Cardiology Flashcards
Causes of bradycardia?
Sick sinus syndrome
Hypothyroidism
Cushing reflex
Medications
BBB
Anterior/ inferior MI
What is sick sinus syndrome?
Degenerative sclerosis of conductive system needing pacemaker
What are the adverse signs of bradycardia?
Shock
Syncope
Heart Failure
Myocardial Ischaemia
Management of bradycardia with adverse features?
Atropine 500mcg IV every 3-5 mins up to 3mg
How does atropine work?
Inputs vagal input
Next steps is atropine 3mg doesnt work in bradycardia with adverse features?
Transcutaneous pacing
Adrenaline 2-10 mcg IV
Isoprenaline 5mcg IV
Transvenous pacing
How does transcutaneous pacing work?
Defib and sedation with electrical capture (QRS) and mechanical capture (pulse)
Bradycardias with risk of asystole?
Mobitz Type 2
Complete heart block
Previous asystole
Ventricular pause >3s
Treatment of bradycardia with risk of asystole?
Atropine 500mcg IV every 3-5 mins til 3mg
Reversal agent in BB/CCB overdose?
Glucagon
Causes of heart block (AV block)?
Idiopathic sclerosis
High vagal tone athletes
Inferior MI
Hyperkalaemia
SLE
Drugs
First degree heart block?
PR prolongation but no dropping of QRS. PR >5ss / 200ms
What is Mobitz Type 1 heart block/ Wenckebach?
Prolonging PR interval til one drops
What is Mobtiz type 2 heart block?
Dropping of QRS every 3:1/4:1 often symptomatic and requires pacemaker
What is third degree heart block?
Complete heart block with no association with atria and ventricles. Urgent pacemaker due to risk of asystole and VT.
Clinical signs of complete heart block?
Cannon waves JVP
Variable intensity S1
Wide pulse pressure
Indications for permanent transvenous pacing?
Complete heart block
Mobitz Type 2
Symptomatic Mobitz 1
Symptomatic Sick Sinus Syndrome
Symptomatic asystole pause >3s
Asymptomatic asystolic pause >6s
Permanent brady following MI anterior most common
Cardiac resynchronisation therapy
What is cardiac resynchronisation therapy?
In severe HF (EF <35%) and symptomatic despite 3 months optimal medical management needs biventricular pacemaker.
If pacemaker used as secondary prevention how long should they not drive for?
6 months
SVT vs sinus tachy?
SVT has no P waves and starts suddenly and will continue at this rate without variation til stops
Regular narrow complex tachycardias include?
Sinus tachycardia
Atrial flutter
AVRT
AVNRT
Junctional tachycardia
AVRT caused by?
Accessory pathway e.g., WPW
What is Multifocal atrial tachycardia?
Autonomous atrial cells acting as SAN most commonly in severe COPD
Management of Tachycardia with adverse features (shock, syncope, HF, myocardial ischaemia)?
Synchronised DC cardioversion up to X3
If synchronised DC cardioversion X3 not effective in tachycardia with adverse features?
Amiodarone 300mg IV 10-20 minutes
Then repeat shock
Amiodarone 900mg over 24 hours
Management of regular broad complex tachycardia without adverse features?
Regular:
VT or unknown: Amiodarone 300mg IV over 20-60 mins then 900mg over 24 hours
Known SVT with BBB: treat as narrow complex
Management of irregular broad complex tachycardia without adverse features?
AF with BBB treat as narrow
Pre excited AF consider amiodarone
Management of regular narrow complex tachycardia without adverse features?
Vagal manoeuvres
Adenosine 6mg, 12mg, 18mg with continuous ECG, every 2 minutes
If ineffective ? flutter = BB
Management of irregular narrow complex tachycardia without adverse features?
Likely AF control rate (BB or verapamil, digoxin in HF) and consider anticoagulation
Adenosine is contraindicated in?
Asthma (risk of bronchospasm)
Long QT
Decompensated HF
Give verapamil
How does adenosine act?
Agonist to A1 receptors in AVN causing transient heart block
WPW syndrome types?
A- Bundle of kent on L side (V1-3 initial upward deflection)
B- Bundle of kent on R side
ECG findings of WPW?
Short PR
Delta wave
Broad QRS
Management of WPW?
Conservative
Amiodarone/ Sotalol if paroxysmal SVT
Radiofrequency ablation
Drugs contraindicated in WPW?
Digoxin
Verapamil
Causes of Atrial Fibrillation?
Mitral valve disease
Rheumatic heart disease
Sepsis
Myocarditis
IHD
Thyrotoxicosis
HTN
Dehydration, PE, alcohol, electrolyte disturbance
JVP in AF?
Single waveform (loss of a wave)
Heart sounds in AF?
Variable intensity S1
Pulses in AF?
Apical radial delay
When to rhythm control AF?
Stable and onset <48 hours
With anticoagulation for 3 weeks if >48 hours
If secondary to reversible cause, new HF or new onset.
How to rhythm control AF?
DC cardioversion with sedation
Medications: Flecanide, amiodarone (structural heart disease)
Catheter ablation between pulmonary veins and L atrium
Rate control in AF?
BB (careful of asthma or hypotension)
CCB (diltiazem/ verapamil- not in HF)
Digoxin (use in HF or hypotension)
Dual- BB and digoxin OR CCB and digoxin
How do BB work?
Beta one adrenoreceptor antagonists
How does Flecanide work?
Blocks Na channels prolonging phase 0 depolarisation
How does amiodarone work?
Blocks voltage gated K channels delaying repolarisation
CHA2DS2VASC score- annual stroke risk
Anticoagulate if men = 1 or women = 2
CHF
HTN
Age 75+ 2
DM
Stroke/TIA/VTE 2
Vascular disease
Age 65-74
Female
ORBIT Score- bleeding risk
Sex
Hb 2 points <13 males/<12 females
Age >74
Bleeding hx 2 points
eGFR <60
anti-plt
Choice of anticoagulant in AF?
DOAC
Warfarin
If using warfarin in AF?
5 days LMWH as prothrombotic for first 5 days
Causes of atrial flutter?
Pulmonary disease- OSA, COPD, PE, Pulmonary HTN
IHD
Sepsis
Alcohol
Cardiomyopathy
Thyrotoxicosis
Management of Atrial flutter?
Treat cause
- BB or CCB
- Cardioversion (electrical)
- Ablation if continues to be symptomatic despite rate control
Anticoagulation
Where to ablate in atrial flutter?
Cavotricupsid isthmus
Causes of QT prolongation?
Inherited
Acquired (TIMMES)
Inherited causes of QT prolongation?
Romano-Ward and Jervell
Lange-Nielson Syndrome
Acquired causes of QT prolongation?
TIMMES
Toxins
Ischaemia
Myocarditis
Mitral valve prolapse
Electrolytes
SAH
What toxins can cause QT porlongation?
Clarithromycin
Anti-arrythmics
Anti- psychotics
Tricyclic antidepressants
Investigations for QT prolongation?
ECG
Bloods- electrolytes
ECHO (structural cause)
Management of TdP?
Unstable -> DC cardioversion
Stable -> 2g IV Mg sulphate over 1-2 minutes
Prevent further episodes with ICD
ALS algorithm?
Shockable- shock, adrenaline after 3rd shock 1mg of 1:10,000 and amiodarone 300mg IV. Repeat adrenaline every other round
Non shockable: adrenaline 1mg 1:10,000 then repeat every other round
Hypothermia definition?
<35
Mild: 35-32
Moderate 32-28
Severe <28
ECG in hypothermia?
Osbourne waves (J waves)- positive deflection at J point
Prolonged QRS
ALS in hypothermia?
Signs of life for 1 min
VF persists after 3 shocks delay further shocks til >30
X adrenaline if <30
30-34 degrees adrenaline every 6-10 mins
What is aortic dissection?
Tear in tunica intima leading to false lumen
Risk factors for aortic dissection?
HTN
Marfans
valvular heart disease
Cocaine
Amphetamines
Diagnosis of aortic dissection?
CT angiogram aorta
Stanford Type A aortic dissection?
Ascending aorta -> surgical intervention
Stanford Type B aortic dissection?
Descending aorta -> conservative unless end organ damage
Medical management of aortic dissection?
Cardiac monitoring
BP controlled hypotension IV metoprolol
G+S
Cardiothoracic discussion
S1 heart sound:
Systole
Mitral and tricuspid valves closing
S2 heart sound:
Diastole
Closure of aortic and pulmonary valves. Aortic closes first as higher pressures
Splitting of S2:
More obvious in ASD, PS, LBBB
As pulmonary valve closes later
Narrow splitting of S2:
AS
Pulmonary HTN
No splitting of S2:
Ventricles at equal pressures in VSD, severe pulmonary HTN
4th HS:
LVH
Rigid left ventricle in LVH correlates to atrial contraction/ just after P wave
Systolic murmurs:
Between S1 and S2
AS, PS
TR, MR
Diastolic murmurs:
After S2
AR, PR
TS, MS
L sided murmurs heard loudest on?
Expiration
Aortic
Mitral
R sided murmurs heart loudest on?
Inspiration
Pulmonary
Tricuspid
Pansystolic murmur at left lower sternal edge?
VSD
Continuous machinery murmur in pulmonary area?
PDA
What is a flow murmur?
ejection systolic murmur caused by pregnancy, anaemia, HOCM, supravavular stenosis (Williamms syndrome)
PS murmur?
Ejection systolic murmur
Heard best in pulmonary region
Causes of PS Murmur?
Tetralogy of Fallot
Noonan Syndrome
William syndrome
Rubella
Clinical signs of PS?
R sided HF
- Oedema and ascites
Widley split S2
R ventricular heave
Raised JVP
P pulmonale on ECG (tall P waves)
Management of PS?
If gradient >50
Valvotomy or Balloon angioplasty (supravalvular lesions)
Murmur of aortic stenosis?
Ejection crescendo-decrescendo systolic murmur
Heard best in aortic region
Radiates to carotids
Louder with expiration
Causes of AS?
Age related calcification if >75
<75 bicuspid valve
Symptoms of AS?
L sided HF
- SOB
- Syncope
- Arrythmia
Signs of AS?
LVH
Left axis deviation
Slow rising carotid pulse
Narrow pulse pressure
Soft S2, absent if severe
What is Gallvarian phenomena?
Musical pan systolic murmur at apex, doesnt radiate to axilla as this is high frequency vibrations from the calcified aortic valve
What is Heyde’s Syndrome?
Rare complication of AS leading to coagulopathy as depletion of VWF-2a occurs causing intestinal angiodysplasia and GI blood loss causing IDA
Criteria for severe AS?
Peak gradient >40
Valve area <1
Aortic jet velocity >4
Clinically absent S2
Monitoring of AS?
Severe 6 monthly ECHO
Mild- moderate yearly ECHO
Criteria for surgical intervention in AS?
Symptomatic despite medical management
Asymptomatic LVEF <50
Asymptomatic LVEF >50 but symptoms or fall in BP during exercise testing
Asymptomatic LVEF >50 and:
- aortic peak velocity >5.5
- Severe calcification and peak velocity progression 0.3+
- Markedly raised BNP
- Pulmonary artery systolic >60
Options for surgical intervention of AS?
TAVI - >75’s, co-morbidity or previous surgery
SAVR - <75 and low risk
Mitral Regurgitation murmur?
Pansystolic blowing murmur
Apex loudest
Loudest expiration
CXR sign of mitral regurgitation?
Double heart border due to L atrial enlargement
Acute MR?
Pulmonary oedema and cardiogenic shock due to:
- Ischaemic papillary rupture due to posterior-inferior MI
- Ruptured chordae tendinae (IE, Rheumatic heart disease, trauma)
- Prosthetic valve IE/ thrombus
Chronic MR causes?
IE
SLE
Scleroderma
Marfan’s
Drugs- ergotamine, bromocriptine
Signs of MR?
AF
VTE
IE
HF
P mitrale on ECG bifid P waves
Surgical intervention of MR if symptomatic with?
Valvuloplasty (repair)
Replacement (mechanical long lasting but lifelong anticoag, bioprosthetic limited durability but no anti coag)
Mitral stenosis murmur?
Mid diastolic murmur
Loudest on expiration on L lateral position
Causes of mitral stenosis?
Rheumatic heart disease
Symptoms of mitral stenosis?
When valve area <1.5
fatigue
SOB
Palpitations
Haemoptysis (pulmonary HTN)
Hoarseness
Why do you get hoarseness in mitral stenosis?
Ortner’s syndrome
L atrial enlargement causing compression of recurrent laryngeal nerve
Signs of Mitral Stenosis?
Malar flush
Low volume pulse
Prominent A wave on JVP
Loud S1 and 2
Complications of mitral stenosis?
AF due to L atrial enlargement
Pulmonary HTN
HF
Management if symptomatic of mitral stenosis?
Balloon valvuloplasty
Percutaneous mitral valvotomy
Open repair/ replacement
Mitral stenosis with pulmonary HTN prognosis ?
<3 years
Tricuspid regurgitation murmur?
Pansystolic murmur loudest on inspiration in L parasternal region
Causes of Tricuspsid regurgitation?
Rheumatic heart disease
IE
JVP of tricupsid regurgitation?
Prominent V waves on JVP
What is Ebstein’s anomaly?
Young person with R sided HF due to structurally abnormal tricuspid valve causing TR
Risk factors for IE?
IVDU
Poor dentition
Valvular disease
Congenital heart disease
Prosthetic valves
>60y
HIV
Intravascular devices
IVDU IE more likely?
Staph aureus
Tricuspid involvement
Common organisms of IE?
Strep viridans
Strep bovis
Enterococci
HACEK
Staph aureus coagulase +ve
Coagulase negative staph. epidermis
Non infective causes of IE?
Malignancy
Pancreatic malignancy
Libman-Sacks endocarditis (SLE)
HACEK organisims:
Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella
All culture negative
Common organism in prosethetic valves?
Staph epidermis coagulase negative
Common organism in poor dental hygiene?
Strep viridans
Strep bovis in IE linked to?
Colorectal Ca
Symptoms of IE?
Fever
Night sweats
Weight loss
Myalgia
Signs of IE:
Clubbing
Splenomegaly
New murmur
Bradycardia
Septic emboli
Janeway lesions
Oslers nodes
Roth spots
Why do you get bradycardia in IE?
Aortic root abscess to AVN causing heart block
What are septic emboli in IE?
Stroke
Splenic infarct/ abscess
Osler’s nodes of IE?
Painful lumps to fingers
What are roth spots in IE?
Boat shaped retinal haemorrhages with pale centre
Investigations for IE?
ECG (if PR prolongation ? aortic root abscess)
Urine dip
X3 blood cultures at different times and sites
TTE ECHO
CT CAP septic emboli
Diagnosis of IE by modified dukes criteria mnemonic
BE FIVE PM
2 major
OR
1 major and 3 minor
OR
all 5 minor
Major criteria in modified dukes criteria?
BE
Blood culture X2 typical organisms (viridans, bovis, HACEK, enterococcus) OR 3+ with other.
ECHO TTE signs of vegetation, abscess, new valve regurg
Minor Modified Dukes Criteria:
FIVE PM
Fever >38
Immunological phenomenon
Vascular phenomenon
ECHO minor
Predisposing factors
Micro evidence other
Immunological phenomena in IE?
Roth spots
Splinter haemorrhages
Oslers nodes
Vascular phenomena in IE?
Janeway lesions
Septic emboli
Management of IE?
6 weeks IV abx (midline required)
Surgical management if aortic root abscess
Any prophylaxis in dental procedures?
No longer recommended
What is rheumatic fever?
Molecular mimicry to Lancefield group A beta haemolytic streptococcus infection (scarlet fever) with antibodies attacking endocardium 2-4 weeks post
Diagnosis of rheumatic fever is by the?
Jones Criteria
Evidence of recent strep infection e.g., ASOT + 2 major
OR
1 major and 2 minor
Jones major criteria?
Arthritis (migratory)
Pancarditis (new murmur)
Syndenhams chorea (ceases with sleep)
Erythema marginatum (geographical rash with clear centre)
SC nodules (extensor surfaces)
Jones minor criteria?
Fever
Arthralgia
High CRP/ESR
Prolonged PR
Management of rheumatic fever?
IV Benzylpencillin STAT
10 days phenoxymethylpenicillin
NSAIDs for pain
Management of rheumatic fever if HF?
Steroids no NSAID
Most common valve problem following IE?
Mitral stenosis
Signs of cardiac tamponade?
Becks triad
- Hypotension
- Muffled heart sounds
- Raised JVP
Pulsus paradoxus
What is pulsus paradoxus?
Large drop in systolic BP when inspiring
Management of cardiac tamponade?
Pericadiocentesis
- CXR following to ensure no pneumothorax
What is dilated cardiomyopathy (DCM)?
Dilated ventricles causing HFrEF
Causes of DCM?
Idiopathic
Genetic
Toxin related: alcohol. cocoaine, clozapine, chemo
Cocksakie B virus
Haemochromatosis
Sarcoidosis
Wet beri beri
What is wet beri beri?
Thaimine deficiency
Signs of DCM?
S3 gallop (rapid ventricular filling)
Displaced apex beat
What is restrictive cardiomyopathy?
Impaired diastolic filling with normal systolic function often seen with AF
Causes of restrictive cardiomyopathy?
Inherited
Infiltrative (amyloidosis, sarcoidosis, hurler)
Storage (Fabry, haemochromatosis)
Chemo
What is ARVC- arrhythmogenic R ventricular cardiomyopathy?
AD genetic condition in desmosomes causing fatty fibrous material to replace myocardium
ECHO findings of ARVC?
R ventricle hypokinetic segment
What is Takotsubo cardiomyopathy?
Stress induced apical ballooning of myocardium seen as troponin +ve, STEMI with normal angiogram
ECHO findings of Takotsubo cardiomyopathy?
Apical ballooning of mid and apical segments
What is hypertrophic cardiomyopathy?
AD condition leading to sarcomere mutation with disorganised beta-myosin heavy chain causing LVH and risk of sudden death
Signs of hypertrophic cardiomyopathy?
Double apex beat
Harsh ESM
Apical thrill
A wave in JVP
ECHO findings of Hypertrophic cardiomyopathy?
MR SAM ASH
Mitral Regurgitation
Systolic Anterior Motion of mitral valve leaflets
Asymmetrical Septal Hypertrophy
Management of hypertrophic cardiomyopathy?
Genetic testing
Avoid stressful exercise
BB - first line
Surgical management
ICD if risk of sudden death
When is surgical management needed in hypertrophic cardiomyopathy?
Severe L ventricular outflow tract obstruction (LVOTO)
Or symptoms refractory to medical management
What surgical options are there for hypertrophic cardiomyopathy?
Septal myectomy
Alcohol septal ablation
Atrial septal defects (ASD) can cause?
Ischaemic strokes needing closure of foramen ovale
Ventricular septal defects (VSD) leads to?
If untreated pulmonary HTN causes RVH and lead to Eisenmenger’s syndrome shunting blood R to L causing cyanosis
JVP is?
R atrial pressure as connected with no valves to jugular veins, normally <4cm biphasic
3 waves of JVP?
A wave- atrial contraction
C wave- ventricle contraction
V wave- R atrial filling
Following C wave of JVP?
X descent
Rapid atrial filling
Following V wave of JVP?
Y descent
Ventricular filling
Large A wave is caused by?
Increased atrial contraction
Tricuspid stenosis
R sided HF
Pulmonary HTN
Cannon A wave shows?
Atria contracting against a closed tricuspid valve
Complete Heart Block
Ventricular ectopics
VT
Absent A wave of JVP?
AF
Large V wave on JVP?
Tricuspid regurgitation
Prominent X descent and slow Y descent?
Cardiac tamponade
Kussmaul sign?
JVP rising with inspiration seen in cardiac pericarditis
Deep Y descent?
Constrictive pericarditis
Most common cause of HF in developing world?
Chagas disease
Classification of HF? NYHA
1- no limitation
2- ordinary activity causes symptoms
3- marked limit to physical activity
4- symptoms at rest
L sided HF seen by?
SOB
Pink frothy sputum
PND
Orthopnoea
Signs of L sided HF?
Pulsus alternans (strong and weak pulse)
S3 gallop
Right sided HF symptoms?
Peripheral oedema
Raised JVP
Ascites
Bloods for HF?
NT pro BNP
Routine bloods
TFTs
Lipids
HbA1c
-> rule out high output HF and look at modifiable risk factors
NT pro BNP and referrals?
> 2,000 TTE <2 weeks
400-2,000 TTE <6 weeks
<400 unlikely
Other investigation for HF?
TTE
ECG
CXR- pulmonary congestion
TTE findings of EF?
50-70% normal
> 40% with raised BNP = HFpEF
<40% = HFrEF
Lifestyle modification of HF?
Stop smoking
Salt and fluid restriction
Supervised exercise group rehab
Influenza vaccine annual
One off pneumococcal vaccine
Symptom management in HF?
Loop diuretics- furosemide/ bumetanide
Mortality benefit in systolic HF?
BASH
BB
ACEi
Spironolactone
Hydralazine
Medical management of HF?
ACE-i (or ARB) + BB (or hydralazine)
If symptoms persisting class 3-4:
+ Spironolactone
+ Hydralazine (afro-Caribbean)
+ SGLT2i dapagliflozin
ACEi and spironolactone may cause?
Hyperkalaemia
Surgical/ interventional treatments of HF?
Cardiac resynchronisation therapy
ICDs
Indications for ICD in HF?
QRS <120, high risk of cardiac death, class 1-3
QRS 120-149 without LBBB, class 1-3
QRS 120-149 with LBBB class 1
What is angina?
cardiac sounding chest pain relived by rest <5 mins or GTN spray
Classification of angina?
1- strenuous activity
2- Slight limitation
3- Marked limitation
4- on any activity
Investigations of angina?
ECG
Bloods
CT angiography -> stress ECHO -> myocardial perfusion SPECT
Treatment of angina?
Aspirin 75mg OD
Statin 80mg
GTN spray
BB or CCB (verapamil)
BB + long acting dihyropyridine
BB + long acting dihydropyridine + ISMN/ Ivabradine
Revascularisation
When is revascularisation indicated in angina?
3 agents not effective
Complex 3 vessel disease
Significant left main stem affected
Revascularisation in angina can be done by?
PCI
CABG- from long saphenous in leg OR internal mammary artery in chest. Under GA
CABG preferred if?
> 65
DM
Complex 3 vessel disease
NSTEMI diagnosis?
2 of the following:
- Dynamic troponin rise
- ECG findings
- Cardiac sounding chest pain
STEMI diagnosis?
ST elevation >2mm chest leads
ST elevation >1mm limb leads
New LBBB with chest pain
Troponins measured at?
0h
2h
6h
Investigations for chest pain?
ECG
Troponin
U+E (for PCI)
CXR
Territories:
L S A
I L S L
I I A L
Inferior leads supplied by?
RCA
Anterior leads supplied by?
LAD
Septal leads supplied by?
LAD proximal
Lateral leads supplied by?
L circumflex
Treatment of STEMI?
Morphine- diamorphine
Oxygen if hypoxic
GTN for symptom relief
Aspirin 300mg PO + Clopidogrel (on anti coag)/ prasugrel (no anti coag)
Primary PCI
Primary PCI timing in STEMI?
Presents within 12 hours of pain onset
AND
<2 hours since first medical contact
Treatment of NSTEMI/ UA?
Morphine
Oxygen if hypoxic
GTN
Aspirin 300mg PO + fondaparinux
Prasugrel/ ticagrelor
GRACE Score- if high angiogram within 96 hours of pain onset
All ACS patients should have?
ECHO ? HF
Cardiac rehabilitation
Secondary prevention following ACS?
Aspirin 75mg OD + Clopidogrel/ Ticagrelor
BB
ACEi- ramipril
Atorvastatin 80mg ON
Post MI complications include?
DARTH VADER
Death
Arrythmia (ventricular)
Rupture (ventricular free wall)
Tamponade
HF/ block- inferior
Valve disease
Aneurysm of L ventricle
Dressler’s syndrome
Embolism
Recurrence (stent thrombosing)
Left ventricular aneurysm following MI due to?
Anterior MI, diagnosis on ECHO, ECG may show persistent ST elevation
Ventricular free wall rupture post MI?
Due to wall necrosis causing death
How is acute mitral regurg seen post MI?
Infero-posterior MI causing papillary rupture seen with pansystolic murmur at apex and sudden HF
What causes and how can you see VSD following MI?
Anterior- inferior MI leading to loud pan systolic murmur at left sternal border- emergency surgery
What is dresslers syndrome?
Pericarditis seen 2-3 weeks following MI
Signs of dresslers?
Fever and pleuritic chest pain 2-3 weeks post MI
Treatment of dresslers?
Aspirin
Complications of cardiac catherisation?
Bleeding (femoral)
Arterial thrombus
Arrythmias
Perforation of great vessels causing tamponade
Allergic reaction
Atheroemboli (cholesterol emboli)
How can you see atheroemboli, a consequence of cardiac catherisation?
Renal failure
Eosinophillia
Livido recticularis
What is Wellen Syndrome?
ECG pattern in severe proximal LAD stenosis (high risk of anterior MI)
ECG finding of Wellen syndrome?
Deeply inverted ot biphasic T waves in V2-3
Next steps in Wellen syndrome?
TTE
Angiogram
PCI to LAD
Incomplete BBB?
QRS between 110-120
Complete if >120
LBBB ECG pattern
W in V1 - rS
M in V6
Causes of LBBB?
AS
IHD
Hyperkalaemia
Digoxin toxicity
New MI
Causes of RBBB?
RVH
PE
IHD
Normal variant
Malignant HTN is?
BP causing sudden end organ damage, treat by reducing BP slowly over 24 hours to 160/100
If malignant HTN causing hypertensive encephalopathy?
IV labetalol
Pulmonary oedema and malignant HTN?
GTN infusion or sodium nitroprusside
Malignant HTN in phaeochromacytoma?
IV Phentolamine
Causes of secondary HTN (<40’s)?
Renal artery stenosis (CT angiography)
Anaemia
Hyperthyroidism
Aortic regurg
Coarctation of aorta
Cushings
Conns syndrome
Phaeochromocytoma
Conns syndrome seen as?
Elevated aldosterone
HyperNa
HypoK
New diagnosis of HTN investigations?
QRSIK statin if >10%
Reversible risk factors
End organ damage review:
- Urine Dip
- ACR
- BM
ECG for LVH
Medical management of HTN if under 55?
ACE-i (ramipril)
If not tolerated ARB candesartan
Medical management of HTN if >55 or afro-caribbean?
CCB (Nefedipine)
Second line medical management HTN?
ACE-i (ARB) + CCB
Third line medical management for HTN?
ACE-i + CCB + thiazide like diuretic (Indapamide)
Fourth line medical management of HTN?
ACE-i + CCB + thiazide like
If K >4.5 increase thiazide
If K <4.5 spironolactone
Pericarditis is seen by?
Pleuritic chest pain with fever, relieved leaning forwards following a viral infection. On examination pericardial rub
Pericarditis can lead to?
Cardiac tamponade with becks triad of raised JVP, muffelled heart sounds and hypotension
Causes of pericarditis?
Coxsackie B virus most common
Echovirus
CMV
Bacterial: Staph, strep
Malignancy: breast, lung, hodgkins
Dresslers
Radiation
Drugs- chemo, phenytoin
SLE
ECG of pericarditis?
Widespread saddle ST elevation
PR depression
Investigations of pericarditis?
ECG
Troponin
ECHO
Angiogram
Management of pericarditis?
Exercise restriction + NSAID + colchicine
second line steroids
What is myocarditis?
Inflammation of myocardium secondary to inflammatory cells infiltrate
Classical presentation of myocarditis?
Young person with chest pain and dull heart sounds
Causes of myocarditis?
Viral infection: Cocksackie B
Chagas disease
Autoimmune
Clozapine
Mesalazine
What is Chagas disease?
Trypanosoma cruzi infection causing DCM, mega oesophagus and unilateral eyelid oedema
Myocarditis blood test?
CK-MB raised
Viral serology
Troponin raised
Gold standard investigation for myocarditis?
Endomyocardial biopsy
Management of myocarditis?
Supportive and corticosteroids if viral cause
Hyperkalaemia ECG changes?
Peak tall tented T waves
P wave prolongation
Broad QRS
Risk of conduction blocks and VF
Hypokalaemia ECG changes?
<2.7
Widened P wave
Prolonged PR
ST depression
T wave inversion
U wave
AF/ atrial flutter/ VT/ VF
What is right heart strain?
R ventricular dysfunction as struggles to pump against increased pulmonary pressures due to PE, pulmonary HTN, PS, CLD
ECG in right heart strain?
R axis deviation
P pulmonale (peaked P waves- in R atrial enlargement)
ST depression and T wave inversion in inferior leads
S1Q3T3
What is cor pulmonale?
Enlargement of R heart due to disease of the lungs and pulmonary vessels
What is pulmonary HTN?
Mean pulmonary arterial pressure >25 on ECHO/ R heart catheterisation
What causes pulmonary HTN?
Lung diseases: COPD, ILD, CF
PE, portal HTN, idiopathic
Hypoventilation sleep apnoea, neuromuscular conditions
Heft heart disease
Treatment of pulmonary HTN?
Treat underlying condition
Reduce pulmonary vascular resistance with LTOT
Nifidipine/ sildenafil
What is Brugada syndrome?
AD Na channelopathy predisposing to arrythmia and sudden cardiac death with a structurally normal heart
Who is brugada syndrome most commonly seen in?
South east asian men with triggers such as high alcohol, tricyclic antidepressants, flecainide, verapamil
Diagnosis of brugada syndrome?
ECG changes + history of:
- VF or TdP
- FHx suden cardiac death <45
- Syncope
- ECG signs in family
- Inducible VT
- Nocturnal agonal breathing
ECG changes in brugada syndrome?
Coved ST elevation >2mm in >1 V1-3 followed by negative T wave
Treatment of brugada syndrome?
Avoid triggers
ICD
If recurrent arrthymias Quinidine
What is Buerger’s disease?
Non atherosclerotic vasculitis of small-medium vessels due to smoking and an inappropriate immune resposne
Presentation of Beurgers disease?
Acute limb ischaemia
Raynaud’s
Ulcers
Superficial migratory thrombophlebitis
Investigation for beurgers?
Arterial doppler distant pulses absent or diminshed
Arterial suplex corckscrew collaterals (Mortorelli sign)
Management of Buergers?
Stop smoking
Nifedipine
What is the action of digoxin?
Inhibits Na/K ATPase and parasympathetic on SAN slowing HR and increasing contractility
Digoxin toxicity seen by?
N+V
Blurred vision
Yellowing of vision
Syncope
Risk factors for digoxin toxicity?
Electrolyte disturbance
Elderly
When to measure digoxin level?
6h post dose
ECG changes in digoxin toxicity?
reverse tick sign- down sloping ST depression
Treatment of digoxin toxicity?
Stop digoxin
Correct electrolytes
Digifab (specific antibody if life threatening)
Slow rising pulse =
AS
Waterhammer pulse =
AR
L ventricular heave?
LVH (AS)
R ventricular heave?
RVH (pulmonary HTN)
MI with angioplasty no driving for?
1 week
MI with no angioplasty no driving for?
4 weeks
Pacemaker insertion no driving for?
1 week
Syncope while sat no driving for?
4 weeks
Unexplained syncope no driving for?
6 months
What is cardiac amyloidosis?
Deposition of misfolded proteins in the heart with green birefringence on congo red staining
Most common amyloids in cardiac amyloidosis?
AL (light chain mediated)
ATTR (transthyretin mediated)
AL cardiac amyloidosis is?
More severe
ATTR cardiac amyloidosis needs?
genetic testing
Combo seen in cardiac amyloidosis?
HF
Carpal tunnel syndrome
Cardiac amyloidosis of cardiac MRI?
L ventricular wall thickness with diastolic dysfunction
If mother Anti-Ro and anti-la Positive SLE consider what in baby?
Risk of complete heart block
Ankylosing spondylolitis can cause?
Proximal aortitis
What is a cardiac myxoma?
Benign cardiac tumour seen in L atrium composed of unspecialised mesenchymal cells with mucopolysaccharide stroma
Signs of cardiac myxoma?
High inflammatory markers
Fever, weight loss, clubbing
What is carney complex?
Inherited AD disorder causing cardiac and cutaneous myxoma, schwannomas and endocrine tumours with abnormal skin pigmentation
Medications not to use in pregnancy?
ACE-i
Warfarin
Both teratogenic
Pregnancy complication for heart in second trimester?
DCM
Pregnancy complication for heart in final month/ post partum?
Peripartum cardiomyopathy
Q waves are normal in?
I, aVL, V5-6
