Cardiology Flashcards
Causes of A fib
SMITH
- Sepsis
- Mitral stenosis or regurgitation
- Ischaemic heart disease
- Thyrotoxicosis
- Hypertension
*Alcohol, caffeine and age
DDx of irregularly irregular pulse
- atrial fibrillation
- ventricular ectopics (disappear at high rate and exertion)
A fib investigations
- ECG
- Echocardiogram - valvular disease, heart failure
Special types of A fib
- Paroxysmal atrial fibrillation
- Valvular atrial fibrillatioin (if due to mitra stenosis or mechanical heart valve)
Paroxysmal atrial fibrillation Ix
episodes of atrial fibrillation 30 sec - 48 hrs
24-hour ambulatory ECG recording (Holter monitor)
Paroxysmal atrial fibrillation Mx
Flecainide - Pill in pocket + anticoagulation
if:
- Patient able to recognize symptoms
- infrequent episodes
- no structural heart disease
Risk of flecainide in PAF
conversion to flutter with 1:1 AV conduction
Indications for rhythm control in AF
- Acute presentation < 48hrs
- Reversible cause of AF
- Heart failure despite AF
- Symptomatic despite rate control
How is rhythm control done in AF
Immediate (when < 48hrs or haemodynamically unstable)
- pharmacological cardioversion : Flecainide or amiodarone (if structural heart disease)
- Electrical cardioversion
Delayer (after 48hrs or hemodynamically unstable)
- Electrical: transesophageal echocardiography guided cardioversion (amiodarone before and after)
How is rate control achieved in AF?
- Beta-blocker (bisoprolol) or non-DHP CCB (verapamil or diltiazem if asthmatic)
- Digoxin
*dont give BB and CCB together - risk of heart block
Long-term rhythm control
- Beta blocker ie bisoprolol
- Dronedarone
- Amiodarone (if HF or ventricular dysfunction)
If AF not responding to anti-arithmetics
Catheter ablation
CHA2DS2VASc score
- Congestive heart failure
- Hypertension
- Age >= 75 (2)
- DM
- Stroke or TIA (2)
- Vascular disease
- Age 65-74
- Female
Consider DOAC if a score of 1 in males
Give DOAC if score > 2
ORBIT
risk of bleeding on anticoagulation
- Older age > 75
- Renal impairment eGFR < 60
- Bleeding hx
- Iron deficiency
- Taking anti-platelets
HF ejection fraction
< 40% is reduced HFrEF (issue with ventricular contraction)
>50% is preserved HFrEF (issue with ventricular filling)
HFrEF mx
ABAL
1. ACEi (or ARB if not tolerating or if afro-Caribbean)
2. Beta-blocker
3. Aldosterone antagonist e.g spironaloctone (mineralcorticoid receptor antagonist)
4. Loop diuretics
**Check potassium before spironolactone, K sparing
HF presentation
- Tachycardia and tachypnoea
- Dyspnoea
- Productive cough - pink and frothy
- Orthopnoea
- Bibasal crackles
- Paroxysmal nocturnal dyspnoea
- Peripheral oedema
- Fatigue
HF Ix
Bedside - ECG
Bloods - NT-proBNP, FBC, UE, LFT, TFT etc
Imaging - Echo, CXR (cardiothoracic index)
New York Heart Association classification
- No symptoms
- No symptoms at rest, symptomatic with ordinary activities
- No symptoms at rest, symptomatic with any activity
- Symptomatic at rest
Chronic HF mx
HFpEF - monitor and manage co-morbidities
HFrEF
- BB + ACEi (ARB if intolerant)
- spironaloctone
(3rd line in another flashcard)
*flu (annual) and pneumococcal vaccination (1),
cardiac rehabilitation,
smoking cessation
optimise co-morbidities
written care plan
3rd line mx for chronic heart failure
- Sacubitril-valsartan if EF < 35%
- Ivabradine if EF < 35% + sinus rhythm > 75
- Hydralazine and nitrate in afro-caribbean
- Digoxin if HF
AF and CHA2DS2VASc is 0
Do echo to rule out valvular disease
*AF + valvular disease = need anticoagulation
Adult bradycardia guidelines
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AF cardioversion
If acute (<48hrs)
- unstable: electric cardioversion
- stable: decide between electric and pharmacological
if chronic (>48hrs)
- anticoagulation for 3 weeks, then electric cardioversion (↓ stroke)
Broad complex tachycardia ddx
- AF with bundle branch block
- AF with ventricular pre-excitation
- Torsades de pointes
*seek expert help
