Cardiology Flashcards
Acute coronary syndrome (ACS)
Myocardial ischaemia commonly caused by plaque rupture and thrombosis, inc:
- STEMI
- NSTEMI
- Unstable angina
pathophysiology of ACS?
- atherosclerotic plaque
- gradual narrowing - less blood to myocardium - angina on exertion
- sudden plaque rupture - sudden occlusion - MI
STEMI: infarction with ST elevation on ECG
NSTEMI: infarction without ST elevation on ECG
Unstable angina: ischaemia causing chest pain at rest or minimal exertion OR in a crescendo like fashion
types of MI?
Type 1 – spontaneous e.g. atherosclerotic plaque rupture
Type 2 – secondary to ischaemic imbalance eg coronary artery vasospasm, hypotension, severe anaemia
Type 3 – MI resulting in death without biomarkers
Type 4a – MI from PCI
Type 4b – MI from stent thrombosis
Type 5 – MI from CABG
ACS risk factors?
Unmodifiable
- Older age, male, FHx
Modifiable
- Smoking, DM, HTN, hypercholesterolaemia, obesity
ABCDEF
- Age, BP, cholesterol, diabetes, exercise, fags / fat / family
ACS Px?
- > 20mins sx
- chest pain - central/left side, may radiate to jaw/L arm, heavy, like dyspepsia
- silent MI - diabetics/elderly
- palpitations, SOB, sweaty, clammy, pale, faint
- N+V
- HF sx
- tachycardia, hypotensive
ACS Ix?
Bloods
- FBC, U/E, LFTs, lipids, glucose
Serial troponins - I/T - take at px, 3hrs, 6hrs
12 lead ECG
Coronary angiography if high risk for CV event mortality
stemi ecg findings?
- ST elevation, tall/hyperacute T waves, new LBBB
- pathological Q waves after >6hrs
- long term - ST normal/depressed, T wave inversion, Q waves persist
- inf MI - PR prolongation (RCA -> AVN)
NSTEMI ECG findings?
- ST depression, T wave flattening / inversion
- normal ECG
unstable angina ECG findings?
- normal
ECG coronary territories?
Anterior – V1-4 – LAD
Inferior – II, III, aVF – RCA (LCx in minority of pts)
Lateral – I, V5-6 – LCx
Posterior – horizontal ST depression in V1-3, STEMI V7-9 – RCA / LCx
ACS general Mx?
- morphine
- O2
- nitrates - sublingual GTN
- aspirin 300mg
- insulin infusion to keep BM<11
- cardiac rehab
- stop smoking, drink less, healthy eating, regular exercise, lose weight
STEMI Mx?
ABCDE
Analgesia
Nitrates
Aspirin 300mg
Primary PCI - if <12hrs since sx onset and possible in <2 hours
- Prasugrel/Ticagrelor 180mg / Clopidogrel 300mg
Thrombolysis if available - alteplase / streptokinase / tenecteplase
- + give antithrombin - heparin/fondaparinux
CABG
- consider if multivessel coronary artery disease…
NSTEMI / unstable angina diagnostic criteria?
NSTEMI
- raised trop, may have normal ECG / ST depression / T wave inversion
Unstable angina
- sx of ACS, normal trop, normal ECG / ST depression / T wave inversion
NSTEM / unstable angina Mx?
B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)
GRACE risk assessment
>3% (intermediate, high, highest) - is high risk
Coronary angiography +/- PCI - for the following:
- immediate - hypotensive
- <72hrs - GRACE >3%
- sx of ischaemia after admission
PCI - give:
- heparin
- DAPT
Conservative
- DAPT
ACS secondary prevention medication?
- Aspirin 75mg once daily indefinitely
- Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
- Atorvastatin 80mg once daily
- ACE inhibitors (e.g. ramipril) titrated as high as tolerated
- Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
ACS complications?
D: Death
A: Arrhythmia
R: Rupture of the heart septum or papillary muscles
T: Tamponade
H: Heart failure
V: Valve disease
E: Embolism
D: Dressler’s syndrome
A: Aneurysm
R: Recurrence or mitral regurgitation
what is Dressler’s syndrome?
2-6wks - autoimmune reaction - fever, pleuritic pain, pericardial effusion, raised ESR/CRP, tx with NSAIDs/steroids
stable angina?
- chest pain caused by insufficient blood supply to myocardium
- cause by atherosclerosis
- demand for O2 greater than supply
- stable - pain on exertion, relieved by rest/GTN
- unstable - angina of increasing frequency/severity, present at rest
angina presentation?
All 3 core features – typical angina, 2 features – atypical, 0-1 – non-anginal chest pain
Core features
- constricting, heavy chest pain, radiation to jaw/neck/L arm
- Sx on exertion
- relieved by rest <5mins/GTN
- sweaty, clammy, SOB, N+V, faint
angina investigations?
- ECG
- BP
- Bloods - FBC, U/E, LFTs, lipids, TFTs, HbA1c, fasting glucose
[ cardiac stress testing
- CT coronary angiography
- invasive coronary angiography]
angina management?
- refer to cardio - rapid access chest pain clinic
- stop smoking, eat healthily, exercise, healthy weight, limit alcohol
Short-term
- sublingual GTN - 1 to 2 puffs and repeat after 5 mins
Long-term
- BB - bisoprolol
- CCB - diltiazem / verapamil (amlodipine if adding to BB)
Secondary prevention
- aspirin 75mg OD
- atorvastatin 80mg OD
- ACEi
- BB
Secondary care
- isosorbide mononitrate
- ivabradine (HCN channel blocker, slows HR)
- nicorandil
- ranolazine
persistant Sx? Surgical
- PCI - angioplasty + stent
- CABG
admit if - pain at rest / minimal exertion
acute pericarditis?
- inflammation of pericardial sac <4-6wks
- may lead to effusion/tamponade
acute pericarditis risk factors?
- Idiopathic (no underlying cause)
- Infection (e.g., TB, HIV, coxsackievirus, EBV)
- Autoimmune and inflammatory conditions (e.g., SLE & RA)
- Injury to the pericardium (e.g., after myocardial infarction, open heart surgery or trauma)
- Uraemia (raised urea) secondary to renal impairment
- Cancer
- Medications (e.g., methotrexate)
acute pericarditis presentation?
KEY Sx = chest pain + low grade fever
Chest pain is:
* Sharp
* Central/anterior
* Worse with inspiration (pleuritic)
* Worse on lying down
* Better on sitting forward
- pericardial rub on ausc
acute pericarditis investigations?
- ECG - diffuse saddle-shaped ST elevation, PR depression
- ECHO - effusion
- Bloods - FBC, raised CRP/ESR, trops
acute pericarditis management?
- can tx as OP
1. tx cause - no strenuous activity until resolution
2. NSAIDS or aspirin + gastroprotection
3. Colchicine - may need prednisolone
- pericardiocentesis if indicated
constrictive pericarditis?
- pericardium becomes rigid
- fibrosis, calcified, impairs diastolic filling of heart
- eg post-pericarditis, viral, TB, idiopathic
constrictive pericarditis presentation?
- SOB
- RHF - elevated JVP, ascites, oedema, hepatomegaly
- pericardial knock - loud S3
- Kussmaul’s sign - rise in JVP on insp
constrictive pericarditis Ix?
- CXR - pericardial calcification
- ECG - low voltage QRS
- ECHO - thickened pericardium, small ventricles
- CT / MRI
constrictive pericarditis Mx?
pericardiectomy
pericardial effusion?
- fluid in pericardial sac
cardiac tamponade?
- life threatening pericardial effusion that constricts heart, drops CO
causes of pericardial effusion?
- any cause of pericarditis
- myocardial rupture, aortic dissection, trauma, TB, malignancy
- post-cardiac surgery, central line insertion
pericardial effusion Px?
- muffled heart sounds
- apex beat obscured
- JVP raised
- Ewart’s sign - bronchial breathing at left base (compressed LL lobe)
- SOB, chest pain, nausea, tachycardia
cardiac tamponade Px?
Beck’s
- low BP
- muffled HSs
- raised JVP
- Kussmaul’s sign - rise in JVP with inspiration
- Pulsus paradoxus - >10mmHG reduction in BP with inspiratio
pericardial effusion Ix?
- CXR - large globular heart
- ECG - low voltage QRS, sinus tachy, electrical alternans
- ECHO
Mx of pericardial effusion?
Effusion
- spontaneously resolve
- pericardial fenestration
- pericardiocentesis - can be diagnostic or therapeutic
Mx of tamponade?
ABCDE
- pericardiocentesis
- cardiac surgery - midline sternotomy / thoracotomy
myocarditis definition and causes?
- inflammation of myocardium
Causes - Viral – coxsackie B, HIV
- Bacteria – diphtheria, clostridia
- Lyme disease, Chagas, toxoplasmosis
- Autoimmune
- Drugs – doxorubicin
myocarditis Px?
- acute onset
- chest pain
- SOB
- arrhythmias, palpitations
- faint, dizzy
- recent flu-like sx
myocarditis Ix?
- bloods - raised CRP/ESR / trops / BNP
- ECG - non specific abnormalities: tachycardia, arrhythmias, ST elevation, T wave inversion, other S/T changes
- CXR
- ECHO - to rule out valve dysfunction and dilated cardiomyopathies
myocarditis Mx?
- tx cause, eg abx
- supportive tx - of HF / arrhythmias
- avoid exercise until recovered
infective endocarditis?
- infection of endocardium, most commonly heart valves
- mitral mostly, tricuspid in IVDU
- valves have no direct blood supply
- septic emboli / immune complexes thrown off
IE causes?
- S aureus - most common
- Strep - viridans - mouth/dental
- Staph epidermidis - indwelling lines
- Strep bovis - colorectal cancer
- enterococcus
- pseudomonas, HACEK, fungi
- SLE, malignancy, CKD, malnutrition
IE risk factors?
Normal valves:
- IVDU
- skin breeches e.g. recent piercing
- immunosuppression
- DM
- CKD
Abnormal valves:
- Rheumatic fever
- structural heart pathology - eg valvular disease, HOCM
- prosthetic heart valves
- PDA
IE Px?
- fever, fatigue, night sweats, myalgia, anorexia
- new/changing murmur
- aortic root abscess -> long PR / AV block
- splinter haemorrhages
- petechiae
- Osler’s nodes
- Roth spots
- AKI / glomerulonephritis
- Janeway lesions
- Organ abscesses
- splenomegaly / finger clubbing
IE Ix?
- Bloods - FBC, U/E, CRP, cultures (3 sets from 3 sites at 3 different times >6hrs)
- urinalysis - haematuria
- ECHO - TOE more accurate
- ECG - ?HB
- CXR
- CT - for emboli
IE modified Duke’s criteria - to Dx?
Dx requires either
- 1 major + 3 minor
- 5 minor
Major criteria
- Positive blood cultures on 2+ samples
- Specific imaging findings – eg vegetation on ECHO
Minor criteria
- Predisposition – eg IVDU, valve pathology
- Fever >38
- Vascular phenomena – splenic infarct, intracranial haemorrhage, Janeway lesions, petechiae, splinter haemorrhages
- Immunological phenomena – Ostler’s nodes, Roth spots, glomerulonephritis
- Microbiological phenomena – eg positive cultures 1x
IE Mx?
IV abx for 4-6 weeks:
native valve: amoxicillin + gentamicin
NB if pen allergic give vancomycin
prosthetic valve: vancomycin + rifampicin + gentamicin
Surgery to repair valve if:
- severe valvular incompetence, resistant to tx, abscesses
chronic heart failure definition and pathophysiology?
- heart unable to pump enough blood to meet metabolic demands of the body
- cor pulmonale - right heart enlargement - from disease of lungs/pulmonary vessels
- also RAAS activation and salt/fluid retentio
key causes of HF?
IHD, valvular heart disease (AS), HTN, arrhythmias, cardiomyopathy
what causes left or right ventricular failure HF?
left ventricular failure: caused by IHD, MI
right ventricular failure: chronic lung disease, pulmonary stenosis, LVF
HF Px?
Breathlessness - worsened by exertion
Cough - produce frothy white/pink sputum
Orthopnoea - breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use)
Paroxysmal nocturnal dyspnoea
Peripheral oedema
Fatigue
LVF: dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, low exercise tolerance
RVF: peripheral oedema
HF patho in terms of ejection fraction and cardiac output ?
HF-rEF - inability of ventricle to contract normally - reduced CO, EF<40% - systolic dysfunction
- IHD, MI, dilated cardiomyopathy, arrhythmias, myocarditis, AS
HF-pEF - inability of ventricle to relax + fill normally, SV decreased, EF>50% - diastolic dysfunction
- HOCM, restrictive cardiomyopathy, tamponade, constrictive pericarditis
High-output HF - increased metabolic demands of body
- anaemia, AV malformation, Paget’s disease of bone, pregnancy, thyrotoxicosis
Low-output HF - CO reduced, fails to increase normally with exertion
HF signs on examination?
Tachycardia
Tachypnoea
Hypertension
Murmurs - valvular heart disease
3rd heart sound
Bilateral basal crackles (sounding “wet”) - indicating pulmonary oedema
Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck
Peripheral oedema of the ankles, legs and sacrum
HF Ix?
- CXR
- ECG
- ECHO
- Bloods: BNP, U&Es, LFTs, fbCC, TFTs
BNP 400-2000 = echo in 6 weeks
BNP >2000 = echo in 2 weeks
HF CXR findings?
Alveolar oedema – ‘bat’s wing shadowing’
Kerley B lines – interstitial oedema
Cardiomegaly – cardiothoracic ratio >50%
Dilated prominent upper lobe veins (upper lobe diversion)
Pleural Effusions
New York Heart Association (NYHA) HF classification?
Class I – no symptoms on ordinary physical activity
Class II – mild sx, slight limitation of physical activity
Class III – moderate sx, comfortable at rest but less than ordinary activity leads to sx
Class IV – severe sx, inability to carry out any activity without s
HF Mx - all patients?
R – Refer to cardiology
A – Advise them about the condition
M – Medical treatment
P – Procedural or surgical interventions
S – Specialist heart failure MDT input e.g. heart failure specialist nurses, for advice and support
Medical 1st line:
A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated
B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated
L – Loop diuretics (e.g., furosemide or bumetanide)
Medical 2nd line:
A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone)
HF-pEF Mx
- manage comorbidities
- tx cause
HF-rEF Mx
1st line
- ACEi (ramipril) + BB (bisoprolol)
- ARB (candesartan) if not tolerating ACEi
- hydralazine + nitrate if intolerant of ACEi/ARB
- add MRA (spironolactone/eplerenone) if sx continue
- check U/E (before/after each drug + dose change)
Specialist mx if sx continue
- replace ACEi/ARB with sacubitril valsartan if EF<35%
- add ivabradine if sinus rhythm >75, EF<35%
- add hydralazine + nitrate, esp if Afro-Caribbean
- digoxin
- SGLT2 inhibitor - dapagliflozin
- amiodarone
Specialist procedures
- cardiac resynchronisation therapy (CRT) - triple chamber pacemaker
- implantable cardioverter defibrillator (ICD)
- heart transplant
HF complications?
- arrhythmias, depression, cachexia, CKD, sexual dysfunction, sudden cardiac death, VTE, hepatic dysfunction
acute HF / acute pulmonary oedema pathology?
- acute deterioration in cardiac function
- LVF -> CO reduced, backlog of blood, excess fluid leaks -> pulm oedema - lung/alveoli filled with interstitial fluid - impaired gas exchange
De-novo AHF - AHF w/o hx of HF - eg ischaemia, viral, toxins, valvular
causes of AHF / pulmonary oedema?
Cardiac
- acute LVF, ACS, arrhythmias, valvular heart disease, HTN, cardiomyopathy, tamponade
Non-cardiac
- fluid overload, high-output HF, ARDS, RAS
Triggers
- preload increase - eg IV fluids, retention
- contractility decrease - ischaemia, infarction, arrhythmias, valvular, cardiomyopathy
- afterload increase - HTN
- direct lung damage
AHF Px?
- acutely SOB
- cough - frothy white / pink sputum
- hypoxia, cyanosis, increased RR/HR
- bibasal creps on ausc
- peripheral oedema
- fatigue, raised JVP
- 3rd HS
- chest pain, fever, palpitations (depends on cause)
- BP normal / increased
AHF Ix?
- A-E
- ECG
- Bloods - FBC, U/E, BNP, ?trop, ABG, Mg, Ca, TFTs
- CXR
- ECHO
AHF Mx?
S – Sit up
O – Oxygen (15L)
D – Diuretics (IV furosemide 40mg)
I – Intravenous fluids should be stopped
U – Underlying causes need to be identified and treated (e.g., myocardial infarction)
M – Monitor fluid balance
- IV morphine 2.5-10mg
- IV GTN 1mg/ml at 2ml/hr - if BP not low
- cardiogenic shock - dobutamine (inotrope) / noradrenaline (vasopressor)
- CPAP
- intubate
- continue regular HF meds
HTN?
- high BP
- clinic reading >140/90, 24hr BP avg >135/85
HTN causes?
Primary / essential HTN
- 90%, no cause
Secondary
- Renal - glomerulonephritis, chronic pyelo, PKD, RAS
- Endocrine - hyperaldosteronism, phaeo, Cushing’s, Liddle’s, CAH, acromegaly
- other - glucocorticoids, NSAIDs, pregnancy, coarctation of aorta, cOCP
[ROPED]
HTN RFx?
- older, ethnicity, FHx, overweight, sedentary, smoking, alcohol, diabetes, stress
HTN Px?
- asym
- headaches
- visual disturbance
- seizures
HTN Ix?
- BP monitoring - clinic / 24hr ABPM / home BP monitoring
- Stage 1 - >140/90 / >135/85 at home
- Stage 2 - >160/100 / >150/95 at home
- Stage 3 - >180/120
- BP both arms
- urine albumin:creatinine ratio
- urine dipstick
- Bloods - HbA1c, U/E, lipids
- fundoscopy
- ECG
- QRISK
HTN general Mx?
- healthy diet, stop smoking, reduce alcohol, lower caffeine/salt, exercise
- <40yo, ?refer to r/o secondary causes
BP targets
<80yo - <140/90 in clinic, <135/85 at home
>80yo - <150/90 in clinic, <145/85 at home
- if stage 1 - tx if <80yo AND organ damage / CV disease / renal disease / DM / QRISK>10%
- stage 2 - drug tx regardless of age
- stage 3 - same day assessment for retinal haemorrhage / papilloedema / phaeo / life-threatening sx
HTN Mx algorithm?
Step 1
<55yo / T2DM
- ACEi (ramipril)
- if T2DM Afro-Caribbean - ARB (candesartan)
- change to ARB if ACEi not tolerated
> 55yo / Afro-Caribbean
- CCB (amlodipine)
Step 2
- if on ACEi/ARB - add CCB / thiazide-like (indapamide)
- if on CCB - add ACEi/ARB / thiazide-like (ARB in Afro-Caribbean)
Step 3
- add the 3rd drug left
Step 4
- K<4.5 - low dose spironolactone
- K>4.5 - add alpha/beta blocker
- specialist review if still not controlled
HTN complications?
- IHD, CVA, PAD, aortic dissection, AAA, atherosclerosis
- hypertensive retinopathy
- hypertensive nephropathy
- LVH
- HF
- malignant HTN / hypertensive emergency
hypertensive emergency?
Hypertensive urgency – severe hypertension with no evidence of acute end organ damage
Hypertensive emergency – severe hypertension with evidence of acute end organ damage
Malignant/accelerated hypertension – a hypertensive emergency involving retinal vascular damage
hypertensive emergency Px?
- headache, visual disturbance, N+V, confusion, seizures, coma, drowsy
- ischaemic chest pain, SOB, bibasal creps, raised JVP
- focal neurology
- tearing chest pain…
hypertensive emergency Ix?
- CT head
- fundoscopy
- ECG, urinalysis, U/E, CXR
- Ix for secondary causes
hypertensive emergency Mx?
- A-E
- IV Sodium nitroprusside
- IV labetalol
- IV GTN, nicardipine
- If asymptomatic - start chronic HTN mx
discuss broad complex tachycardia
- QRS >120ms / 3 small squares
VT
- broad complex tachycardia originating from ventricles
- monomorphic / polymorphic / Torsades de pointes (…long QT)
- ALS guidelines to mx - synchronised DC cardioversion / IV amiodarone
- Mg for Torsades de pointes
AF with BBB
- tx as AF
SVT with BBB
- tx as SVT
VF
- cardiac arrest rhythm
discuss narrow complex tachycardia?
- high HR with QRS <120ms
Sinus tachycardia
- normal PQRST pattern
- tx cause
AF
- technically an SVT
AFl
- technically an SVT
SVT
- tachycardia that originates from above the ventricles
SVT
- tachycardia that originates from above the ventricles
- signal re-enters atria from ventricles, then goes through AVN to ventricles - loop
Paroxysmal SVT: SVT reoccurs / remits
AVNRT: re-entry point through AVN
AVRT: re-entry point is accessory pathway - eg WPW
Atrial tachycardia: signal from atria somewhere other than SAN
Junctional tachycardia: impulse from AVN/junction - ECG narrow QRS, absent/inverted P waves
WPW syndrome ?
- congenital accessory pathway (bundles of Kent) between atria / ventricles - AVRT
- L/R sided
- pathway causes abnormal early depolarisation
- if SAN delivers premature beat, signal travels down septum then back up accessory pathway - re-entry circuit - tachyarrhythmia
Associations
- HOCM, mitral valve prolapse, Ebstein’s, thyrotoxicosis, secundum ASD
ECG
- Short PR
- Wide QRS, slurred upstroke - delta wave
- LAD if R sided pathway
- RAD if L sided pathway
SVT Px?
- chest pain, palpitations, sweaty/clammy, faint, dizzy, HF
SVT Mx?
- ALS guidelines
- synchronised DC cardioversion if unstable
- modified valsalva
- IV adenosine
- BBs / verapamil
- long-term - BB / CCB / amiodarone
- radiofrequency ablation
- WPW + AF/AFl - use procainamide / electrical cardioversion
AF
- Disorganised electrical activity of atria leading to fibrillation and irregularly irregular ventricular contraction
- type of SVT
- blood can stagnate in atrial appendage - stroke risk
- HF from impaired diastolic filling of ventricles
- may go into AF wRVR - tachycardic ventricular rate
AF causes?
- idiopathic
- atrial damage - fibrosis
- HTN
- HF
- coronary artery disease, IHD
- valvular heart disease - eg mitral stenosis
- cardiomyopathy
- rheumatic heart disease
- alcohol, caffeine
- thyrotoxicosis
- infection
- anaemia
types of AF?
- first detected episode
- recurrent - 2+ episodes
- paroxysmal AF - terminates spontaneously, <7d, typically <24hrs
- persistent AF - not self-terminating - >7d
- permanent AF - continuous AF - rate control/anticoagulation goals
AF Px?
- Palpitations
- SOB
- Chest pain
- Syncope, dizziness
- Sx of associated condition, eg infection, stroke
- Irregularly irregular pulse
AF Ix?
- Bloods - FBC, U/E, TFTs, LFTs, coag, Mg, Ca
- ECG - absent P waves, irregularly irregular QRS, absence of isoelectric baseline, may be tachycardic
- CXR
- ECHO
- 24hr ambulatory ECG (Holter) / cardiac event recorder - for paroxysmal AF
- CHA2DSVASc / ORBIT
overview of AF Mx?
Unstable
- synchronised DC cardioversion
<48hrs of sx onset
- rate / rhythm control
> 48hrs of sx onset / uncertain of onset
- rate control
- if ?long-term rhythm control - delay cardioversion until >3wks anticoagulation
Catheter ablation
- if no response to antiarrhythmics
LAA occlusion
- anticoagulate first
- may insert catheter, place plug into LAA
AF rate control use and options?
Offer as first line apart from:
- AF has reversible cause
- HF primarily caused by AF
- new onset <48hrs
- AFl suitable for ablation
- clinical judgement that rhythm control better
- BB - bisoprolol / metoprolol
- CCB - diltiazem (not in HF)
- digoxin - eg if pt does no exercise
AF rhythm control options?
Offer to pts:
- reversible cause for AF
- new onset AF <48hrs
- HF caused by AF
- sx despite rate control
<48hrs onset AF - immediate cardioversion
- heparin
- electrical - synchronised DC shock
- pharm - flecainide / amiodarone
> 48hrs onset AF - delayed cardioversion
- >3wks anticoagulation
- TOE to exclude LA appendage thrombus
- electrical cardioversion
- 4wks amiodarone / sotalol before
- anticoagulate >4wks after
Long term rhythm control
- BBs
- dronedarone
- amiodarone - esp if co-existing HF
paroxysmal AF?
- may use pill-in-the-pocket approach
- flecainide / BB when sx of AF develop
reducing stroke risk in AF?
CHA2DS2-VASc
- risk of stroke with AF
ORBIT
- risk of bleeding
Mx
- DOAC
- warfarin 2nd line
when would you refer AF to cardiology?
- If rhythm control is appropriate
- Rate control fails to control sx - <4wk referral
- Valvular disease, LVF on ECHO
- WPW or prolonged QT
atrial flutter? causes?
- organised abnormal atrial rhythm, atrial rate 300
- re-entry circuit in RA
- thrombus risk
- pulse tends to be 150, 100, 75
- typical - rhythm origin in RA at level of tricuspid valve
- atypical - origin from elsewhere
Causes
- idiopathic, coronary artery disease, HTN, HF, COPD, pericarditis, alcoholism, surgery
atrial flutter Px?
- palpitations, SOB, chest pain, dizzy, syncope, fatigue, HF
atrial flutter Ix?
- ECG - sawtooth baseline, narrow complex tachy, regular QRSs
- Bloods - FBC, U/E, CRP, LFTs, TFTs, Mg, Ca
- CXR
- ECHO
atrial flutter Mx?
- rate / rhythm control
- lower energy levels for cardioversion
- radiofrequency ablation of tricuspid valve isthmus
causes of bradycardia?
- HB
- Meds - BBs
- sick sinus syndrome - conditions which cause dysfunction in SAN -> sinus brady, sinus arrhythmias, prolonged pauses
1st degree HB?
- PR >0.2s (5 small squares)
- delayed conduction at AVN, P wave precedes every QRS
Causes
- low K, myocarditis, inferior MI, IHD, BBs, CCBs, digoxin, rheumatic fever, IE, lyme disease, sarcoidosis
Mx
- normally no tx
- tx cause if needed
2nd degree HB - mobitz type 1
Mobitz T1 (Wenkebach)
- progressive PR prolongation, then P wave with no QRS, cycle restarts
- regularly irregular pulse
Causes - AVN blocking drugs, inferior MI, IHD
Px - light-headed, dizzy, syncope
Mx - maybe pacing / tx cause
2nd degree HB - Mobitz type 2
Mobitz T2
- PR interval constant, absence of QRS at regular intervals
- regularly irregular pulse
Causes - anterior MI, mitral valve surgery, SLE, lyme disease, IHD….
Px - SOB, CP, light-headed etc
Mx - pacemaker, tx cause
3rd degree HB
- complete dissociation between P waves + QRS complexes
Causes
- structural heart disease, IHD, HTN, endocarditis….
Px
- syncope, HF, regular bradycardia, wide pulse pressure, variable S1
Mx
- atropine
- transcutaneous pacing / PPM
BBB
block in lower conduction system
RBBB?
- lack of depolarisation down R branch - signal spreads from LV across septum, RV contraction delayed
Causes
- normal, RVH, cor pulmonale, PE, MI, ASD, IHD…
- splitting of S2 on ausc
ECG
- Broad QRS >120ms
- MARROW
LBBB?
- lack of depolarisation down L branch - impulse spread from RV across septum to LV
Causes
- new LBBB always pathological
- MI - Sgarbossa criteria
- HTN, AS, cardiomyopathy, high K…
- reverse splitting of S2
ECG
- broad QRS >120ms
- WILLIAM
- associated with - LAD, poor R wave progression
Left anterior fascicular block (LAFB)
- Anterior fascicle inserts into upper lateral wall of LV
- Left axis deviation
- qR complexes in I, aVL - positive
- rS complexes in II, III, aVF - negative
- prolonged R wave peak time in aVL >45ms
Left posterior fascicular block (LPFB)
- Posterior fascicle inserts into inferoseptal wall of LV
- Right axis deviation
- rS complexes I, aVL - negative
- qR complexes II, III, aVF - positive
- Prolonged R wave peak time aVF
Bifascicular block
2/3 fascicles are blocked, so conduction is via single remaining fascicle, one of two patterns:
- RBBB + LAFB, manifested as left axis deviation
- RBBB + LPFB, manifested as right axis deviation
Trifascicular block
Conduction delay in all 3 fascicles below AVN (RBBB, LAFB, LPFB)
Manifests as bifascicular block + 3rd degree AV block, one of two patterns:
- 3rd degree AV block + RBBB + LAFB
- 3rd degree AV block + RBBB + LPFB
prolonge QT
- QT interval - from start of QRS to end of T wave
- use QTc - >440ms (men), >460ms (women) is prolonged
- prolonged repolarisation of myocytes - can lead to spontaneous depolarisation of myocytes -> Torsades de pointes, VT, arrest
- Long QT syndrome - inherited condition causing prolonged QT - most commonly defects in K channels
causes of prolonged QT?
ASTHMATIC
- amiodarone
- sotalol, SSRIs
- terfenadine
- haloperidol
- methadone, macrolides
- antiarrhythmics class Ia
- TCAs
- chloroquine
- congenital
- low Ca, low K, low Mg
- acute MI, myocarditis, hypothermia, SAH
Prolonged QT Px
- syncope, palpitations…
- exertional syncope
- sudden cardiac death
Prolonged QT Ix
- ECG - prolonged QTc
- bloods
Prolonged QT Mx
- stop meds causing it
- correct electrolytes
- IV Mg
- BBs
- pacemaker / ICD
ventricular ectopics?
- premature ventricular complexes (PVCs)
- beats originate from ventricular myocardium - wide QRS
- common, healthy
- more common if IHD, HF, HTN, MI etc
- bigeminy / trigeminy / quadrigeminy - every 2nd/3rd/4th beat is PVC
Px
- asym
- cardiac sx
- pulse irregular
Ix
- ECG
- maybe ECHO
Mx
- reassure if healthy, infrequent
- refer if concerning sx
- BBs for sx
Junctional / ventricular escape rhythms
- abnormal heart rhythm with impulses originating from AVN / bundles of His at AV junction
Types
- Junctional bradycardia – <40BPM
- Junctional escape rhythm – 40-60BPM
- Accelerated junctional rhythm – 60-100BPM
- Junctional tachycardia – >100BPM
- ventricular escape rhythm - from ventricles
Causes
- anything that impairs SAN
- sinus brady, sinus arrest, 3rd HB, high K, BBs, CCB, digoxin
Px
- asym / SOB, CP etc
Ix
ECG
- P waves - absent / inverted before/after QRS
- junctional escape - narrow QRS
- ventricular escape - broad QRS
murmur memory aid: murmur, character and systolic or diastolic?
P/ARD - decrescendo
P/ASS - crescendo decrescendo
T/MSD - decrescendo crescendo
T/MRS - pansystolic
what is S2?
- Closing of pulmonary / aortic valves at end of ventricular systole
- Soft (?) in aortic stenosis
- Splitting during inspiration is normal
what is S1?
- Closing of tricuspid / mitral valves at start of ventricular systole
- Loud in mitral stenosis
what is S4? what causes it?
- Just before S1, atria contract and force blood against stiff / hypertrophic ventricle – sound is blood hitting ventricle wall
- Always pathological
- Heard in aortic stenosis, HOCM, HTN
what is S3?
- After S2, tensioning of chordae tendineae with rapid ventricular filling at start of diastole - ‘guitar twang’
- Can be normal in young people
- Can indicate HF – ventricles / chordae are stiff / weak
- Heard in LVF, mitral regurg
aortic stenosis: cardiac cycle, character, breathing, location, radiation?
- systolic
- ejection systolic
- expiration
- 2nd intercostal space, right sternal edge
- radiate to carotid
pulmonary stenosis: cardiac cycle, character, breathing, location, radiation?
- systolic
- ejection systolic
- inspiration
- 2nd intercostal space, left sternal edge
- left shoulder / infraclavicular
mitral regurgitation: cardiac cycle, character, breathing, location, radiation?
- systolic
- pan systolic
- expiration
- apex
- axilla
tricuspid regurgitation: cardiac cycle, character, breathing, location?
- systolic
- pansystolic
- inspiration
- left sternal edge
aortic regurgitation: cardiac cycle, character, breathing, location?
- early diastolic
- decrescendo
- expiration
- left sternal edge or 2nd intercostal space right sternal edge)
pulmonary regurgitation: cardiac cycle, character, breathing, location?
- early diastolic
- decrescendo
- inspiration
- 2nd intercostal space left sternal edge
mitral stenosis?
- Mid/late diastolic
- Expiration
- apex
aortic stenosis?
- narrowing of aortic valve
- calcification / congenital bicuspid valve
- reduced valve SA, increased afterload, LVH, LVF
which murmur radiates to carotid?
aortic stenosis
which murmur radiates to axilla?
mitral regurgitation
aortic stenosis px?
- angina
- syncope
- HF
- SOB
- dizziness
- sx worse on exertion
- ejection systolic crescendo-decrescendo murmur - radiates to carotids
- slow rising pulse, decreased pulse amplitude, narrow pulse pressure
- thrill
aortic stenosis Ix? (same for all other valve diseases too)
- ECHO
- ECG
- CXR
aortic stenosis Mx?
- aortic valve replacement - surgical / TAVI
- balloon valvuloplasty
mitral regurgitation - definition and causes?
- blood leaks back through incompetent mitral valve during systole
- EF / SV reduced, LA enlargement, LVH, progressive heart failure
Causes
- mitral valve prolapse
- coronary artery disease / post MI
- IE
- rheumatic fever
- congenital
- EDS / Marfan’s
mitral regurgitation Px?
- SOBOE, fatigue
- palpitations
- signs of HF / pulm oedema
- pansystolic murmur - radiates to axilla
- thrill
mitral regurgitation Mx?
- drugs to increase CO in acute cases - nitrates, diuretics, inotropes, aortic balloon pump
- HF - ACEi, BBs, spironolactone
- surgery - repair/replacement - when sx / EF<60%
aortic regurgitation - definition and causes?
- incompetent aortic valve - blood leaks back into ventricle from aorta during diastole
- increased preload, LV dilatation / hypertrophy -> LVF
Causes
- rheumatic fever, calcification, RA/SLE, bicuspid aortic valve, IE
- ankylosing spondylitis, HTN, syphilis, Marfans, EDS, dissection
aortic regurgitation Px?
- HF / pulm oedema sx
- collapsing pulse
- wide pulse pressure
- early diastolic murmur
- Quincke’s sign - nailbed pulsation
- De Musset’s sign - head bobbing
aortic regurgitation Mx?
- medical mx of HF
- aortic valve replacement - if sx / LV systolic dysfunction
mitral stenosis?
- narrow mitral valve, restricting blood flow from LA -> LV
- increased pressure in LA, pulmonary vessels, R heart
- rheumatic fever, IE
mitral stenosis Px?
- SOBOE, oedema, angina etc
- haemoptysis
- mid-diastolic murmur, loud S1, opening snap after S2
- malar flush
mitral stenosis Mx?
- balloon valvuloplasty
- mitral valve replacement
discuss prosthetic heart valves?
Biological
- cow/pig
- deteriorate over time - replace in 10yrs
- warfarin for first 3mo then aspirin
Mechanical
- last longer
- life-long warfarin
- metallic click on ausc
Cx
- thrombus, IE, haemolytic anaemia
types of cardiomyopathy?
- disorders of the heart muscle
Primary - predominantly involving heart
Genetic:
- HOCM
- ARVD/C
Mixed:
- dilated cardiomyopathy
- restrictive
Acquired:
- peripartum
- Takotsubo
Secondary - pathological myocardial involvement due to systemic disorder
- eg coxsackie B, amyloidosis, HHC, alcohol, sarcoidosis, DM, thyrotoxicosis, acromegaly, DMD, thiamine, SLE
Hypertrophic obstructive cardiomyopathy (HOCM)
- autosomal dominant thickening/hypertrophy of LV
- LV outflow blocked, thick wall poorly compliant, poor diastolic filling, reduced CO
- increased arrhythmia/HF/MI risk
HOCM Px
- asym
- SOBOE
- angina, syncope, dizziness, palpitations
- HF sx
- sudden death
- jerky carotid puls
HOCM Ix
- ECG - LVH
- ECHO
- CXR
- cardiac MRI
- genetic testing
HOCM Mx
- BBs / verapamil
- amiodarone
- ICD
- surgical myomectomy
- alcohol septal ablation
- heart transplant
- avoid intense exercise, heavy lifting, dehydration
- avoid - ACEi, nitrates, inotropes
Arrhythmogenic right ventricular dysplasia / cardiomyopathy (ARVD/C)
- autosomal dominant - progressive fatty/fibrous replacement of ventricular myocardium
- arrhythmia risk
ARVD Px
- palpitations
- syncope
- sudden death
ARVD Ix
- ECG
- ECHO
- MRI
- genetic testing
ARVD Mx
- BB, amiodarone
- catheter ablation
- ICD
- heart transplant
Dilated cardiomyopathy - definitions and causes?
- thinning / dilatation of heart muscle
- genetic / secondary
- poorly contracts - systolic dysfunction
Causes
- idiopathic, myocarditis, IHD, peripartum, HTN, drugs, DMD, HHC, sarcoidosis….
Dilated cardiomyopathy Px
- HF sx
- systolic murmur
- S3
Dilated cardiomyopathy Ix
- CXR - balloon appearance of heart
- ECHO
- ECG
Dilated cardiomyopathy Mx
- medical mx of HF
Restrictive cardiomyopathy
- heart becomes rigid / stiff -> impaired ventricular filling during diastole
- genetic / secondary causes
- amyloidosis, sarcoidosis, post-radiotherapy…
Restrictive cardiomyopathy Px
- raised JVP, hepatomegaly, oedema, SOB, fatigue
Restrictive cardiomyopathy Ix
- CXR, ECHO, ECG
- cardiac catheterisation / MRI / heart imaging etc
Restrictive cardiomyopathy Mx
- poor prognosis
- heart transplant
- HF mx
Peripartum cardiomyopathy
- weakness of heart muscle that develops between last month pregnancy + 5mo post-partum
- more common older, higher G/P
- causes HF
Alcohol-induced cardiomyopathy
- type of dilated cardiomyopathy caused by long-term alcohol use
Takotsubo cardiomyopathy
- Stress-induced cardiomyopathy - rapid onset of LV dysfunction / weakness
- Broken heart syndrome
- Chest pain, HF sx
- Transient apical ballooning of myocardium
- Supportive tx, sx resolve with time
discuss pacemakers - very long care!
- Pulse generator + pacing leads – carry electrical impulses to heart to improve function
Indications
- Bradycardia with sx
- Mobitz T2
- 3rd degree block
- AVN ablation for AF
- Severe HF – biventricular pacemakers
Single chamber
- RA/RV
Dual chamber
- both RA/RV
Biventricular (triple chamber) pacemaker
- RA,RV,LV
- CRT
ICDs
- shock if VF/VT
ECG changes
- sharp vertical line
Indications for temporary pacemaker
- sx/unstable bradycardia, unresponsive to atropine
- post-anterior MI
- trifascicular block prior to surgery
atrial myxoma
- most common primary cardiac tumour
- 75% in LA, attached to fossa ovalis
Px - SOB, fatigue, wt loss, fever, clubbing
- emboli
- AF
- mid-diastolic murmur
Ix - ECHO - pedunculated heterogenous mass
Mx - surgical removal by median sternotomy
Brugada syndrome
- autosomal dominant condition causing arrhythmia - can cause tachycardia
Px - dizzy, syncope, SOB, palpitations
Ix
ECG - Downward sloping ST segment, inverted T wave, incomplete RBBB – in V1-3
- Changes more apparent after flecainide
Mx - ICD
shock definition
Circulatory failure leading to inadequate organ perfusion and tissue hypoxia
causes of shock?
Hypovolaemic
Cardiogenic
Obstructive
Distributive - reduced SVR
- Septic shock
- Anaphylactic shock
- Neurogenic shoc
hypovolaemic shock?
- shock due to low BV
- haemorrhage, D+V, burns, diuresis
hypovolaemic shock Px?
- Reduced GCS, agitation, confusion
- Skin pale, cold, sweaty, vasoconstricted
- Cool peripheries
- Tachycardia
- Tachypnoea
- Oliguria - reduced urine output
- Increased cap refill time (CRT)
- Weak, rapid pulse
- Reduced pulse pressure
hypovolaemic shock Ix?
- A-E
- bloods
- Ix for cause - CXR, ECG, ECHO, CT, FAST
hypovolaemic shock Mx?
- IV fluids
- blood - MHP etc
- tx cause
cardiogenic shock ? causes, Px, Ix and Mx
- shock due to cardiac dysfunction / failure of the pump action of heart
Causes
- MI, myocardial contusion, myocarditis, cardiac arrhythmias, BBs, CCBs
Px
- signs of heart disease
- signs of shock
Ix
- for cause
- ECG / ECHO
Mx
- tx caus
neurogenic shock?
- spinal cord injury above T6 - loss of sympathetic outflow, decreased SVR, decreased preload/CO
Px
- Instant hypotension
- Warm, flushed peripheries
- Priapism
- Bradycardia
- Flaccid paralysis, loss of reflexes
- Loss of bladder / bowel control
Mx
- IV fluids
- adrenaline infusion
obstructive shock?
- shock due to obstruction of cardiac output
- tension PTX, massive PE, cardiac tamponade
Mx
- tx cause
sepsis?
- body launches large immune response to infection, causing systemic inflammation + organ dysfunction
- cytokine/interleukin/TNF release -> systemic inflammation, release of vasodilators
- SOFA score to assess severity of organ dysfunction
sepsis RFx?
- <1yo / >75yo
- Chronic conditions
- Chemo, immunosuppressants, steroids
- Surgery, recent trauma, burns
- Pregnancy, childbirth
- Indwelling devices - catheters, central lines
sepsis Px?
- sx of infection source - cough, SOB, dysuria, N+V, abdo pain, cellulitis….
- reduced UO
- mottled skin, cyanosis
- warm peripheries, clammy skin
- bounding pulse
- confusion, drowsy, off legs
- high HR/RR/temp, low BP,
sepsis Ix?
- A-E, obs
- Bloods - FBC, U/E, LFTs, CRP, BMs, coag, cultures, VBG
- urine dip + culture
- CXR
- ECG
- CT / LP
sepsis Mx?
- O2
- Broad spec abx - eg tazocin / meropenem
- IV fluids
- Catheter + UO
- Blood cultures
- Serum lactate
anaphylaxis?
- severe life-threatening T1 hypersensitivity reaction
- allergen reacts with IgE ABs on mast cells/basophils - rapid histamine release - capillary leakage, mucosal oedema, shock, airway compromise
- anaphylaxis - ABC compromise
anaphylaxis Px?
Hx of exposure to allergen, rapid onset sx
A – swelling of tongue/throat (angioedema) -> hoarse voice + stridor
B – wheeze, SOB, fatigue, cyanosis, low sats
C – hypotension, tachycardia, shock, confusion, reduced consciousness
D – confusion…
E – urticarial rash, pruritis
anaphylaxis Mx?
- IM adrenaline - 500mcg (>12yo), 300mcg (6-12yo), 150mcg (6mo-6yrs), 100-150mcg (<6mo)
- IV fluids
Refractory anaphylaxis
- IV adrenaline infusion
- IV fluids
- consider salbutamol nebs + ipratropium
anaphylaxis Mx post stabilisation?
- Non-sedating oral antihistamine (chlorphenamine is sedating)
- Serum mast cell tryptase - measure <6hrs of event - confirm dx
- Refer to specialist allergy clinic
- Prescribe 2 adrenaline auto-injectors
- Beware biphasic reactions (20%)
anaphylaxis approach to discharge
Fast-track discharge (>2hrs of sx resolution)
- Good response to single dose adrenaline
- Complete resolution of sx
- Has epipen, trained on how to use
- Adequate supervision following discharge
> 6hrs sx resolution
- 2 doses IM adrenaline needed
- Or previous biphasic reaction
> 12hrs after sx resolution
- Severe reaction requiring 2 doses IM adrenaline
- Severe asthma
- Possibility of ongoing reaction (eg slow release medication)
- Pt presents late at night
- Patient in area where access to emergency care difficult
