Cardiology Flashcards
ECG signs of firs degree block, second degree and third degree heart block
1 = PR interval > 0.2 seconds
- 1 = Increasing delays until dropped
- 2 = Intermittent drops, in a ratio
3 = Complete dissociation
ECG signs of RVH vs LVH?
RVH = Tall R wave in V1, deep S in V6
e.g. cor pulmonale
LVH is Deep S in V1, tall R in V6
e.g. HTN, aortic stenosis and co-arctation
Causes of long QT?
TIMME
Toxins e.g. macrolides / amiodarone Ischaemia Myocarditis Mitral valve prolapse Electrolyte = Low K/Ca/Mg
Short QT causes?
Digoxin, BB, phenytoin
What is a trifasicular block and when do you see it?
1st degree heart block with LAD and RBBB
Commonly presents as falls in the elderly
What is p pulmonale and p mitrale?
Pulmonale = Peaked p wave in RAH e.g. Pulmonary HTN or tricuspid stenosis
P mitrale = Broad bifid p wave in LAH = mitral stenosis
ECG changes in VT?
No p waves or T waves. Regular broad QRS
ECG changes in Brugada syndrome?
RBBB and coved ST elevation in V1-V3
Digoxin ECG changes?
Reverse tick = down sloping ST segment and T-wave inversion
ECG changes in hyperkalaemia vs hypokalaemia?
Hyper = Tall tented t waves, wide QRS and absent/flat p-waves
Hypo = Small T waves, ST depression. Prolonged QT and prominent U waves
Causes of bradycardia?
DIVISION
Drugs e.g. CCB, BB, amiodarone
Ischaemia
Vagal hypotonia e.g. athletes
Infection e.g. infective endocarditis
Sick sinus syndrome = damage to the SAN / AVN or conducting tissue
Infiltration e.g. sarcoidosis
O’s = hypothyroid, hypokalaemia
N = neuro = raised ICP
Investigations of bradycardia?
ECG, bloods (cardiac enzymes), event monitor and exercise testing
Management of bradycardia?
Unstable = Atropine 0.5mg IV bolus, repeat 3mg max
If refractory can use pacing if:
- Complete heart block, systole, mobitz type 2 or ventricular pause > 3 seconds
- transvenous pacing = lead into RV, only for a few days. Mechanical tricuspid is CI
Stable:
Mild = treat underlying cause + theophylline 200mg PO BD
Severe = Treat and temporary dual chamber pacing
Definition of narrow complex tachycardia?
Rate >100BPM, QRS <120ms
2 types of narrow complex tachycardias?
AV independent:
- Sinus tachy
- Atrial tachycardia = different focus takes over from SA node
- atrial fibrillation
- flutter = macro re-entry rhythm, atria rhythm of 300 (ventricles can’t conduct 300 so P:QRS is usually 2:1)
AV node dependent:
- AVNRT = within node so activates atria and ventricles simultaneously
-AVRT = large accessory pathway e.g. WPW bundle of Kent :
+ Can be orthodromic = down AV node and back round up accessory pathway into atria. p follows each QRS, delayed RP interval
+ can be antidromic = conducted down accessory pathway, and re-enters atria via retrograde flow = broad QRS
Management of unstable narrow complex tachycardia?
ABC DC cardio version x 3 Amiodarone 300mg IV over 10 minutes Repeat shock Amiodarone 900mg over 24 hours
management of stable narrow complex tachycardia?
Irregular = treat as AF:
- Rate with BB/CCB + digoxin
- anticoagulate
- onset <48 hours = cardioversion
Regular:
- Vagal manouvres
- Adenosine 6mg IV bolus, then 12 then 12. (Use verapamil in asthmatics) If it is AV dependent the adenosine will stop the arrhythmia as it cause AV block.
If it doesn’t work means independent = Flutter, AF or ST
Management of atrial tachycardia and atrial flutter?
AT: 1st line = Diltiazem or Verapamil 2nd line = amiodarone 3rd line = Flecainide Refractory = ablation
AF:
Unstable = DC cardiovert
Stable = BB e.g. metoprolol 5mg bolus, repeating up to 3 times
- Amiodarone if refractory
Then cardiovert if refractory (electrical or medical with ibutilide)
For ongoing can ablate the tricuspid isthmus if symptomatic, or asymptomatic give Metoprolol
What drugs should you avoid in WPW?
Verapamil and digoxin
Definition of brand complex tachycardia?
> 100 BPM, QRS > 120ms
Classification of broad complex tachycardia?
Most are ventricular:
- monomorphic = single form QRS
- Polymorphic
- Fascicular = Arise from LV with re-entrant into Purkinje’s = Sensitive to verapamil
- RV outflow tract tachy = Due to cAMP activity = uniquely sensitive to adenosine
- Torsades des pointes = type of polymorphic
Some are SVT’s with aberrant conduction
Ventricular tachycardia causes?
MILDE
Myocarditis Infarction Long QT: TIMME Dilated cardiomyopathy Electrolytes low K/Mg/Ca
Management of unstable VT?
ABC DC cardioversion x 3 Amiodarone 300mg IV over 10-20 minutes Repeat shock Amiodarone 900mg over 24 hours
Management of torsades des pointes?
In line with ACLS guidelines for unstable VT.
+ usually due to low potassium / magnesium so aggressively replenish
magnesium sulphate 1-2g IV single dose
KCL max 60mM
Management of stable broad complex tachycardia?
Correct electrolyte balance
Anti-arrhythmics:
- Amiodarone 150mg bolus then 1mg/min for 6 hours then 0.5mg/min for 18 hours
- 2nd line = lidocaine
Ongoing:
Implanatble cardioverter defibrillator if = Cardiomyopathy, previous VT/VF or congenital arrhythmia problem e.g. Long QT
Anti-arrhythmics e.g. Metoprolol 50mg PO BD
What is atrial fibrillation?
Supraventricular tachyarrhythmia, with an irregularly irregular rhythm.
Abnormal atria promoting electrical re-entry
How do we classify atrial fibrillation?
First diagnosed = new diagnosis regardless of duration
Paroxysmal = self terminating, usually within 2 days
Persistent = longer than 7 days, including episodes cardioverted post 7 days
Long standing = continuous > 1 year, have adopted rhythm control
Permanent = No rhythm control
Causes of atrial fibrillation?
Cardiac = HTN, LV failure, ischaemic heart disease
Non-cardiac = thyrotoxicosis, pulmonary e.g. PE, drugs and alcohol
Management of unstable AF?
Unstable = DC cardiovert, if >48 hours must do a TOE to exclude atrial thrombus
Management of Acute AF?
If >65 or Hx of IHD = RATE control:
without heart failure - metoprolol 5mg bolus, repeat up to 3 times then regular metoprolol 50mg PO BD
If asthmatic use diltiazem
Heart failure = use digoxin 0.5mg PO OD
If <65, symptomatic, first presentation, lone AF / secondary to corrected precipitant = RHYTHM:
- <48 hours = immediate cardioversion
+ DC cardioversion with amiodarone therapy 4 weeks prior and 12 months after
+ Flecainide single dose 200mg
+ If evidence of structural heart disease use amiodarone
> 48 hours = establish INR of 2-3 for 3 weeks prior to cardioversion
Anticoagulation in AF?
CHADS score>2
Apixiban if non-valvular
Heparin / warfarin if valvular or kidney disease
Continue 3-4 weeks following cardioversion
Paroxysmal AF management?
Flecainide 200mg pill in the pocket
Rate control with BB (digoxin of heart failure)
Anticoagulate
Management of high INR on warfarin?
Major bleeding = stop warfarin, Vitamin K 5mg IV and prothrombin complex
INR >5, minor bleeding = stop warfarin, 5mg of IV vitamin K (repeat if INR still high after 24 hours), restart when INR < 5
INR >8 no bleeding = Stop warfarin, oral vitamin K, restart warfarin when <5
INR 5-8 no bleeding = Withhold 1-2 doses
Reduce subsequent dosing
How does NSTEMI differ from unstable angina?
NSTEMI has sufficiently severe ischaemia to cause myocardial damage, and therefore release cardiac biomarkers
RF’s for ACS?
Modifiable = HTN, DM, lipids, obesity and smoking
Non-modifiable = Male, increasing age and FHx MI >50
Clinical features of unstable angina?
Rest angina that is new onset (<2 months)
Crescendo pattern in occurence
Radiation to jaw/arm/neck
SOB
Investigations in unstable angina / NSTEMI?
ECG = ST depression and T-wave inversion
Trop normal in UA
FBC and clotting, lipid profile
CXR
Angiography gold standard, use based on GRACE mortality score
Acute management of unstable angina / NSTEMI?
Acutely = Diamorphine 5mg IV every 30 minutes Oxygen if sats <90% GTN 0.3-0.6mg tablets sublingual, max 3 Antiplatelet = aspirin 300mg and clopidogrel 300mg PO for 1 year
Anti-coagulate = fondaparinux 2.5mg SC if not having an angiography within 24 hours and no bleeding risk
Next do a GRACE-6 month mortality score:
- low risk (>3%) = conservative only
- Intermediate / high risk (>3%) do a coronary angiography within 96 hours. Significant findings = PCI
If not = prophylaxis and rehab.
High risk also requires addition go GPIIb/IIIa inhibitor e.g. tirofiban for 3 days
Long term management of UA / NSTEMI/ STEMI?
Conservative = cardiac rehabilitation. Diet, RF’s controlled, exercise
Medical is just like 'A-SBA' = A spirin for life 75mg, clopidogrel 75mg for one year. S tatin - Atorvastatin 80mg PO OD B B - Propranolol 40mg PO BD A CEI - Perindopril 10mg PO OD
STEMI = return to work 2 months, no sex or driving for 1.
ECG changes in a STEMI:
first changes seen, how vessels relate to leads, and criteria for thrombolysis based on ECG findings?
Hyper acute T waves often first sign seen
Inferior = 2, 3, aVF = RCA Anterior = V2-4 = LAD Lateral = V5, V6 and 1 = Left circumflex
Criteria for thrombolysis / PCI:
- ST elevation >2mm in 2 or more consecutive anterior leads
- ST elevation >1mm in 2 consecutive inferior leads
- New onset LBBB
At what times do we need to take troponin?
need a 3 hour and 12 hour
Acute management of STEMI?
Acutely = continuous ECG, IV access and bloods.
Diamorphine 5mg IV every 30 minutes
Oxygen if sats <90%
GTN tablets 0.3-0.6 mg sublingual, max 3
Antiplatelet = aspirin 300mg and clopidogrel 300mg PO for 1 year
Anti-coagulate = fondaparinux 2.5mg SC
If access within 120 minutes and PC <12 hours = PCI = angioplasty and stenting
- consider if >12 hours
If access > 120 minutes = thrombolysis = Streptokinase 1.5 million units IV over 1 hour
Thrombloysis contraindications
AGAINST
Aortic dissection GI bleed <1 month Allergic reaction Iatrogenic e.g. recent surgery Neuro = ischaemic stroke <6 months ago Severe HTN (200/120) Trauma
How is PCI done and complications?
Gain radial artery access, guide wire passed through to coronary and across stenosis. Balloon is the dilated and stented
Can have metal stent or drug-eluting (Reduces restenosis rate)
Home same day, no driving 1 week
Complications = Re-stenoiss, arrhythmias, coronary dissection / rupture, PCI induced MI
CABG procedure and indications?
Sternotomy , although can do more minimally invasive scars.
Off pump done on beating heart. Graft attached to aorta and then distally to stenosis
Internal left thoracic best for graft as maintains latency, although most use great saphenous.
Indications:
Severe refractory angina
Left main stem stenosis or triple vessel disease
Unsuccessful PCI
No driving for 4 weeks
MI side effects?
Short term:
RCA causes heart block 1/2 due to ischaemia of AV node
LAD = complete heart block as infarcts bundle branches in septum
VF = most common cause of death post-MI
Cardiac tamponade = due to thin wall following necrosis
Pupillary muscle rupture = gives acute mitral regurgitation
Dresslers syndrome
Long term:
Arrhythmias
Heart failure
Depression
Angina pectoris classification?
Stable and unstable
Decubitus = brought on lying down
Prinzmetals = younger demographic, during rest, absence of positive exercise test
Syndrome X = angina pain and ST elevation on exercise tolerance BUT no evidence of atherosclerosis on angio
Stable angina management?
MDT approach
Conservative = lifestyle advice
Medical:
Sublingual GTN 0.3-0.6mg PRN
Aspirin 75mg PO OD
Atorvastatin 80mg PO OD
1st line = monotherapy BB propranolol 40mg PO BD
OR
Raste limiting CCB - Verapamil
2nd line = BB with long acting dihydropyridines CCB e.g. Nifedipine as can’t give BB with rate limiting CCB.
3rd line = ivabradine monotherapy
Definition of heart failure?
Insufficient cardiac output to sufficiently supply the tissues of the body
How to classify heart failure by the symptoms?
New York heart association classification:
1 = no limitation of activity 2 = slight limitation of activity 3 = marked limitation of activity although comfortable at rest 4 = Inability to carry out physical activity without discomfort
What is frank starlings law?
Hesrts contractility and therefore SV is directly proportional to diastolic return
How does cardiac dysfunction precipitate change in the heart?
Any reduction in systolic function (loss of isotropy) / loss of diastolic function (poor ventricular compliance) = reduced CO
Reduced CO = neuroendocrine activation e.g. arterial vasoconstriction / increased blood volume = increased pre-load
Increased pre-load = ventricular wall stress = ventricular remodelling
These raised ventricular pressure = backlog
Causes of LVF?
Systolic dysfunction = myocardial damage e.g. IHD / cocaine / sarcoid
Dilated cardiomyopathy
Long standing HTN
Diastolic dysfunction =
Long standing HTN
Aortic stenosis
Restrictive cardiomyopathy
Causes of RVF?
LVF
ASD/VSD
Cor pulmonale
Pulmonary / tricuspid disease
Symptoms of LVF?
Exertional dyspnoea
Orthopnoea
Fatigue
Cough and wheeze secondary to pulmonary oedema
Signs of LVF?
Cold and cyanosed
Bibasal crackles
Gallup rhythm = S3. Causes by rapid ventricular filling.
Cardiomegaly and displaced apex
RVF symptoms?
Fatigue
Abdo discomfort
Nausea
Signs of RVF?
Raised JVP Hepato-splenomegaly Pitting oedema Ascites Pleural effusion
Framingham diagnostic criteria for heart failure?
Need 2 major criteria or 1 major and 2 minor
MAJOR = HN-COWPAT:
Hepatojugular reflex Neck vein distension Cardiomegaly Orthopnea / PND Weight loss >4.5kg in 5 days Pulmonary rales Acute pulmonary oedema Third heart sound
Investigations in heart failure?
Any one with symptoms = do a BNP <100 / NT-pro-BNP <300 rules out heart failure
If high perform a transthoracic echo (NICE recommend within 48 hours)
ECG
CXR findings in heart failure?
ABCDE
Alveolar oedema (Kerley) B lines Cardiomegaly Dilated upper lobe vessels Effusion if RVF
Management of heart failure ?
Treat any underlying cause
Conservative = stop smoking, diet, weight loss, annual influenza vaccine + ono off pneumococcal
Medical: Statins and aspirin Loop diuretic if congested 1st line for all patients = Captopril 10mg PO TDS (up to 50mg TDS) Bisoprolol 1.25mg PO OD (up to 10mg) Spironolactone 25mg PO OD
What are second line treatments for heart failure?
ARB
If you can tolerate an ACEI can try an ARNI = Angiotensin receptor neprilysin inhibitor = entresto (valsartan + sacubitril)
Surgical:
If refractory after 3 months of medical treatment
LVEF <35% and no LBBB = ICD
LVEF <35% and LBBB = CRT with biventricular pacemaker
What medicines shouldn’t you use in heart failure?
CCB’s non-dihydropyridines
What is the grades of HTN and numbers?
normal < 120/80 Pre-HTN >120/80 Stage 1 >140/90 Stage 2 > 160/100 Severe > 180/110
When do we treat HTN?
If it is stage 1 we treat when the patient is less than 80 plus one of: End organ damage CVS / renal disease DM 10 year CVS risk >20%
If stage 2 we treat after average home reading 150/95
Investigations for HTN?
2 separate BP’s at GP
Ambulatory monitoring to confirm the diagnosis
Investigate for organ damage e.g. ECG, urinalysis, fundoscopy
Causes of HTN?
Diet e.g. salt, coffee COCP or HRT Kidneys = RAS, glomerulonephritis Endocrine = Cushings, Conns, Phaeo Preganancy
Management of HTN?
Conservative = diet, relaxation therapy, smoking cessation.
Medical:
1st line <55 = ACEI/ARB
1st line >55 / black = CCB
2nd line = ACEI/ARB + CCB
3rd line = ACEI/ARB + CCB + Thiazide
4th line = specialist referral
A+C+D plus a further diuretic K-sparing
Examples and doses of your anti-HTN drugs?
ACEI = Lisinopril 10mg PO OD
ARB = Candesartan 4mg PO OD
CCB = Amlodipine 2.5mg PO OD
Thiazide = hydrochlorothiazide 12.5mg PO OD
Spiro same dose
What anti-HTN should you always use first line in diabetics?
ACEI
Blood pressure targets for diabetics and normal?
Diabetics if end organ = 130/80
Without end organ = 140/80
Normal <80 years = <140/90
Normal >80 = <150/90
Signs and management of severe/malignant HTN?
Papilloedema. 180/110, severe headaches, SOB
Admit
Controlled reduction over 2 days
1st line BB = labetalol 20mg IV every 10 minutes
Causes of aortic stenosis?
>65 = calcification <65 = bicuspid valve
Can also get things like rheumatic fusion and LV hypertrophy
Clinical features of aortic stenosis?
Triad = Angina, exertion dyspnoea and syncope
Ejection systolic murmur loudest at
RSE, 2nd ICS
Radiates to carotids
Slow rising pulse and narrow pulse pressure
Investigations for suspected aortic stenosis?
TTE
ECG can see deep S in V1 and tall R in V6, due to LVH
Aortic stenosis management?
Treat any co-morbidities
Asymptomatic;
Valve replacement if EF <50%, or aortic valve gradient >40mmHg
non-surgical = 6 monthly follow up
Symptomatic:
Low surgical risk = surgical replacement
High risk surgery = Transcatheter aortic valve replacement
- New valve mounted on stent and deployed via a catheter entering heart via femoral or apical incision
Long term anti-coagulation and IE prophylaxis
In aortic stenosis valve replacement who gets prosthetic who gets metallic?
Young = mechanic + anticoagulation as last longer
- INR 3.0
Older = bioprosthetic
What is aortic regurgitation?
Diastolic leakage of blood from the aorta into the left ventricle
Common causes of aortic regurgitation?
Acutely = infective endocarditis
Chronic = Bicuspid aortic valve
Rheumatic disease
Clinical features, signs and murmur of aortic regurgitation?
LVF, arrhythmias and angina
Collapsing pulse = Corrigans
De mussets = head bobbing
Quinckes = pulsating nail beds
Murmur = Early diastolic murmur at left sternal edge
What is an Austin-flint murmur?
Severe aortic regurgitation gives you a mid-diastolic low pitched rumbling
Management of aortic regurgitation?
Mild/moderate = treat underlying cause
Severe:
Asymptomatic with EF >50 = Nifedipine. Asymptomatic decompensated (EDD >70mm) = valve replacement / TAVR
Symptomatic = Valve replacement / TAVR
Mitral regurgitation definition?
Retrograde flow of blood from the LV into the LA via the mitral valve during systole
Causes of mitral regurgitation?
Acute = IE, post-MI papillary muscle rupture
chronic = Mitral valve prolapse, annular calcification
clinical features of mitral regurgitation?
Angina, exertion dyspnoea
Pulmonary congestion = LHF
Displaced apex, quiet S1
high pitched blowing pan-systolic murmur.
Radiates to the axilla
Management of mitral regurgitation ?
Acute = emergency surgery
Valvuloplasty or annuloplasty
Asymptomatic chronic:
EF >60 = ACEI and BB
EF <60, or LV-ESD >45mm = Surgery
Symptomatic chronic = surgery and medical
Mitral stenosis causes?
Rheumatic fever
Mitral stenosis features?
Left sided failure signs
Middle aged female Malar flush AF Tapping, non-displaced apex Right ventricular heave
What murmur is mitral stenosis?
mid-diastolic murmur with opening snap
What is Barlow syndrome?
mitral valve prolapse into the LA during systole
What is the management of mitral stenosis?
If severe symptomatic = surgery
Causes of Barlow syndrome? Clinical features?
MI, connective tissue disease e.g. Marfans
Slim young female, mid-late systolic clicks
Late systolic murmur
Tricuspid regurgitation causes?
Primary defects are rare e.g. Ebsteins anomaly
Secondary = RVF, IE, rheumatic disease
Clinical features of tricuspid regurgitation? (same for T stenosis)
RHF signs
Of advanced = hepatomegaly
Fluid retention with peripheral oedema
Pan-systolic murmur lodest at LLSE
Management?
LFT’s to check for any liver disease
Treat underlying cause
Tricuspid replacement or annuloplasty
What is ebsteins anomaly?
Downward displacement of the tricuspid valve
Causes of tricuspid stenosis?
Late complication of rheumatic disease
Pulmonary stenosis murmur?
Systolic ejection, loudest at left USE
Causes of plumonary stenosis?
Majority are congenital = Turners, Noonans, ToF and Williams
What is infective endocarditis?
Colonisation / invasion of the heart valves. Causes platelets and thrombin to adhere causing prothrombotic milieu
Which side valves are affected most in IE?
Organisms?
Left sided in 95%
S. Viridians = Affects abnormal valves, most prevalent
S. Aureus = IVDU, classically right sided, although still left side affected more
S. Epidermidis in prosthetic valves
Clinical features of IE?
Triad = persistent fever, emboli and changing/new murmur
Abdo = splenomegaly, microscopic haematuria
Cardiac = new murmur
Hands = Janeways and oslo’s
Splinter haemorrhages
Petichiae
Clubbing
DUKES criteria?
need two major, 1 major + 3 minor, or 5 minor:
Major:
+ve blood culture (typical MO, two separate cultures)
Evidence of cardiac involvement = new murmur OR +ve echo signs
Minor: Predisposing heart condition / IVDU Fever >38 Vascular phenomenon e.g. laneway lesions Immunological phenomenon e.g. haematuria MO +ve but not meeting major Echo consistent with IE but not major
IE investigations?
3 cultures 12 hours apart FBC = anaemic ESR and cRP raised Urinalysis ECHO
Management of IE?
Initial = broad spectrum antibiotics:
Native valve = amoxicillin + gentamicin
Prosthetic = Vancomycin + gentamicin + rifampicin
Staph = Native flucloxacillin 4 weeks, prosthetic = Flucloxacillin + Gentamicin + rifampicin 6 weeks
Strep = BenPen 6 weeks
What is rheumatic fever?
Immunological response to GAS (pyogenes)
Jones criteria for rheumatic fever?
Evidence of GAS + 2 major / 1 major and 2 minor
Evidence of GAS = +ve throat culture or +ve rapid antigen test
Major = PACES Pancarditis Arthritis Chorea Erythema marginatum Subcut nodules
Minor Fever ESR raised Polyarthralgia Prolonged PR on ECG
Investigations for rheumatic fever?
Bloods = ESR and CRP, cultures, GAS antigen test
ECG
Echo
Management of rheumatic fever?
Confirmed = Amoxicillin 875mg PO BD for 10 days
Complications / prognosis of rheumatic fever?
Attack will last about 3 months
50% get chronic rheumatic fever
Typically affecting mitral valve, generally do a repair over replacement as younger patients
What is acute pericarditis and its features?
Inflammation of the pericardium. <4-6 weeks
Chest pain sharp and well localised, relieved by leaning forward
Worse lying flat
Fever
Pericardial rub
Causes of acute pericarditis?
Viral e.g. Coxsackie B Systemic e.g. SLE Bacterial e.g. S. Aureus TB Post-MI = Dresslers
Investigations and management of pericarditis?
ECG = saddle shaped ST segement, with PR depression
Echo shows effusion
Management:
Treat any underlying disorder
Pericardiocentesis under ECG and echo monitoring
If purulent = Vancomycin and gentamicin
What is constrictive pericarditis?
Pericarditis that impedes normal diastolic filling. Can be a complication of acute pericarditis, or complete drainage previously
Clinical picture of constrictive pericarditis?
Management?
Congestiv heart failure = Left and right sided signs
Kussmauls breathing = raised JVP on inspiration
CXR = small heart and pericardial calcification
Echo = thickened pericardium
Management = pericardial excision
What is a pericardial effusion?
Accumulation of fluid in pericardial sac. Can result from any condition that causes pericarditis
Clinical features of pericardial effusion/
CHF
Tamponade
What is tamponade?
When accumulation of pericardial fluid cause a rise in the intra-pericardial pressure = poor ventricular filling and low CO
Becks triad = Falling BP, rising JVP and muffled heart sounds
Pulsus paradoxus
Management of pericardia effusion?
Pericardiocentesis
Management of tamponade?
Emergency
20ml syringe and 18G cannula
45-degree angle just left of xiphisternum aiming for the tip of left scapula
Aspirate and continuously watch ECG
What’s myocarditis and its causes?
Group od disorders characterised by myocardial inflammation in the absence of ischaemia
Causes = Viral e.g. influenza, coxsackie
Protozoa e.g. Chagas disease (most common cause of heart failure worldwide
Systemic = SLE
Clinical features of myocarditis?
Prodromal flu 2-3 weeks prior
Chest pain
Dyspnoea, orthopnoea, fatigue
Myocarditis investigations and management?
Bloods = mildly elevated trop ECG = non-specific ST changes CXR = bilateral pulmonary infiltrates due to CHF
management = supportive
Steroids if Autoimmune
Benznidazole if Chagas
What is hypertrophic obstructive cardiomyopathy?
Genetic disorder characterised by asymmetrical LVH with no identifiable cause
Mutation in the B-myosin heavy chain
Clinical features of HOCM?
FHx of sudden cardiac death, Young male Syncope on exertion and angina Systolic ejection murmur due to outflow obstruction = MR Accentuated by standing / exercise Lessened by lying supine / squatting
Investigations for HOCM?
ECG = LVH, deep q-waves and progressive t-wave inversion ECHO = MR, asymmetrical septal hypertrophy
CXR = cardiomegaly
HOCM management?
Restrain from high intensity sport!!!
Symptomatic = BB, low anticoagulation threshold
Amiodarone if arrhythmias
Genetic counselling
What is a cardiac myxoma?
Rare benign cardiac tumour, 90% in the left atrium attached to the septum
Clinical features of cardiac myxoma?
Management?
Mitral valve obstruction = left sided heart failure
Mid diastolic murmur of mitral stenosis
Atriotomy = may need valvular repair or CABG
What is a cardiomyopathy?
Disease of myocardium associated with mechanical or electrical dysfunction that exhibits ventricular hypertrophy or dilation
Causes of dilated cardiomyopathy?
C-DILATE:
Cardiac = IHD, rheumatic, HTN
Dystrophy e.g. Duchennes
Infection = Myocarditis e.g. Coxsackie
Late pregnancy
Autoimmune e.g. SLE
Toxins e.g. alcohol or doxorubicin
Endocrine = thyrotoxicosis
Features and investigations of dilated cardiomyopathy.
Management?
Features = LVF and RVF, arrhythmias
Investigations:
CXR = cardiomegaly, pulmonary oedema
Echo = globally dilated, reduced EF
Management = No alcohol, and treat as for heart failure e.g. BB, ACEI and diuretic
Restrictive cardiomyopathy causes?
IIEE
Idiopathic e.g post radiotherapy
Infiltrations e.g. amyloidosis
Eosinophilic endomyocardial disease
Endomyocardial fibrosis
Clinical features, investigations and management of restrictive cardiomyopathy?
Congestive heart failure + kussmauls
CXR = cardiomegaly and pulmonary oedema Echo = increased LV wall thickness, systolic function normal
Management = treat the cause
what is Marfans?
Autosomal dominant disorder characterised by loss of elastic tissue due to mutation in fibrillar 1 gene
Clinical features of marfans
Tall High arched palate Arachnodactyly Pectus excavtaum Scoliosis Hypermobile
Cardiac = Aortic aneurysms / dissections.
Aortic root dilation = aortic regurgitation
Mitral valve prolapse
eyes = lens dislocation, glaucoma, retinal detachment
Investigations of Marfans?
Echo = root dilation / dissection = AR or MR
Slit lamp
CXR = pneumothorax
blood screening
Management of Marfans?
Referral to cardio and ophthalmology
Medical = BB’s, ACEI’s
Aortic root dilation > 5cm = elective surgery with a modified Davids re-implantation with replacement of the root sparing the aortic valve.
Scoliosis = orthopaedic bracing
Retinal tears = laser photocoagulation
What is Ehlers Danlos?
Genetic disorder affecting connective tissue, particularly collagen. 6 types
Clinical features of Ehlers Danlos?
Often asymptomatic
Recurrent joint dislocation / subluxation
Skin = silky, semi-transparent, elastic and bruises easily
Cardiac = mitral valve prolapse
Investigations of Ehlers Danlos?
Clinical diagnosis, can use genetic testing
Management of Ehlers Danlos?
Asymptomatic = conservative. Avoid contact sport
Pain management and watch out for depression
Physio / OT
What is aortic dissection?
Medical emergency resulting from tear in aortic wall intimate, causing blood flow and false lumen composed of inner and outer layers of lumen
Aortic dissection causes?
Inherited e.g. ED or marfans
HTN
Bicuspid aortic valve
Turners / noonans
Clinical features of aortic dissection
Severe chest pain, classically radiates through to the back
Tearing in nature
Aortic regurgitation
HTN
Stanford classification of aortic dissection?
A = ascending aorta (66% of cases)
B = Descending aorta distal to left subclavian
Aortic dissection management?
A = surgical management =open surgery
B = bed rest and IV labetalol
