Cardiology Flashcards
Differential diagnosis of systolic murmur
Aortic stenosis
Aortic sclerosis
HOCM
Mitral regurgitation (pan systolic)
Pulmonary stenosis
VSD
Flow murmur
Management of severe symptomatic AS
Referral to cardiothoracics for valve replacement
Medical management of AS
Beta blockers
Avoid vasodilator if severe eg ACEi, nitrates and sildenafil
Surgical options in AS
Mechanical aortic valve
Tissue aortic valve
TAVI - transaortic vale intervention
Severity of AS on examination
Slow rising low volume pulse
Narrow pulse pressure
Muted/absent S2
High pitch
Length of murmur
Radiation to carotids
LV heave
Fourth heart side
Clinical findings on Aortic regurgitation
Collapsing pulse
Wide pulse pressure
Pan diastolic murmur
Apex beat thrusting and displaced
Thrill in aortic region
May also have aortic flow murmur (systolic) and a mid-diastolic murmur (Austin-Flint)
Indications for AVR
Severe symptomatic aortic stenosis/regurgitation
Infective endocarditis
Advantages of mechanical heart valve
Longer lasting and more durable although requires life long anticoagulation
Indications for mitral valve repair
Mitral stenosis
Mitral regurgitation
Infective endocarditis
How does the splitting of the second heart sound vary with an ASD
Fixed and widely split, does not vary with respiration
Differentials for MR
Mitral valve prolapse
Tricuspid regurgitation
VSD
Severe MR findings
Raised JVP
Loud P2
S3 gallop rhythm
Apex displaced and thrusting
RV heave
Indication for MR surgery
Symptomatic MR
Asymptomatic but with:
Declining EF
MR with new AF
Increasing LV dilatation
Acute MR following MI
Causes of MR
Age related MR
Papillary rupture following MI
IE or rheumatic fever
CTD - Ehlers danlos
What is the cause of S3
Caused by filling of ventricles
Can be normal in younger patients
Asssociated with heart failure
Occurs in early diastole
What is the cause of S4
Almost always pathological
Caused by pumping blood from atria to ventricles against resistance
Occurs in late diastole
What is Marfan’s
Autosomal dominant inherited disorder in fibrillin gene
Indication for aortic surgery
Dilatation >50mm at aortic root or >40mm with family history of aortic dissection
Increasing >10mm dilatation per year
Noonan syndrome features
Autosomal dominant
Cubitus valgus
Webbed neck
Widely spaced nipples
Pectus excavatum
Short stature
Proptosis
Strabismus
Ptosis
Mild intellectual disability
Difficulties with blood clotting
Motor delay
Congenital heart defects
Symptoms of pulmonary stenosis
Exercise intolerance
Signs of right sided heart failure
Syncope and pre syncope
Palpitations
SOB
Clinical findings in the pulmonary stenosis
Large A waves in JVP
Right ventricular heave from right ventricular heave
Pansystolic murmur from TR
Right sided heart valve
Widely split 2nd heart sound
Radiation to infraclavicular area
Cardiac complications in Noonans syndrome
Pulmonary stenosis
HCM
Septal lesions
Features on ECHO of Pulmonary stenosis
Peak gradient >64mmHg
Area over valve <1cm2
Velocity >4m2 across valve
Features of tetralogy of Fallot
Overriding aorta
Right ventricular hypertrophy
Pulmonary stenosis
VSD
Causes of pulmonary stenosis
Congenital
Tetralogy of allot, Noonan, Williams
Rheumatic fever
Endocarditis
Carcinoid
Management of pulmonary stenosis
Management of underlying cause
Balloon valvuloplasty
Valve replacement surgery
Associated conditions with mitral valve prolapse
Marfans
Ehlers-Danlos
Osteogenesis imperfecta
Polycystic kidney disease
Causes of systolic murmur
AS
Mitral regurgitation
Mitral valve prolapse
HOCM
VSD
Complications of Ehlers-Danlos
Lens dislocation
Mitral valve prolapse
Bicuspid valve
Aortic dissections
Aortic aneurysms
Spontaneous artery dissections
Raynaud’s disease
Arthralgia
Joint dislocation
Concerning features on ECHO of PDA
Raised pulmonary pressures
Dilated pulmonary arteries
Evidence of right ventricular dilatation
Tricuspid regurgitation
Evidence of LV dysfunction
Severity of findings in PDA
Collapsing pulse
Right ventricular heave
LV failure
Why does inspiration make right sided murmurs louder?
In inspiration increased venous return
More flow across right side of the heart
Increases character of the murmur
What is the ductus arteriosus
Connection between the left pulmonary artery and the descending aorta
Allows blood to bypass the pulmonary circulation in the foetus
Usually closes at birth to become the ligaments arteriosum
Failure to close leads to PDA
Management of PDA
If severe findings considered for device closure percutaneously
Clinical findings in PDA
Machine like continuous flow murmur
Louder in expiration
Best heard in 2nd intercostal space left to sternum
Also heard on back
Ix in PDA
ECHO
Cardiac MR
Cardiac CT
Cardiac catheterisation - pressure within pulmonary circulation
What is Eisenmenger’s Syndrome
Process in which long standing left to right shunt is caused by congenital heart defects
Leads to pulmonary hypertension and eventually reversal of shunt to right to left and cyanosis
Causes of Eisenmengers
VSD defect
ASD defect
PDA
Indications for closure in VSD
Evidence of left to right shunt
Other reasons for cardiac surgery
Aortic regurgitation - prolapse of aortic leaflets through defect
LV dysfunction
Complications of Eisenmengers
RV failure
Paradoxysial embolism
IE
Hypoxaemia
Haemoptysis
Causes of clubbing
Cardiac
- Subacute IE
- Cyanotic congenital heart disease
Respiratory
- Lung malignancy
- Suppurative lung pathology
- TB
- ILD
Gastro
- IBD
Familial causes
Indications for lateral thoracotomy scar
Lobectomy
Pneumonectomy
Coarctation surgeries
Blalock-Taussig Shunt - associated with weaker left radial pulse (used as bridging measure in cyanotic heart disease)
Syndromes associated with VSD
Down’s
Edwards
Di George
Management of pulmonary hypertension
Endothelin antagonist eg bosentan
PDE5 inhibitors eg sildenafil
Prostanoid infusions
Cyanotic congenital heart defects
Tetralogy of Fallot
Transposition of the great arteries
Pulmonary stenosis
Pulmonary Atresia
Eisenmengers
Epsteins
Complications following surgery in tetralogy of Fallow
Pulmonary regurgitation
Endocarditis
Polycythaemia
Coagulopathy
Paradoxysial embolism
Arrythmias
Acyanotic congenital heart defects
ASD
PDAs
Coarctation
AS
Causes of constrictive pericarditis
Viral/bacterial pericarditis
Post surgery
Post TB
Post radiation
CTD
Causes of restrictive cardiomyopathy
Endomyocardial fibrosis - Loeffler’s
Sarcoid
Scleroderma
Amyloidosis
Haemochromotosis
Malignancy
Radiation
Long term use of hydroxychloroquine
Treatment of constrictive pericarditis
Diuretics and fluid restriction
Surgical - pericardectomy
Treatment of restrictive cardiomyopathy
Treating underlying causes
Treating symptoms such as those caused by HF
In low cardiac output patients - consider heart transplant
Findings in Ix in restrictive cardiomyopathy
Impaired diastolic function with impaired relaxation of the ventricles
Biatrial enlargement
Clinical findings in constrictive pericarditis
Raised JVP
Jussmauls sign - paradoxical increase in JVP on inspiration
Pulsus paradoxes - >10mmHg drop in systolic pressure in inspiration
Pericradial knock
Ascites
Hepatomegaly
Bilateral peripheral oedema
Clinical IX in constrictive pericarditis
Pericardial calcification
ECHO - high acoustic signal from the pericardium, ventricular interdependence (good differentiation between restrictive cardiomyopathy)
Cardiac catheter - Equalisation of diastolic LV and RV, RA and LA pressures
CT cardiac - thickened pericardium +/- calcification
Cardiac MRI - thickened pericardium, fibrosis, enlarged atria
Causes of MR
Degenerative - flail leaflet
Rheumatic fever
IE
CTD
Dilated Left ventricle - secondary MR
Infiltration e.g amyloid
Management of AF
Rate vs Rhythm
Rhythm:
- Flecainide - structurally normal heart
- DC cardio version - ensure adequately anti coagulated
Rate:
- Beta blockers or digoxin
Need for anticoagulation - CHADSVasc
Indications for surgery in MR
Symptomatic MR with severe MR
Or Severe MR with:
- LVEF <60%
- LV end systolic deminesion of >45
- AF
- Systolic pulmonary artery pressure >50mmHg
If asymptomatic but severe - can do watchful waiting
Surgery can be considered in asymptomatic patients when surgical risk is low, and endurable repair is likely and there is the presence of a flail leaflet or atrial enlargement
What is secondary MR
Valve leaflets and chord are structurally intact - MR results for imbalance in closing and tethering forces on the valve secondary to alteration in the left ventricle geometry - seen in dilated or ischaemic cardiomyopathies
Tx in secondary MR
No evidence that reduction of secondary MR improves survival
Requires optimal medical therapy of secondary MR
Treatment of MR
Anticoagulation of AF
Dieuretic, beta blocker and ACEi
Serial ECHOs
Percutaneous:
- Transcatheter edge-to-edge repair - if high surgical risk and refractory heart failure symptoms despite medial management
Valve repair with annuloplasty ring or valve replacement
Causes of mitral valve prolapse
Associated with CTD (Marfan’s), SVT and HOCM
May present with severe MR, AF, SCD, emboli or endocarditis
Indications for anticoagulation in Mitral valve disease
AF
Previous emboli
Left atrial thumbs
Diagnosis of IE
Dukes criteria
Two major:
- Positive blood cultures in sets in keeping with IE
- ECHO findings in keeping with IE - abscess, large vegetation or dehiscence
Minor finding:
- Pyrexia >38
- ECHO suggestive
- Predisposed e.g. prosthetic valve
- Embolic phenomena
- Vasculitis phenomena - raised ESR or CRP
- Atypical organism on blood culture
Its will need two major, one major and three minor, or five minor
Typical pathogens in IE
S aureus
S Bovis
S viridian’s
HACEK organism
Auscultation findings in MR
Pansystolic murmur
Soft 1st heart sound
Progressive splitting of S2
Presence of S3 (gallop rhythm)
Auscultation findings in MS
Low pitched rumbling murmur often heard best with bell
Accentuated when patient on left lateral position and breath held on expiration
Sharp opening snap
Reduced splitting second heart sound
Severe if opening snap occurs nearer A2 or is inaudible (fixed leaflets and the mid diastolic murmur is longer
Surgical indications in MS
Symptomatic patients with severe disease
Asymptomatic - follow up ECHO every 6 months, if pulmonary pressure >50mmHg despite symptoms refer to surgery
Clinical signs in MS
Malar flush
Irregular pulse if AF present
Tapping apex - palpabel first heart sound
Left parasternal heave - if pHTN or enlarged Left atrium
Mid diastolic murmur with loud first heart sound (opening snap)
Complications of MS
Pulmonary hypertension and right sided heart failure - TR, right ventricular heave, loud P2, sacral and pedal oedema
Pulmonary oedema
Endocarditis
Embolic complications - stroke risk high if MS and AF
Causes of MS
Congenital (rare)
Rheumatic fever
Senile degeneration
Large mitral leaflet vegetation for endocarditis
Ix of MS
ECG - p-mitrale and AF
CXR - enlarged LA, calcified valve, pulmonary oedema
TTE/TOE - valve area (<1cm2, gradient >10mmHg is severe), calcification, left atrial thrombus, right ventricular failure and pHTN (>50mmHg is severe)
Cardiac catheter
Management of MS
Medical - rate control and oral anticoagulants, diuretics as needed
Mitral valvuloplasty
Surgery - closed or open valvotomy or valve replacement
Rheumatic fever diagnosis
Duckett jones diagnostic criteria
Proven B-haemolytic streptococcal infection diagnosed by throat swab, rapid antigen test, anti-streptolysin O titre or clinical scarlet fever plus 2 major or 1 major and 2 minor e.g chorea, poly arthritis, carditis, raised WCC, raised ESR, arthralgia, pyrexia
What other murmur might you hear in mixed aortic disease
Austin flint - regurgitant jet hitting far wall of leg ventricle
Causes of AS
Age related calcification
Congenital bicuspid valve
rheumatic heart disease
SLE
Paget’s
Causes of AR
Acute:
- Aortic dissection
- Trauma
- IE
Chronic:
- Rheumatic heart disease
- Marfans
- Aortitis
- Ankylosing spndylitis
- SLE
- Osteogenesis imperfecta
- Vasculitis (GCA)
- Syphilis
Eponymous signs in AR
De Mussets - head bobbing
Quincke’s - Capillary pulsation in fingertips and lips
Mueller’s sign - uvula pulsation
Corrgan’s - visible vigorous neck pulsation
Traube’s - pistol shot sound over the femoral arteries
Mx of AR
ACEi and ARBs
Regular review of sx and ECHOS
Severity on ECHO - severe if:
- LVEF <50%
- LV size - ESD >50mm and/or EDD >65mm
- Degree of AR - >65% LVOT width
Surgery if acute e.g dissection or aortic root abscess/endocarditis
Surgery in chronic - AVR:
- Symptomatic with dyspnoea and reduced ET (NYHA >II) and/or
- Wide pulse pressure >100mmHg
- ECG changes on ETT
- ECHO features of LV enlargement or reduced function
NYHA class
Class I - No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or shortness of breath.
Class II - Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, shortness of breath or chest pain
Class III - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, shortness of breath or chest pain.
Class IV - Symptoms of heart failure at rest. Any physical activity causes further discomfort.
Causes of dextrocardia
Situs invertus
Kartagener’s syndrome - primary ciliary dyskinesia
VSD
TGA
Findings in HCM
Jerky pulse
Double apical impulse
Thrill at lower left sternal edge
Ejection systolic murmur or pansystolic murmur (LVOT obstruction with MVP)
S4
Causes of Cardiac hypertrophy
Pressure overload:
- HTN
- AS
- Sub aortic membrane
HCM
Fabry’s disease
Amyloidosis
Treatment in HCM
Beta blockers and verapamil if symptomatic and LVOT gradient >30mmHg
Cardiac myosin inhibitors - mavacamten - negative inotrope
Pacemaker
Assess for risk of sudden cardiac death:
- Consider implantation of ICD
Assess genetics
Septal reduction therapy if severe
- Myomectomy
- Alcohol ablation
Heart transplant
Medications to avoid in HCM
Prognosis in HCM
Annual mortality rate 2.5%
Poor prognosis factors and hence indications for ICD:
- Young age at diagnosis
- Syncope
- Documented VT or cardiac arrest
- Family history of SCD
- Septal thickness >300mm
- “burn out” - Reduced LV and fibrosis
Components of tetralogy of Fallot
VSD
Overriding aorta
Pulmonary stenosis
Right ventricular hypertrophy
Management of tetralogy of Fallot
Prostaglandin infusion to keep Ductus arterioles open to maintain pulmonary blood flow
Blalock-Taussig shunt
- Temporising procedure to relieve cyanosis
- Partially corrects the abnormality in infancy by anatomising the subclavian artery, ascending aorta or descending aorta to the pulmonary artery
- May have lateral thoracotomy scars for this
Widening of pulmonary outflow and resection of hypertrophied RV muscle
Follow up with specialist cardiac team
Assess for worsening pulmonary stenosis and right ventricular failure
May need pulmonary valve replacement in future if develops pulmonary regurgitation
Clinical signs in coarctation of the aorta
Hypertension in upper limbs
Absent/weak femoral pulses
Radio-femoral delay
Heaving pressure-loaded apex
Systolic murmur radiating to the back
Loud A2
Associations with coarctation of the aorta
VSD
Bicuspid aortic valve
PDA
Turner’s syndrome
Intracranial abnormality
Ix in coarctation of the aorta
ECG - LVH and RBBB (VSD)
CXR - rib notching and double aortic knuckle
TTE - increased aortic flow velocity on doppler
CT/MRI cardiac
Mx of coarctation of the aorta
Percutaneous endovascular aortic repair
Surgical - dacron patch aortoplasty
Long term anti-hypertensive follow up - aortopathy and hypertension usually persist
Long term surveillance with MRA - late aneurysms and recoarctation
Clinical signs in PDA
Collapsing pulse
Thrill left second intercostal space
Thrusting apex beat
Loud continus ‘machinery murmur’ loudest below clavicle in systole
Complications in PDA
Eisenmengers
Endocarditis
Mx in PDA
Close surgically or plug percutaneously
Clinical signs in AS
Narrow pulse pressure
Slow rising pulse
Apex beat sustained in stenosis
Thrill in aortic area
Lou high pitched crescendo-decrescendo murmur loudest in expiration
Complications of AS
Endocarditis
Right vernacular failure
LVH
Conduction problems
- Acute - IE
- Chronic - calcified aortic valve nodule
Causes of AS
Congenital:
Bicuspid valve - occurs at younger age
Acquired:
Age - senile degeneration and calcification
Rheumatic fever
Conditions associated with bicuspid aortic valves
Marfans
VSD
PDA
Turners
Coarctation of the aorta
Characteristics which favour TAVI in AS
Increasing age (>75)
Previous chest surgery
Previous chest radiation
Frailty
Porcelain aorta
Co-morbidity
Characteristics which favours SAVR in AS
Younger age
Suspicion on endocarditis
Unfavoruable arterial access
Large annulus
Bicuspid or severe AR
Indication for other cardiac surgery
Clinical signs in Mitral stenosis
Malar flush
irregular pulse - if AF is present
Tapping apex 0 palpable first heart sound
Left parasternal heave if pHTN present or enlarged L atrium
Loud S1
Mid diastolic murmur
Severity clinically in Mitral stenosis
OS occurs nearer A2
OS inaudible
MDM is longer
Complications of Mitral stenosis
Pulmonary hypertension and right heart failure
- Tricuspid regurgitations
- Right ventricular heave
- Loud P2
- Pedal oedema
Pulmonary oedema
Endocarditis
Embolic complications
Causes of Mitral stenosis
Rheumatic fever
Senile degeneration
Large mitral leaflet vegetation in IE
Management in Mitral stenosis
Medical:
- Manage AF
- Oral anticoagulation
- Diuretics
Mitral valvuloplasty
Closer or open valvotomy or valve replacement
Causes of Mitral Regurgitation
Acute:
- IE
- Chordae rupture
Chronic:
- Degenerative disease e.g. post-MI
- Prolapse
- CTD
- Dilated cardiomyopathy (functional)
- Calcification
Treatment in Mitral Regurgitation
Medical:
- Anticoagulation if AF present
- Diuretics, beta-blocker and ACEi
Percutaneous:
- Mitraclip
Surgical:
- Valve repair
Conditions associated with mitral valve prolapse
Marfans
SVT
HOCM
Clinical signs in tricuspid regurgitation
Raised JVP with giant CV waves
Thrill left sternal edge
High pitched pan systolic murmur loudest in tricuspid area
Reverse split second heart sound
S3
RV failure - pulsatile liver, ascites, peripheral oedema
Pulmonary hypertension - RV heave and low P2
Causes of TR
Congenital - Ebstein’s abnormality (also associated with ASD)
Acquired:
- IE (IVDU)
- Functional - Dilated RV and annulus due to left heart disease
- Implantable device leads - splint tricuspid valve open
- Carcinoid
- Rheumatic fever
Treatment in TR
Medical: Diuretics, beta blockers, ACEi and support stockings for oedema
Surgical: Valve repair/annuloplasty if medical treatment fails
Clinical signs in pulmonary stenosis
Raised JVP with giant A waves
Left parasternal heave
Thrill in pulmonary area
ESM heard best in pulmonary area, loudest in inspiration
Widely split second heart sounds - due to delay in RV emptying
Right ventricular failure, ascites, peripheral oedema
Severe if: inaudible P2, longer murmur duration obscuring A2
Associated conditions with pulmonary stenosis
Tetralogy of Fallot
Noonan’s syndrome
Carcinoid syndrome
Functional TR and VSD
Management in pulmonary stenosis
Pulmonary valvotomy - if gradient >70mmHg or if there is RV failure
Percutaneous valve implantation
Surgical repair/replacement
Cardiac issues in carcinoid sndrome
PS and TR
Usually liver metastasis with gut primary secreting 5-HT
Other symptoms include diarrhoea, wheeze and flushing
Treatment: long acting somatostatin analogue and cytoreduction - ablation, embolisation and surgical resection
Complications of heart valve
Thromboembolus
Bleeding if on anticoagulants
Bioprosthetic dysfunction and LVF - usually within ten year
Haemolysis (usually metallic valve)
IE
Atrial fibrillation - particularly if MVR
Complications of implantable device insertion
Acute:
- Haemorrhage
- Infection - pouch or lead
- Pericardial effusion/tamponade
- Pneumothorax
Chronic:
- Tricuspid regurgitation
- Endocarditis
Indications for implantation of ICD
Primary prevention:
- MI >4 weeks ago
– LVEF <35% and non-sustained VT and postive EP study OR
– LVEF <30% and QRS >120ms
- Familial condition:
– Brugada, ARVD, LQTS, HOCM, complex congenital heart disease
Secondary prevention:
- Cardiac arrest due to VT or VF
- Haemodynamically compromising sustained VT
- Sustained VT with LVEF <35%
Indication for CRT
Extra LV pacemaker lead via the coronary sinus - improves mortality/symptoms
Considered if:
- LVEF <35%
- NHYA class II-IV on optimal medical therapy
- QRD >150ms or >120 if LBBB
Clinical signs in ASD
Raised JVP
Pulmonary area thrill
Pulmonary ESMa nd tricuspid flow murmur with large LTR shunts
Fixed spit second heart sounds which do not vary with respiration
Signs of deterioration:
- Pulmonary HTN - RV heave and loud P2 +/- clubbing and cyanosis (Eisenmengers with RTL shunt)
- Congestive heart failure
Complications of ASD
Paradoxical embolus
Congetsive heart fialure
Eisenmenger’s - RTL shunt
Atrial arrhythmias
Treatment in ASD
Valve closure if:
- Symptomatic paradoxical embolus
- Significant shunt with RV dilatation
Avoid if Eisenmenger’s or severe pHTN present
Methods of valve closure:
- Percutaneous closure device - for secundum ASD only
- Surgical patch repair
Clinical signs of VSD
Thrill at LLSE
High pitched pan systolic murmur at LLSE with no radiation
If Eisenmenger’s develops then the murmur often gets quieter as the gradient diminishes
Other findings which may be present:
- AR
- PDA
- Fallot’s tetralogy
- Coarctation
- pHTN - loud P2 and RV heave
- Eisenmengers - findings of pHTN with cyanosis and clubbing
- Endocarditis
Associated conditions with VSD
Congenital:
- Tetralogy of Fallot
- Coarctation of the aorta
- PDA
Acquired:
- Traumatic - post-operative or post-MI
Management of VSD
Conservative - small peri-membranous VSDs close spontaneously
Percutaneous - Abplatzen device
Surgical - pericardial patch
Associated conditions with Coarctation
Cardiac:
- PDA
- VSD
- Bicuspid aortic valve
Non-cardiac:
- Aneurysms
- Turner’s syndrome
Treatment in Coarctation of the aorta
Percutaneous repair - EVAR
Surgical - Dacron patch aortoplasty
Will need long term anti-hypertensive treatment
Surveillance for late aneurysms and recoarctation
Clinical signs in HCM
Jerky pulse
Double apical impulse - palpable atrial and ventricular contraction
Thrill at LLSE
ESM without radiation to carotids
May be associated MVP
Differential diagnoses in LVH
Athletic heart
HCM
Hypertensive heart disease
Fabry disease
Cardiac amyloidosis
Treatment in HCM
Avoidance of strenuous exercise and vasodilators and dehydration
Symptomatic and LVOT gradient >300mmHg
- Beta blockers and verapamil
Cardiac myosin inhibitors - mavacamten
Pacemaker
Alcohol septal ablation or surgical myomectomy
ICD
Heart transplant
Genetic counselling
Causes of Heart failure
Inherited
Acquired:
- Structural heart disease
- Obesity
- Drugs e.g. anthracyclines and dystrophy
- Ishcaemic, infection, infiltration (amyloidosis and sarcoidosis), inflammation
- Liver and kidney disease
- A baby - post partum, arrhythmias
- Thyrotoxicosis
- Etoh, elevated BP
- Diabetes
Treatment of HF
Cardiac rehab
Treat underlying cause
Alcohol and smoking cessation
Exercise and good diet
Medical:
- Beta blocker
- ACEi/ARB
- MRA
- Diuretics if required
- SGLT2i
ICD/CRT implantation
Surgery;
- Ventricular volume reduction surgery - improves LVEDP stroke volume relationship
- LVAD - left ventricular assist device
- Heart transplantation
Indications for heart transplantation:
- Severely impaired LV systolic function, HCM, intractable VT or angina
- NHYA class III or IV despite optimal medical therapy
- Cardiac cachexia
Refractory cariogenic shock despite mechanical support and inotropes
Inherited cardiomyopathies
HCM
Long QT syndrome - Potassium channelopathy
- Can cause ventricular arrhythmias with tornado de pointes
- Long QT on ECG
Catecholaminergic polymorphic VT (CPVT)
- Calcium channelopathy
- No ECG changes at rest usually, but ETT or prolonged ECG monitoring may reveal ventricular ectopy or tachycardia
Brugada syndrome
- Sodium channelopathy
- Cove shaped ST segments - can be precipitated with flecainide
Arrhythmogenic right ventricular dysplasia
- Associated with epsilon wave and TWI V1-3
- Fatty infiltration of the right ventricular wall
Wolf-Parkinson White syndrome:
- Congenital accessory pathway, with predilection for AVRT and AF/flutter
- Associated with delta wave
