Cardiology Flashcards
Define SVT
Rate > 100bpm
QRS <120ms
Causes of SVT
AF
AVRT
AVNRT
Management of SVT
- O2 and IV access
- Regular rhythm-> Continuous ECG
- Vagal manoevres. (valsalva/carotid sinus massage)
- Adenosine 6mg → 12mg → 12mg (verapamil 5mg over 2 mins if asthma/fails) can cause chest tightness.
- Amiodarone/digoxin/atenolol.
if haemodynamic compromise -
- Sedate
- DC cardiovert
- Amiodarone 300mg over 20-60mins.
Prophylaxis: Beta blockers, AVRT: flecainide AVNRT: verapamil.
Wolf parkinson white define + ECG + management
Congenital accessory conduction pathway between atria and ventricles. Short PR interval. Wide QRS (delta wave/slurred upstroke) ST-T changes.
Mx: Refer to cardiology
Sotalol (not if AF), Flecainide, Amiodarone
Electrophysiology
Ablation of accessory pathway.
Definition and Causes of Bradycardia
<60bpm
DIVISIONS
Drugs: Antiarrythmics type 1a (procainamide), amiodarone
B blockers
Ca channel blockers
Digoxin
Ischaemia (inferior MI)
Vagal hypertonia (athletes, vasovagal syncope, carotid sinus syndrome)
Infection (viral myocarditis, Rheumatic fever, infective endocarditis)
Sick sinus syndrome (damage to SAN/AVN/conducting tissue - SVT /sinus brady +/- arrest/SA/AV block).
tx: PACE (brady) AMIODARONE (tachy)
Infiltration (restrictive/dilated cardiomyopathy)
- Autoimmune
- Sarcoid
- haemochromatosis
- amyloid
- muscular dystrophy
O
Hypothyroid
Hypokalaemia
hypothermia
Neuro (raised ICP)
Septal defect (primum ASD)
Management of bradycardia
Asymptomatic Rate >40 -> No treatment
Rate <40 -> treat underlying cause
- Medical - Atropine 0.6-1/2g IV, Isoprenaline IVI
- External Pacing.
Causes of AF
Common: IHD, Rheumatic Heart disease, Thyrotoxicosis, Hypertension
Other: Alcohol, Pneumonia, PE, Post op, Hypokalaemia, RA.
Management of Acute AF <48h
Haemodynamically unstable: HR >150, chest pain, critical perfusion.
- DC cardiovert.TOE guided. sedation/anaesthesia. give LMWH
- IV amiodarone. 300mg over 1h (check tfts, pulm fibrosis, photosensitive, liver function).
Stable: Control ventricular rate: 1. Diltiazem or verapamil or metoprolol 2. Digoxin or amiodarone 300mg IV over 60mins (LMWH +) then 900mg over 23h. . 3. LMWH 4. Cardiovert:
Flecainide (no LV dysfunction, coronary disease), Amiodarone or electrical.
If sinus restored, no RFs, dont need long term anticoagulation.
Management of persistent AF
> 7days
CCF/<65/first presentation/secondary to treated precipirant -> RHYTHM CONTROL
- TTE (structural abns)
- WARFARIN/DOAC 3 weeks.
- SOTALOL/Amiodarone 4 weeks if failure risk
- Electrical cardioversion/pharmacological
- 4 weeks of anticoagulation after.
Rate control: -> <90
- B blocker
- add Digoxin
- amiodarone
Can RFA, Maze procedure, Pacing.
CHAD2DS2VAS score determines necessity of anticoagulation in AF
CHa2DS2 VAs score
Determines necessity of anticoagulation in AF CHF:1 HTN: 1 Age>75 (2) 65-74 (1) Diabetes:1 Stroke/tia/vTE: 2 Vascular disease (MI/Peripheral artery disease/aortic plaque)1 Sex (female 1) Score 0-1 - None/ANtiplatelet >1 - Doac
STEMI mx
12 lead ECG
O2 aim 94-98
IV access - FBC,U+E, glucose, Lipids
Brief assessment - CVD hx, Thrombolysis CIs, CV exam
Aspirin 300mg PO, Clopidogrel 300mg PO
Analgesia - morphine 5-10mg IV
metoclopramide 10mg IV
ANti ischaemia - GTN 2 puffs, B blocker atenolol 5mg iv
LMWH
Admit for CCU monitoring - arrythmias
<12h Primary PCI
> 24h - thromboylysis - Alteplase,
Continuing therapy STEMI
ACEi (within 24h) e.g. lisinopril 2.5mg B blocker (bisoprolol 10mg OD) Cardiac rehab - exercise/info/manual Aspirin Lifelong. 75mg. Clopidogrel 75mg 12 m Statin (atorv 80mg)
Advice: stop smoking, diet, exercise, work 2m, sex 1m, driving 1m
NSTEMI mx
Aspirin Clopi Fondaparinux 2.5mg SC morphine 5-10mg Metoclopramide 10mg IV GTN, B blocker,
HIGH RISK: Persistent/Recurrent ischaemia, ST depression, DM, positive trop -> Angiography +/- PCI in 96h. Tirofiban,eptifabatide
LOW RISK: no further pain, flat/inverted t waves/ normal ECG, neg trop . -> d/c in 12h if trop neg.
OP angio, perfusion scan, stress echo.
stop LMWH - when pain free/3-5 days
ongoing mx ; Same as STEMI Acei B blocker cardiac rehab statin
Aspirin lifelong, clopi 1 yea
CCF Mx
- ACEi/ARB
- B blocker (increase) e.g. bisoprolol
- Frusemide
- Lifestyle advice - smoking , exercise, salt, weight, exercise, aspriin, statins.
(specialist advice)
- spironolactone
- Hydralazine + ISDN
- Digoxin
LEVF <35%: ICD
transplant
<30% LBBB
cardiac resynchronisation therapy w BV pacemaker
Acute HF (severe pul edema mx)
sit up o2 IV access + ECG (trop, fbc, u+e, BNP, ABG) Diamorphine 2.5mg + metoclopramide 10mg Frusemide 40-80mg IV GTN hypotensive: Inotropes CPAP, ISMN infusion
Monitor: BP, HR, RR, JVP, UO, ABG
Cardiogenic Shock MX
ABCDE O2 Diamorphine 2.5mg + metoclopramide 10mg correct arrythmias, Electrolyte, acid base CXR, ECHO, CT Consider FLuids, CPAP Monitor CVP, BP, ABG, ECG, UO Consider Dobutamine
Causes cardiogenic shock
MI Hyperkalaemia Endocarditis Aortic dissection Rythm disturbance Tamponade
Obstructive - Tension PTX
Massive PE.
Tamponade Signs
Becks triad: low BP, high JVP, muffled HS
Kussmauls sign: raised JVP on inspiraion
Pulsus paradoxus - pulse fades on inspiration.
IX: ECHO
CXR- globular heart.
Hypertension Mx
> 140/90 -> 1. ABPM
2. HBPM
Ix: risk of CVS disease
End organ damage.
> 180/120
observe for signs of retinal haemorrhage
papilloedema
- ACEi ARB/CCB
- +CCB/thiazide
- +both
- add spironolactone, alpha/beta blocker.
Aortic stenosis causes
Calcification w age
Congenital bicuspid
Rheumatic fever.
Aortic stenosis signs
ESM rt 2nd ICS
(louder sitting forward on expiration)-> carotids.
Slow rising pulse
narrow pulse pressure.
Quiet s2
forceful apex
Ix AS
Bloods: FBC, Lipids, U+E, glucose
ECG: LVH
CXR: Calcified valve
LVH, dilatation aorta.
Echo. + dopplers.
exercise stress if asymptomatic.
AS Mx
Optimise RFs: statins, antihypertensives, DM
Monitor
B blocker if angina
HF - ACEi, diuretics.
surgical:
valve replacement if severe symptoms, low EF, undergoing CABG.
Mechanical if younger.
bioprosthetic - older.
Balloon valvuloplasty
tAVI
Aortic regurgitation causes
Acute: Infective endocarditis, Type A aortic dissection.
Chronic: Congenital bicuspid aortic valve, rheumatic heart disease, Connective tissue disease (marfans/ED) , autoimmune Ank Spond, RA.
Sx: LVF: SOBOE, PND, Orthopnea, arryhmias AF
angina.
Signs of Aortic regurgitation
Collapsing pulse Wide pulse pressure. Apex displaced. Soft S2 EDM at URSE + 3rd left parasternal. sitting forward. expiration. severe - MDM (austin flint murmur).
Quinkes sign -nail bed pulsation
corrigans sign - pulsation.
AR ix:
FBC lipids, u+E, glucose
ECG - LVH
CXR - Cardiomegaly, Dilated aorta, pul oedema
ECHO
AR mx
optimise Rfs
monitor echo
reduce HTN (reduce afterload)
Surgery - replacement. if HF, LV dysfunction
Mitral stenosis causes
Rheumatic fever
prosthetic valve
congenital (rare)
MS pathophysiology
Valve narrows -> increased left atrial pressure -> Loud S1 /atrial hypertrophy -> AF
pul oedema /pul htn -> loud p2/PR -> RVH -> left parasternal heave.
TR-> v waves
RHF -> JVP , oedema, Ascites.
Signs of Mitral stenosis
AF Malar flush JVP - a waves, v waves. LEft parasternal heave. Tapping apex. Loud S1 Loud P2 (PHT) Rumbling mid diastolic murmur at apex. radiates t axilla . Graham steel murmur if pR.
ix of MS
Bloods ECG - AF RVH - ST dep/Twi v1-2. CXR - LA enlargement, Pul oedema, calcification ECho + doppler. Catheterisation assess coronarys.
Mx: MS
Optimise RFs Monitor echo Pen V - rheum fever prophylaxis. AF - rate control/anticoagulate. Diuretics -
Surgical - mod severe -
PERCUTANEOUS BALLOON VALVULOPLASTY
surgical valvotomy
replacement.
Mitral regurgitation causes
Mitral valve prolapse LV dilatation (AR/AS/HT) Calcification Post Mi - papilary rupture rheumatic fever connective tissue disease inf endoc
Signs MR
AF
SOB, fatigue, pul HTN, oedema
Left parasternal heave
displaced apex - > volume overload - > eccentric hypertrophy
Soft S1
loud p2
blowing Pan systolic murmur
apex -> axilla
Ix MR
BLoods Ecg - LVH, AF p mitrale CXR- LA/lv hypertrophy pul odema Echo + doppler
Mx MR
optimise RFs
monitor echo
af rate control nad anticoagulate
drugs -> reduce afterload - ACE i / b blockers, diuretics
Surgical - replacement or repair. severe.
TR Causes, Symptoms, Signs, Ix, Mx
Causes: RV dilatation, rheum fever, infective endocarditis, carcinoid
Symptoms: Fatigue, Hepatic pain on exertion
ascites, oedema
Signs: raised JVP (giant Vwaves) RV heave PSM LLSE (on inspiratin) pulsatile hepatomegaly jaundice
Ix: LFTs, EcHO
MX: tx cause, diuretics, acei, digoxin, valve replacement.
Infective endocarditis RFs
Cardiac disease: -> subacute. Normal valves -> acute Prosthetic valves degenerative valvulopathy vsd, PDA, CoA Rheumatic fever Dental caries post op wounds IVDU (tricuspid) Immunocompromised
Infective endocarditis Casues
Culture +ve
S viridans
S aureus
Culture neg Haemophilus Actinobacilus cardiobacterium eikenella Kingella Coxiella chlamydia
Non infective
SLE
Marantic (libman sacks)
Clinical features Infective endocarditis
sepsis - fever, rigors nt sweats wt loss anaemia splenomegaly clubbing
Cardiac - new/changing murmur MR 85%, AR 15%
aV block
LVF
Embolic - abscesses brain, liver, heart, kidney , spleen, gut.
Janeway lesions
Immune complex - Micro haematuria (GN) Vasculitis roth spots splinter haemorrhages oslers nodes
Dukes criteria IE
2 major
1 major 3 minor
5 minor
Major: 1. +ve blood culture (2 separate cultures, e.g. 3 12 h apart)
2. +ve echo - > vegetation, abscess, valve dehiscence, new regurgitation murmur.
Minor:
- Predisposition (cardiac lesion/ IVDU)
- fever >38
- Emboli (septic infacts, splinters, janeways)
- Immune phenomenon (GN common, Oslers, roth spots, RF)
- +ve blood culture not meeting criteria.
Ix IE
Bloods Normochromic normocytic anaemia ESR CRP IgG RF Cultures 3 x 12 h apart. serology
urine - micro haematuria
ECG: AV block/LVF
Echo - TTE - Vegetations >2mm
TOE (more sensitive )
Mx: IE
Empiric: Acute severe: Fluclox + gentamicin IV
Subacute: Benpen + gent IV
rifampicin if staph
surgery - if HF, Emboli, valve obstruction, prosthetic valve.
Rheumatic fever
Cause
Group A strep
(strep pyogenes)
cross reactivity t2 hypersensitivity
Jones criteria
Evidence of GAs infection - +ve throat culture -rapid strep ag test -ASOT increase , DNase B - recent scarlet fever \+ 2 major - Carditis -arthritis -Sydenhams chorea -Erythema marginatum -Subcutanoeus noduels
1 major + 2 minor
- Fever
- ESR, CRP
- Arthralgia
- prolongedPR
- prev rheum fever
Ix Rheum fever
BLoods: strep ag test
ASOT titire
FBC
ESR,CRP
ECG
ECHO
Mx rheum fever
Bed rest until CRP normal for 2 weeks
BENpen 0.6-1.2mg IM 10 days
analgesia NSAIDS
can use haldol or diazepam for chorea
Causes of pericarditis
Ix, MX:
Viral: Coxsackie, Flu, EBV, HIV
Bacterial: pneumonia, rheumatic fever, TB, staph
Fungi
MI, Dresslers
Drugs: penicillin, isoniazid, procainamide, hydralazine
Other: uraemia, RA, SLE, sarcoid, Radiotherapy.
Ix: ECG: saddle ST elevation + PR depression
bloods: FBC, esr, trop, cultures, virology.
Mx: Analgesia - ibuprofen 400mg PO /8h
consider steroids, immunosuppression
txcause
Symptoms and Signs of HOCM
Sx: Angina, SOB, Palpitations (AF/WPW/VT)
exertional syncope
Sudden death
Signs: Jerky pulse
Double apex beat
Harsh ESM @LLSE
S4
Ix and MX of HOCM
ECG, ECHO - assymetric septal hypertrophy
Mx: Medical : 1. B blocker, 2. verapamil
Amiodarone if arrhythmias
anticoagulate if AF/emboli
Septal myomectomy if severe sx.
consider ICD
causes of dilated cardiomyopathy
Dystrophy Infection (myocarditis) Late pregnancy Autoimmune (SLE) Toxins (etoh, doxorubicin, cyclophosphamide, DXT) Endocrine (thyrotoxicosis)
Cardiac causes of clubbing
Infective endocarditis
Congenital cyanotic heart disease
Atrial myxoma
Broad complex Tachycardia definition
Rate > 100bpm
QRS > 120ms
Broad complex tachy Differentials
VT
Torsades de points
SVT with BBB
Causes of VT
IM QVICK
Infarction (esp with ventricular aneurysm)
Myocarditis
QT interval
Valve problem (AS, mitral prolapse)
Iatrogenic ( digoxin, antiarrythmics, catheter)
Cardiomyopathy (dilated)
K (hypokalaemia, hypomagnesemia, hypoxaemia, acidosis).
Mx of VT
O2 + IV access
Unstable -> sedate -> DC cardioversion (200-300 - 360J)/amiodarone (300mg over 20-60m) then 900mg over 23h.
Stable - Correct electrolyte problems (e.g. 60mM KCL @ 20mm/h. /4ml 50% MgSO4 in 30mins.
Regular rhythm (VT) -> Amiodarone, lignocaine.
Irregular (AF + BBB) -> Flecainide /Amiodarone
TDP -> MgSO4 2g IV over 10mins
fails-> DC cardiovert.
Indications for a pacemaker
Sinus node dysfunction: -symptomatic sinus bradycardia. -complete heart block -symptomatic 2nd degree. chronic bifasicular block. Cardiac transplant Post MI HOCM Severe HF Congenital heart disease
