesium.

Question 15

What is the management plan for Non-Shockable Rhythms (PEA or Asystole)?

Answer 15

CPR and Adrenaline. No defibrillation.
Atropine (once) if rate <60bpm

Question 16

What is Cardiac Arrest?

Answer 16

Sudden state of circulatory failure due to a loss of cardiac systolic function

Question 17

What is the Secondary Prevention of MI (long-term management) ?

Answer 17

Dual Antiplatelet Therapy (aspirin + ticagrelor/clopidogrel)
ACEi (ramipril), Beta Blocker (bisoprolol)
Statin (atorvastatin 80mg - secondary prevention dose)

Question 18

What is the initial management for Acute ACS?

Answer 18

MOAN

• Morphine (patients with severe pain)
• Oxygen (only if sats <94%)
• Aspirin (300mg)
• Nitrates (contraindicated if hypotensive, <90mmHg)

Question 19

What is the management for STEMI?

Answer 19

• 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.

Question 20

What is Supra-Ventricular Tachycardia?

Answer 20

A regular, narrow-complex tachycardia with no P waves and a supraventricular origin. (regular = distinguishing feature from AF which is irregular)

Question 21

How does Wolf-Parkinson-White Syndrome present on an ECG?

Answer 21

Delta waves (slurred upstroke in QRS) after SVT termination

Question 22

What is the management for Supra-Ventricular Tachycardia?

Answer 22

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

Question 23

What is the management for AF and when is rhythm control preferred over rate control?

Answer 23

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

Question 24

What is VT and how does it present on an ECG

Answer 24

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).

Question 25

How does Torsades de Pointes present on an ECG

Answer 25

Polymorphic VT - VT with varying amplitude → associated with long QT interval. Corkscrew appearance

May deteriorate into VF and cause sudden death.

Question 26

What is the management for Ventricular Tachycardia?

Answer 26

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)

Question 27

How does an VF ECG present?

Answer 27

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

Question 28

What is the management for Ventricular Fibrillation?

Answer 28

Check if patient has a pulse → Initiate ALS

Urgent Defibrillation and Cardioversion (and CPR)
Survivors will need an Implantable Cardioverter Defibrillator (ICD)

Question 29

What are the ECG presentations for the different types of Heart Block

Answer 29

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)

Question 30

What is the management for Heart block?

Answer 30

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