Cardiology 2 Flashcards
Management of COMPENSATED acute heart failure (pulmonary oedema)
Sit up
Oxygen if sats <94
IV Furosemide
SC Morphine
Advanced managemnt of acute heart failure
CPAP
IV Furosemide over 24hr
IV Dopamine over 24hr (inhibits SNS - increases myocardial contractility)
Intra-aortic balloon pump if in shock
Ultrafiltration if diuretics CI
Criteria for cardiac resynchronisation therapy
Symptomatic despite full medical management of ACEi, BB, Furosemide, Ivadbradine, Spironolactone, Hydralazine (if afro-carib)
1) LBBB on ECG
2) LVEF <30%
3) NYHA III
4) QRS >130ms
NYHA Classification of Heart Failure
I - no physical limitations
II - slight limitation, comfort at rest
III - marked limited activity, comfort at rest
IV - discomfort at rest
Pt is admitted with worsening SOB. RR 30, sats 91%, pulse 90bpm.
ECG shows normal sinus rhythym with a narrow QRS complex. LVEF 25%.
Current meds are Ramipril, bisoprolol, spironolactone, Bumetanide, Atorvastatin, Aspirin and Isosorbide Mononitrate.
She is treated with IV Furosemide. What intervention should she receive after her acute management? (+ other indications for this management)
Implantable cardioverter-defibrillation (ICD)
- LVEF <35%
- Good QoL
- Ventricular Fibrillation or Ventricular Tachycardia
Management of DECOMPENSATED acute heart failure (pulmonary oedema) secondary to Atrial Fibrillation
IV METOPROLOL (Beta-blockade, unless asthma/ COPD)
Pt presents with syncope and palpitations. ECG shows a long QT interval.
Congenital cause of Long QT Syndrome
Acquired cause of Long QT Syndrome
Treatment of Long QT?
Congenital: Jervell-Lange-Nielsen syndrome (mut. Cardiac Na/K channels)
Acquired: HypoK, HypoCa, amiodarone, TCAs, bradycardia, MI, diabetes
Tx:
Underlying
+ IV Isoprenaline if acquired
Pt presents with 2hrs of palpitations and malaise. Her pulse is 140bpm but other vitals are normal. She is haemodynamically stable.
ECG reveals regular tachycardia with QRS duration 80ms.
Diagnosis? 1L management? 2L Management?
What would the management be if she were haemodynamically unstable?
Narrow QRS = Supraventricular Tachycardia, haemodynamically stable
1L Vagal manoeuvre
- carotid sinus massage
- blowing into empty syringe
2L IV Adenosine
3L BB
If haemodynamically unstable: DC Cardioversion
Pt’s ECG shows a series of broad QRS complexes and tachycardia. There are no abnormalities on examination.
What is the most appropriate management?
Broad QRS = Ventricular tachycardia
No abnormalities = stable
Tx: IV Amiodarone 300mg (Then 900mg over 24hrs)
Pt’s ECG shows a series of broad QRS complexes and tachycardia. He has no pulse.
What is the most appropriate management?
= ventricular tachycardia but really bad
Chest compressions + unsynchronised shock
Pt’s ECG shows a series of broad QRS complexes and tachycardia. He has a pulse but has experiences two episodes of syncope.
What is the most appropriate management?
= unstable ventricular tachycardia
DC Cardioversion (Synchronised)
Pt presents with palpitations. Their ECG has a corkscrew appearance. She recently has been taking clarithromycin and amoxicillin to treat CAP.
Likely diagnosis?
Torsades des pointes (Ventricular Tachycardia)
Pt presents with tachycardia and ECG shows broad QRS complexes. They have had palpitations for 5hrs. There are no signs of oedema or raised JVP.
Likely diagnosis? Management?
Haemodynamically stable Sustained Ventricular Tachycardia
IV Amiodarone
Asthmatic pt presents with SOB and palpitations. ECG shows supraventricular tachycardia of 180bpm.
How should we slow the rate to be able to identify the arrhythmia?
Asthmatic :. adenosine contraindicated
Therefore VERAPAMIL
Pt presents with SOB and palpitations. ECG shows supraventricular tachycardia of 180bpm.
How should we slow the rate to be able to identify the arrhythmia?
ADENOSINE
What is the most common ECG finding in pulmonary embolism?
Sinus tachycardia
Pt presents with a fast irregular pulse and muscle weakness. Their breathing is deep and slow (Kussmaul’s). THeir ECG shows progresdive abnormalities, including tall T-waves.
Likely diagnosis? Investigations? What other ECG abnormalities might you expect? Treatment?
What are the complications of this?
Hyperkalaemia
Serum K+ >5.5mmol/L
ECG:
- progressive
- Tall T wave
- SMALL P-WAVE
- WIDE QRS
Non-urgent: stop offender (ACEi, spironolactone, NSAID) + POLYSTYRENE SULFONATE RESIN (binds K+ in gut)
Urgent: K>6.5
- IV CALCIUM GLUCONATE
- IV ACTRAPID + GLUCOSE
- IV SALBUTAMOL
Complications:
- Ventricular fibrillation
- heart failure
Wolf-Parkinson-White ECG
Pathophysiology
= Atrioventricular Re-entry Tachycardia
Wide QRS
Short PR
Delta Wave
Accessory pathway > re-entrant loop > supraventricular tachy
Types of Supraventricular Tachycardia
1, Atrioventricular Nodal Re-entrant: re-entry back through AVN
- Atrioventricular Re-entrant: re-entry via accessory pathways (WPW)
- Atrial tachycardia: signal originates in atria but not SAN
Normal PR interval
0.12-0.20s
PR depression
Pericarditis
Short PR in an arrhythmia
Wolf Parkinson White
Normal QRS range
0.08-0.12s
Wide QRS
RBBB/ LBBB Hyperkalaemia (sine) WPW Ventricular rhythm TCA poisoning
HASBLED
Risk of bleeding for patients on anticoagulants
Heart failure
- medications that improve prognosis
- medications that give symptomatic relief
Prognostic improvers
- ACEi
- BB
(start at different times!)
Symptomatic relief:
- Diuretics
Furosemide pharmacology
Loop Diuretic
Inhibits Na/K/Cl transporter on ASCENDING limb
K-sparing diuretics pharmacology
eg Amiloride, Spironolactone
Inhibit ENaC on DCT
Thiazide diuretics pharmacology
eg Bendroflumethiazide
Inhibit Na/Cl transporter in DCT
MI Complications
DARTH VADER
Death Arrhythmia Rupture (V.septum/papillary muscles) Tamponade Heart failure
Valve disease Aneurysm of ventricle Dressler's syndrome Embolism Regurgitation (mitral)/ recurrence
Pansystolic murmur loudest at apex
Diagnosis? Cause?
Mitral Regurgitation
Poor supply to papillary muscles/ septum > rupture > valve incompetence
Complication of acute severe mitral regurgitation
Acute pulmonary oedema - SOB
HMG CoA reductase inhibitors are what type of medication?
Statins
Warfarin pharmacology
Vitamin K antagonist
Avoid spinach
Grapefruit helps
When is pericardiocentesis indicated in pericarditis?
- BACTERIAL cause
or complication:
- cardiac tamponade
- pericardial effusion
Complications of pericarditis
- Cardiac tamponade
- Pericardial effusion
- Constrictive pericarditis
ECG serial changes in Pericarditis from week 1-8
1-3wks - T-wave flattens
3-8wks - T-wave inverts
8+wks - Normal ECG
Pericarditis ECG
= GOLD standard
Diffuse Saddle ST-elevation + PR depression
Pt presents with sharp pleuritic pain that is worse on inspiration and when lying on their back (supine). They have a low-grade fever and are unable to shake off a hiccup.
On auscultation, there is a “squeaky” sound.
Likely diagnosis? Investigations? Management?
Pericarditis, probably S. pyogenes (Lancefield Group A B-haemolytic)
Inv:
- raised troponin
- ECG
- Diffuse saddle ST-elevation
- PR depression
Management
Viral:
limit exercise, NSAIDs, colchicine (CI in renal/ liver impairment)
Bacterial:
- IV ABx
- Pericardiocentesis if purulent
- Pericardiectomy if adhesions/ recurrent tamponade
Gold standard investigation for Infective Endocarditis
TransOESOPHAGEAL Echocardiogram
Aschoff Bodies
Rheumatic carditis
Typical organisms for IE
S viridians (poor dental) S Bovis HACEK S aureus (IV user) Enterococcus
SSSHE
