Cardiology Flashcards
No ST elevation
AND
Troponin is normal
Unstable angina
Non occlusive thrombus
No ST elevation
AND
Troponin is raised
Non ST elevation myiocardial infarction
NSTEMI
Occluding thrombus sufficient to cause tissue damage and mild myocardial necrosis
ST elevation
ST elevation myocardial infarction
STEMI
Complete thrombus occlusion
(May present new LBBB)
Classic symptoms of acute coronary syndrome
Chest pain
Central/left sided/ substernal/ epigastric
May radiate to the jaw, left arm or shoulder
Described as heavy or constricting “elephant on my chest”
Other symptoms> dyspnoea, sweating, nausea and vomiting, may appear pale and clammy
remember that pxs with DM or elderly may not experience any chest pain! = Silent MI
Unmodifiable Risk factors of Ischemic Heart Disease
Increasing age
Male gender
Family history
Modifiable Risk factors of Ischemic Heart Disease
Smoking DM Hypertension Hypercholesterolaemia Obesity
ST elevation on DII, III and aVF
Inferior MI
Right coronary
ST elevation on DI, aVL, V5 and V6
Lateral MI
Left Circumflex
ST elevation on V1, V2, V3 and V4
Anterior (anteroseptal) MI
Left Anterior Descending
ST elevation on DI, aVL, V4, V5, V6
Anterolateral MI
Left anterior Descending
OR
Left Circumflex
Wide spread ST depression
ST elevation in aVR
Left main coronary artery occlusion
EMERGENCY CORONARY ANGIOGRAPHY
Management of Acute settings in ST elevation
MONA Morphine O2 Nitrates Aspirin 300mg \+ Heparin (unfractionated or LMW --> enoxaparin or fondaparinux)
If the patient with ACS presents within …… of the onset of the symptoms then a …… can be done
12 hours
PCI/angioplasty (stent) (percutaneous Coronary Intervention)
GOLD STANDARD
What should be done if PCI is unavailable or the patient presents after 12 hours of the onset of symptoms?
Thrombolysis
Alteplase is preferred over Streptokinase
Chronic/Long term Management of MI
-Aspirin for life
-Ticagrelor or Prasugrel or Clopidogrel for 12 months
-Beta blockers for 12 months (atenolol, bisoprolol)
-ACE inhibitor for life (captopril, enalapril, ramipril)
If intolerant then ARBs (losartan, valsartan, irbesartan)
-Statins for life Atorvastatin 80mg PO OD
**5 drugs= AABC+S
Aspirin, ACE inhibitors, Beta blockers, Clopidogrel, Statins
Management of NSTEMI & Unstable Angina
-Aspirin 300mg
+
-Antithrombin>LMWH (enoxaparin, dalteparin or Fondaparinux)
AS SOON AS POSSIBLE
- Nitrates or morphine to relieve pain
- Second antiplatelet (clopidogrel, prasugrel)
- IV glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban)
- Coronary angiography should be considered
Who should LMWH be offered to?
Pxs with NSTEMI & Unstable Angina who are not at high risk of bleeding and who are not having angiography in the next 24 hours
If angiography is likely or creatinine is >265 umol/l, unfractionated heparin should be given (UH is IV!)
To whom should IV glycoprotein IIb/IIIa receptor antagonists be given?
Epifibatide and tirofiban
Pxs with NSTEMI & Unstable Angina who have intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3%) and who are scheduled to undergo angiography within 96 hours of hospital admission
Who should be considered for coronary angiography?
Pxs with NSTEMI & Unstable Angina who have predicted 6-month mortality above 3%.
It should be considered within 96 hours of 1st admission to hospital
It should be performed as soon as possible in patients who are clinically unstable.
Px with acute chest pain radiating to jaw and shoulder WITHOUT ST elevation, what should be done next?
Measure cardiac enzymes (troponin)
Px with acute chest pain radiating to jaw and shoulder WITHOUT ST elevation, and high troponin levels, what should be done next?
Give subcutaneous LMWH or Fondaparinux + Aspirin 300mg
60 YO man with Hx of smoking, HTN and DM complaining of 25 minutes of left side dull aching chest pain radiating to the jaw. He was given 300mg of Aspirin. He is no longer in pain and the ECG is NORMAL. The troponin levels are 202 ng/L (Normal < 5ng/L). What is the next step?
A) Alteplase
B) SC fondaparinux
C) IV Glyceryl trinitrate
D) IV Morphine
Since the ECG is normal, alteplase is WRONG
ECG normal with high troponin levels = NSTEMI
Correct answer: Anticoagulation (LMWH> Dalteparin, Enoxaparin, Fondaparinux)
62 YO man with Hx of smoking and HTN complaining of 25 minutes of left side constricting chest pain radiating to his left shoulder. He was given 300mg of Aspirin and trinitrates for the pain. The ECG shows ST elevation in V1-V4. What is the most appropriate next step in management?
PCI- Percutaneous Coronary Intervention
If not among the choices> Atleplase (thrombolysis)
59 YO with Hx of HTN, complaining of chest pain for around 4 hours. Vitals are stable. He was given IV morphine for his chest pain. ECG shows T wave inversion in DII, DIII and aVF. What is the next step in management?
Chest pain+T wave inversion = myocardial ischemia
ASPIRIN 300mg
AND
LMWH or Fondaparinux
59 YO with Hx of HTN, complaining of chest pain for around 4 hours. Vitals are stable. He was given IV morphine for his chest pain. ECG shows wide spread ST depression and ST elevation in aVR. What is the next step in management?
Wide spread ST depression + ST elevation in aVR = Left Main Coronary Artery Occlusion
–> EMERGENCY CORONARY ANGIOGRAPHY
Cardiac tamponade triad
Beck’s triad> hypotension, muffled heart sounds, high JVP (distended neck veins)
Other symptoms: dyspnea, pulsus paradoxus, tachycardia
How can a cardiac tamponade develop after a MI?
Acute pericarditis
>Pericardial effusion
>Cardiac Tamponade
Trauma is the most important cause of cardiac tamponade
How does a cardiac tamponade looks in a Chest X-ray?
Enlarged GLOBULAR heart
(It can also be a pericardial effusion)
Looks like a leather bag filled with water
Dx and Rx of a cardiac tamponade
Echocardiogram
Urgent pericardiocentesis
Initial Rx of a patient in hypovolemic shock and cardiac tamponade.
1-2 L of IV fluids**
Oxygenation and ventilation
Bedside pericardiocentesis
Atrial Myxoma
Benign tumour
75% in the left atrium
Tend to grow on the wall (inter-atrial septum)
10% are inherited–> familiar myxoma
Mitral valve obstruction caused by atrial myxoma
Mid-diastolic murmur, dyspnea, syncope and congestive HF
What happens if small pieces of an atrial myxoma break off and travel to the arteries?
Ischemia
Lung- Pulmonary embolism
Brain- Stroke
Peripheries- Clubbing and blue fingers
Px with mid-diastolic murmur, dyspnea, syncope, congestive HF, clubbing and blue fingers with Hx of pulmonary embolism and atrial fibrilation.
Dx?
Obstruction of mitral valve–> mid-diastolic murmur, dyspnea, syncope and congestive HF
Small pieces may break off and travel to arteries –> PE, Stroke or clubbing and blue fingers
Atrial fibrilation
=Atrial Myxoma
An echocardiogram shows a pedunculated heterogeneous mass typically attached to the region of fossa ovalis (inter-atrial septum)
Dx?
Atrial Myxoma
Px with Atrial Myxoma with sudden painful swollen limb with a loss of pulse.
Acute limb ischemia
Rx> Urgent catheter Embolectomy
QRS in lead I is up (+) and lead II is down (-)
Left axis deviation
-30 to -90
QRS in lead I is down (-) and in lead II is up (+)
Right axis deviation
90 to 150
QRS in lead I is down (-) and in lead II is down (-)
Right superior axis deviation
150 to 270
QRS positive in lead I and II
Normal axis
-30 to 90
Causes of Left Axis deviation
Inferior MI
Left ventricular hypertrophy
Left Anterior Fascicular block (or hemiblock)
Obese
Wolff-Parkinson-White syndrome (delta wave)
Causes of right axis deviation
Lateral MI Right ventricular hypertrophy Left posterior fascicular block (or hemiblock) Thin, tall, children Chronic lung disease Pulmonary embolism
Causes of extreme right axis deviation
Congenital heart disease
Left ventricular aneurysm
PR interval >0.2 seconds
PR occupies more than 1 large square or 5 small squares
1st degree heart block
2nd degree heart block
Mobitz I
Progressive prolongation of the PR interval until a dropped beat occurs
2nd degree heart block
Mobitz II
PR is constant but the P wave is often not followed by a QRS complex
Complete (third degree) heart block
No association between P waves and QRS complexes
1st degree and Mobitz I heart block management
Do not require treatment as long as the patient is asymptomatic
Mobitz II and 3rd degree heartblock management
Permanent pacemaker
How long is a small square and a big square in an ECG?
small= 0.04 seconds
big= 0.2 seconds
Agents used to control rate in patients with atrial fibrilation
Beta blockers (atenolol, bisoprolol, metoprolol) –> 1st line but contraindicated in Asthma
Calcium channel blockers (diltiazem, verapamil) –> in asthmatic patients
Digoxin (less effective controlling rate during exercise, no longer 1st line) Preferred in patients with coexistent HF
Patient with atrial fibrillation hemodynamically unstable
Cardioversion
Atrial flutter management
Cardioversion
Patient conscious or semiconscious with VT and stable
Amiodarone
HE IS STABLE!
What is VT?
a broad complex tachycardia originating from a ventricular ectopic focus
It can develop into a FV therefore requires urgent treatment!
P wave might be present or absent
Patient unconscious with VT but with present pulse
Cardioversion!
Unstable but HAS A PULSE!
Patient unconscious, collapsed, not breathing and no pulse with VT
Defibrillation (asynchronized shock)
Most important cause of ventricular tachycardia
Hypokalemia (low K)
Atrial Fibrillation symptoms and treatment
Palpitation, tachycardia, dyspnea, fibrillatory waves on the ECG, irregularly irregular rhythm
Beta blockers
If asthmatic give calcium channel blocker
Atrial Flutter symptoms and treatment
Fluttering feeling in the chest
Sawtooth waves
Cardioversion
Ventricular tachycardia symptoms and treatment
Ongoing lightheadness, palpitations, chest pain
Amiodarone
If unstable–> Cardioversion
Ventricular fibrillation symptoms and treatment
Older adult, sudden collapse, not breathing, unconscious, no pulse.
Defibrillation
Sinus bradycardia symptoms and treatment
Lightheadness, hypotension, vertigo, syncope, dizziness.
Symptomatic bradycardia–> atropine
The following medications have shown to reduce mortality in pxs with Left Ventricular failure.
- ACE-inhibitors
- Beta-blockers
- ARBs
- Aldosterone antagonists (eplerenone, spironolactone)
- Hydralazine with nitrates
Loop diuretics and nitrates are key in the acute decompensated HF, but they have no effect on long-term survival.
Tx for HF with symptoms
What if the px has DM?
Diuretics to relieve symptoms and reduce overload
Start with ACEi OR Beta-blocker (ONLY 1)
If symptoms persist add the other one (ACEi, BB or ARB)
If symptoms still persist add Spironolactone
If the px has DM we start with ACEi
Spironolactone is a….
Potassium-sparing diuretic
AND
an aldosterone antagonist
What drug should be administered if the patient has HF and AF?
Digoxin!
Inhibition of the Na/K ATPase in the myocardium.
Personal note: More recent randomized trials have shown an increase in mortality in HF patients with digoxin.
Why furosemide + ACEi don’t lead to hyperkalemia?
Furosemide= loop diuretic leads to hypOkalemia
ACEi and Spironolactone= lead to hypERkalemia
Which is the most accurate investigation to demonstrate a patent foramen ovale
Transesophageal echocardiography with bubble contrast
What is a patent foramen ovale?
The foramen allows blood to pass from RA to LA.
The opening closes soon after birth. In about 1 out of 4 people it never closes.
It may cause paradoxical embolism (an embolism that travels from the venous side to the arterial side)
Most common cause of death following a MI and treatment
Cardiac arrest due to ventricular fibrillation.
Tx= Defibrillation
What may occur 48 hours after a MI
Pericarditis
Pleuritic chest pain that worsens on lying flat and during inspiration + fever + pericardial rub (extra heart sound, 2 systolic and 1 diastolic that resembles a squeaky leather, described as grating, scratching or rasping)
ECG that shows
Widespread saddle shaped ST elevation with upward concavity and PR depression
Pericarditis
Px with fever + pericardial rub + pleuritic chest pain
The X-ray will show…?
Pericardial effusion
An enlarged globular heart can be observed and is confirmed by echocardiography
Px with pleuritic chest pain that shows widespread saddle shaped ST elevation with upward concavity and a PR depression.
Dx and Rx?
Pericarditis
Full dose of NSAID
Aspirin 2-4g daily
Ibuprofen 1200-1800mg daily
Indomethacin 75-150mg daily
At least 7-14 days.
Px with Hx of MI 3 weeks prior, complains about pleuritic chest pain + fever + and a pericardial rub with ECG that shows widespread saddle shaped ST elevation with PR depression.
Dx and Rx?
Dressler’s syndrome
Thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers
Rx> NSAIDs
It tends to occur 2-6 weeks following a MI
It may show a raised ESR (erythrocyte sedimentation rate)
Px with Hx of MI 4 weeks prior, complaining of shortness of breath.
The ECG shows ST elevation.
Most likely diangosis?
Left ventricular aneurysm
The ischaemic damage may weaken the myocardium resulting in a thin muscular layer> aneurysm formation
Usually occurs 4-6 weeks post MI
High risk of stroke due to a thrombus> anticoagulate!
ECG, Chest X-Ray and Echo of a left ventricular aneurysm
ECG> persistent ST elevation
CXR> enlarged heart with a bulge at the left heart border
Echo> paradoxical movement of the ventricular wall (instead of moving inward, it moves away from the septum during systole)
Px with Hx of MI 5 days ago, complaining of dyspnea, orthopnea, chest pain and diaphoresis. A pan-systolic murmur can be heard.
Dx and Rx?
Ventricular septal defect (VSD)
Presents in the 1st week post MI
Only 1-2%
Presents with acute heart failure with pan-systolic murmur
The echocardiogram is diagnostic and excludes acute mitral regurgitation which is similar.
Rx> Urgent surgical correction
Acute Mitral Regurgitation
Occurs x days after MI Due to... Presents with ... on auscultation Dx is with... Rx?
Occurs 2-15 days after MI
Due to ischemia or rupture of the papillary muscles of the mitral valve
pan-systolic murmur is typically heard
May present with hypothension, tachycardia and pulmonary edema
Dx> echocardiogram
Rx> vasodilator therapy but often requires emergency surgical repair.
A px presents with ST elevation and chest pain.
Management?
What if it’s not available?
STEMI
MONA and then
PCI if not obtainable
> Alteplase, if not available
> streptokinase
A px presents with chest pain and NO ST elevation.
Management?
oral aspirin 300mg
LMWH or Fondaparinux
1st, 2nd and 3rd choice for symptomatic bradycardia
1st- atropine (0.5mg IV push and may be repeated up to 3mg)
2nd- Dopamine
3rd- Epinephrine
If the question says “the next best step” or “the initial line” –> O2!!!
A patient presents with fever, malaise and rigors, and a new murmur can be heard
Dx?
Initial step?
Infective endocarditis
> Blood culture and then echo
Risk factors for infective endocarditis?
A previous episode of IE (strongest RF)
Rheumatic valve disease
Prosthetic valves
Congenital heart defects
IV drug user (typically causes tricuspid lesion)
Causative organisms of IE?
Staph. aureus is the most common in general
Staph epidermis is the most common in prosthetic valve surgery
Strept. viridans is the most common in people with poor dental hygiene or following a dental procedure
(Strept. mitis and sanguinis)
Positive Modified Duke criteria
2 major criteria or
1 major and 3 minor
5 minor
Major Duke criteria
1) Positive cultures
2 + blood cultures showing typical organisms (Strep viridans and HACEK group)
OR
Persistent bacteraemia from 2 blood cultures taken >12h apart or 3 or more + cultures where pathogen is less specific such as Staph aureus and epidermis
2) Evidence of endocardial involvement (+ Echo for IE)
+ echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves)
OR
New valvular regurgitation
Minor Duke criteria
1) Predisposing heart condition or IV drug use
2) Microbiological evidence that does not meet the major criteria
3) Fever >38C
4) Vascular phenomena–> Major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, Petechiae or purpura
5) Immunologilcal phenomena–> glomerulonephritis, Osler’s nodes, Roth spots.
Osler’s Nodes
painful, red nodules on the hands or feet that can persist for hours to days
Janeway lesions
Non-tender, small, erythematous or hemorrhagic macular or nodular lesions on the soles or palms. (they occur due to septic microemboli that deposit the bacteria under skin)
IE empirical therapy
Amoxicilin + low dose Gentamicin
OR
Vancomycin+ low dose Gentamicin (if apenicillin allergic or MRSA Staph Aureus is suspected or severe sepsis)
If Hx of prosthetic valve endocarditis–>
Vancomycin+low-dose Gentamicin+ Rifampicin
A man had dental extraction a few days ago that presents with petechia. His vitals are stable except for his temperature which is 38.9C. On examination he has petechiae, painful nodules on his palms, and a cardiac murmur.
Most likely Dx?
Next investigating step?
Initial management?
IE (fever+new murmur)
Blood culture (followed by echo)
Amoxicilin+low dose Gentamicin
What score should we use in in atrial fibrilation
CHA2DS2-VASc Score
What does CHA2DS2-VASc Score determines and what does it measure?
The need to anticoagulants in a patient who has atrial fibrillation
C- congestive heart failure - 1pt H- Hypertension (BP>140/90) - 1pt A2- Age >75 years - 2pt D- DM - 1pt S2- Prior stroke or TIA or Thromboembolism - 2pts V- vascular disease (MI, PVD, Aortic plaque) 1pt A- Age 65-74 years - 1pt Sc- Sex category (female = 1 pt)
A patient with CHA2DS2-VASc Score of 2 pts or more should be given…
Warfarin or DOAC (direct-acting oral anticoagulants) like Apixaban, rivaroxaban, edoxaban, dabigatran
Consider warfarin or DOAC to men who score >1 or more
What are some advantages and disadvantages of DOAC?
Advantages
No need of INR monitoring
Faster Onset of action (2-4 hours)
Reduces the risk of intracranial hemorrhage
Disadvantages
No antidote
Requires strict compliance by the patients
ABCD2 score
Is used to identify the risk of future stroke in pxs who have had a suspected TIA in the following 7 days. (Not advised to use according to recent 2019 CKS guidelines)
HAS-BLED score
estimates the risk of major bleeding for patients on anticoagulation for atrial fibrillation
DRAGON score
predicts the 3 month outcome in ischaemic stroke patients receiving tissue plasminogen activator (tPA like alteplase)
QRISK2 score
determine the risk of a cardiovascular event in the next 10 years.
What is the mechanism of a pulmonary edema?
Often caused by congestive heart failure. When the heart is not able to pump efficiently–> the blood may return into the veins –> then the lungs.
As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs.
Features of a pulmonary edema
Desaturation Dyspnea Orthopnea Crepitations (crackles-rales) Tachycardia
Investigation of pulmonary edema
Chest X-ray is the single most appropriate investigation
BUT
the underlying cause requires echocardiogram (HF, complication of MI, ventricular aneurysm)
“The most appropriate investigation” = Chest X-ray
“The investigation needed to identify the underlying cause” = Echocardiogram
Management of pulmonary edema
MONF (MONA but the A is replaced by Furosemide)
Morphine
O2
Nitrates
Furosemide
Sit the px up and give O2 (>95% or >90% in COPD)
Spray 2 puffs of sublingual GTN (Glyceryl TriNitrates)
Give furosemide 40mg IV (SLOWLY)
Diamorphine (2.5-5mg IV slowly) or Morphine (5-10mg IV SLOWLY) to relieve pain, anxiety and distress
Difference in the diagnosis between Pulmonary Edema and Pulmonary Embolism
Pulmonary edema can be diagnosed by chest x ray (Kerley Lines> expansion of the interstitial space by fluid; + Bat’s wings hilar shadow)
Pulmonary embolism needs CTPA (CT pulmonary angiogram)
Dissecting Aneurysm or aortic dissection may present as a MI
However, name some clinchers that could direct us towards a DA and not a MI
Unequal pulses in upper limbs
Hx of Marfan Syndrome
Hx of Ehlers-Danlos syndrome or Turner syndrome
Severe tearing chest pain that radiates to the back
HTN is the most important risk factor
The pxs present with hypotension, dyspnea, tachycardia, and sweating.
Symptoms caused by low blood supply to organs like a stroke or mesenteric ischemia
Aortic dissection pathophysiology
Tear in the tunica intima of the wall of the aorta.
The injury allows blood to flow between the layers of the aortic wall, forcing the layers apart.
What is the best diagnostic test for aortic dissection?
Transoesophageal echocardiogram (TEE) Sens 98% and Spec 97%
CT scan with contrast is also good or MRI
In emergency use US or CT scan
Stanford classification of aortic dissection
Type A> ascending aorta, 2/3 of cases
Type B> descending aorta, distal or left subclavian origin. 1/3 of cases
Management of Type A Standford classification
Ascending aorta dissection.
Surgical management, but blood pressure should be controlled to a target systolic of 100-120mmHg whilst awaiting intervention
Management of type B Stanford classification
Descending aortic dissection
Conservative management, bed rest, reduce blood pressure.
IV labetalol to prevent progression
Left Brundle Branch Block (LBBB) features on ECG
Notched (M shaped) broad complex QRS usually in lead I, aVL and V6 but not always.
Deep inverted QRS usually in V1
Left axis deviation
Patient complaining of chest pain and dyspnea. The ECG shows a notched broad complex QRS in DI and aVL and deep negative QRS in V1. He has no cardiac Hx.
Management?
New onset of LBBB!
Myocardial infarction!
Thrombolysis or PCI
(and MONA)
A px presents with sudden severe abdominal pain, hypotension and sweating, and has no lower limb pulse.
Dx?
Ruptured abdominal aortic aneurysm (AAA)
Triad> pain, hypotension, pulsatile tender abdominal mass.
Sudden onset of severe abdominal pain ± lower back ± flank pain.
Shock (hypotension, sweating and fainting)
Absent lower limb pulse and mottled skin.
A px presents with sudden severe abdominal pain, signs of shock and has no pulse on lower limbs.
Management?
Surgical emergency!
The initial investigation is an ultrasound
If not available then CT scan.
Screening for abdominal aortic aneurysm in the UK
Men only
Once only
In 65th year
by ultrasound.
A px with Hx of 5 years with dyspnea, orthopnea, lower limb edema that has DM
Management?
Symptomatic relief–> furosemide (loop diuretics)
Start with ACEi instead of BB (DM patients)
If the symptoms persist add BB
If still symptomatic add spironolactone (potassium sparing diuretics)
Coronary artery dominance
The artery that supplies the posterior descending artery (PDA) determines the coronary dominance
In 85% of the population, the right coronary artery (RCA) gives off the PDA (right dominant)
In 15% of the population, the left circumflex gives off the PDA (left dominant)
Hence, the artery dominance is the RCA, as it gives off the PDA in 85% of people.
Px with furosemide that presents with muscle weakness and cramps and the ECG shows a U-wave.
Dx and management?
U-wave and muscle weakness and cramps = hypOkalemia
Thiazide like diuretics and loop diuretics are the main cause
NOT potassium sparing diuretics like Spironolactone (hypERkalemia)
Rx> oral or IV Potassium chloride (based on severity> K <2.5 = IV)
Stop/treat the cause (thinking about diuretics, vomiting and diarrhea, Cushing syndrome and Conn’s disease)
Causes of hypokalemia
Loop diuretics
Thiazide like diuretics (bendroflumethiazide, indapamide)
Vomiting and diarrhea
Villous adenoma
Renal tubular failure
Cushing syndrome
Primary hyperaldosteronism (Conn’s disease)
Causes of hyperkalemia
ACEi
ARBs
Potassium sparing diuretics (spironolactone or eplerenone)
CKD/acute renal failure
Addison’s (primary adrenal insufficiency)
Congenital adrenal hyperplasia (CAH)
20 YO px complaining of palpitations and light headedness. Hx of asthma. Presents with 130 HR, rest of vitals stable. The ECG shows narrow-complex ventricular Tachycardia.
Dx and management?
Paroxysmal supraventricular tachycardia
Rx
Valsalva manouver or carotid massage
IN ASTHMATIC> Verapamil! (CCB)
(adenosine is contraindicated)
Adenosine 6mg IV
Adenosine 12mg IV
Adenosine 12mg IV
Cardioversion
To prevent future episodes> B blockers or radio frequency ablation.
Broad QRS
Prolongued QT
Fainting episodes
May be young px who is an athlete
Polymorphic Ventricular Tachycardia (Torsades De Pointes)
Tx if pulse!
IV Magnesium Sulphate. (Verapamil SHOULD NOT BE USED in VT)
Stage 1 Hypertension
Clinic BP>140/90mmHg and subsequent ABPM daytime average or HBPM average BP≥135/85mmHg
Stage 2 hypertension
Clinic BP ≥ 160/100mmHg and subsequent ABPM daytime or HBPM average BP ≥ 150/95mmHg
Stage 3 hypertension
“Severe hypertension”
Clinic systolic BP ≥ 180mmHg or clinic diastolic BP ≥ 110mmHg
Lifestyle management of hypertension
Low salt diet Caffeine intake should be reduced Stop smoking Drink less alcohol Eat a balanced diet rich in fruits and vegetables Exercise more Lose weight
When to treat stage 1 hypertension?
<80 years old AND any of the following Target organ damage Established CV disease Renal disease DM A 10-year CV risk equivalent of >20%
If not = Lifestyle modification and follow up
What should be done in stage 2 hypertension patients before drug management?
Record either ABPM or HBPM
What should be done in px <40 years old with stage 2 or 3 hypertension?
Consider specialist referral to exclude secondary causes of HTN.
When should we ALWAYS treat HTN patients?
If ABPM or HBPM ≥ 150/95mmHg (confirmed stage 2 or higher)
White + <55 YO
with HTN, Rx?
Start with ACEi/ARBs
White + >55YO with HTN, Rx?
Start with CCB
Calcium channel blocker
Afro-caribbean + any age with HTN, Rx?
start with CCB
Calcium channel blocker
Step 2 in HTN management in a px who is still hypertensive after the 1st step and lifestyle changes.
Add ACEi/ARBs
Add CCB
A+C (ACEi + CCB)
Step 3 in a HTN management who is still hypertensive
Add D (Thiazide Diuretic)
ACEi+CCB+Thiazide like Diuretic (A+C+D)
Examples of Thiazide like Diuretics
Chlorthalidone 12.5-25mg OD
Indapamide 1.5mg modified release OD
or 2.5mg OD
Bendroflumethiazide is NO LONGER recommended by NICE as an hypertensive.
Step 4 in HTN management in pxs who are still hypertensive?
A+C+D
consider further diuretic treatment
If K<4.5mmol/l add spironolactone 25mg OD (K sparing)
If K>4.5 mmol/l add higher dose thiazide like diuretic
If diuretic therapy is not tolerated or is contraindicated or ineffective consider an alpha or beta-blocker
HTN patients who fail to respond to step 4 of HTN management
A+C+D + further diuretic or alpha/beta blocker
If optimal tolerated doses of four drugs is not enough
–> seek expert advice!
BP targets in HTN+DM
If end organ damage <130/80mmHg
If not <140/80mmHg
BP targets for >80 YO pxs with HTN without DM
Clinic BP <150/90mmHg
ABPM/HBPM 145/85mmHg
BP targets for <80 YO pxs with HTN without DM
Clinic BP < 140/90mmHg
ABPM/HBPM 135/85mmHg
Why are ACEi used for DM and HTN pxs?
It is reno-protective (unless eGFR is low <30= advanced CKD)
It has protection against diabetic retinopathy
It has positive effect on glucose metabolism
Management of HTN
52 YO px with Hx of DM and who is African-British
ACEi+CCB!
If he was only diabetic start with ACEi regardless of age as it is reno-protective (unless eGFR < 30)
as he is Afro-Caribbean start with both ACEi and CCB!
Postural hypotensiob (Orthostatic Hypotension) definition and dx?
A drop in systolic BP of at least 20mmHg within 3 minutes of standing
OR
drop of diastolic BP of at least 10mmHg within 3 minutes of standing
Dx> monitor BP
Postural hypotension is most common in which people?
Elderly people
especially those who take multiple drugs (polypharmacy)
Pxs with HTN due to drugs.
Remember that baroreflex mechanisms that control HR and Vascular resistance decline with age, specially in pxs with HTN
An elderly man complains of difficult mobilization. He often feels dizzy upon trying to stand ± he has Hx of recurrent falls. Management?
BP monitoring and assess and review the pxs medications.
Px presents with palpitations. His ECG shows absent P wave and irregularly irregular rythm. Dx and Management?
Atrial Fibrillation
1st line> beta-blockers
If asthmatic> avoid B-blockers and give CCB
If associated HF> digoxin
Calculate CHAD2S2-VASc-Score and give Warfarin, DOAC or nothing
Px with a sense of a skipped beat, unsustained palpitation, dyspnea and dizziness. What will the ECG most likely show?
An early and broad QRS complex = Ventricular ectopic
If it has 3-beat patterns= Ventricular trigeminy
50% of all the population has silent/asymptomatic ventricular ectopics which are discovered incidentally on a routine ECG
Causes of ventricular ectopics
Ischemic heart disease (MI) Cardiomyopathy Stress Alcohol Caffeine Cocaine Medications or-------> naturally
If these Ventricular ectopics are due to ischemic heart disease or cardiomyopathy > may precipitate life-threatening arrhythmias like VF
A px with chronic HF developed gout. A medication for his gout is prescribed. A few days later the patient comes back complaining of worsening of his heart failure symptoms (shortness of breath and orthopnea).
What is the cause of this worsening?
Gout> NSAIDs.
Never give NSAIDs nor selective COX-2 inhibitors to CKD, CHD, IHD.
NSAIDs inhibit synthesis of prostaglandins–> decrease the eGFR, retain more salt and water (worsening HF)
Thiazide like diuretics and loop diuretics decrease the clearance of uric acid –> leading to gout (hyperuricemia)
NSAIDs are used to treat gout.
In-hospital Cardiac Arrest algorithm
- Collapsed patient
> SHOUT for help and assess the patient - No signs of life (no pulse and not breathing) > ring bell/code blue
- Start CPR 30 compressions and 2 ventilations
ASK FOR THE DEFRIBILLATOR - Use defibrillator
Advanced Life Support Team arrives.
Why do DM patients may die suddenly and silently without feeling any chest pain when having a MI?
Autonomic neuropathy
>painless MI or silent MI
UK guidelines on alcohol
A person should drink…
No more than 14 units a week
(1 unit= 10mL or 8g= amount of alcohol that can be processed in an hour by an adult)
No more than 3 units a day
at least 2 alcohol-free days a week
(a pint of strong lager is 3 units; a low strength lager has just over 2 units)
A px drinks 7 units of alcohol a week and smokes 20 cigarettes a day. We should refer him to an Alcohol Cessation Clinic or a Smoking Cessation Clinic or both?
Smoking Cessation Clinic
No more than 14 units of alcohol a week
His alcohol intake is insignificant as per NICE guidelines.
Pre-hospital analgesia (while in ambulance) for MI
GTN> Glyceryl Trinitrate sublingual or spray
±opioids IV> 2.5-5mg Diamorphine or 5-10mg morphine
Remember 1/3 of pxs have nitrate resistant chest pain, therefore, morphine is given additionally to relieve chest pain.
Why should we give IV analgesia and not IM in the ambulance in the case of a MI?
IM absorption is unreliable
If the px receives thrombolysis later on, the site of injection IM might bleed.
An ECG showing broad complex tachycardia in a still conscious patient ± atrial activity
Ventricular tachycardia
GIVE IV AMIODARONE
Most important cause of ventricular tachycardia clinically
Hypokalemia
Tall tented T wave in ECG is…
hyperkalemia
U wave in ECG is…
hypokalemia
Causes of hyperkalemia
ACEi Spironolactone NSAIDs Renal Failure Acidosis Adrenal insufficiency Addison's disease
Rx of hyperkalemia
First protect the cardiac membrane by giving IV calcium gluconate (or calcium chloride)
Then reduce the serum potassium by giving Insulin with dextrose or Salbutamol
M shaped QRS in leads I, aVL, V6
AND
Negative inverted QRS in V1
LBBB
Left Bundle Branch Block
Associated with acute MI!!!
A px with an ejection systolic murmur heard on the right ICS just lateral to the sternum that radiates to the carotid artery.
Aortic Stenosis
Symptoms> dyspnea on activity, anginal chest pain, syncope.
Px with early diastolic murmur heard on the right ICS just lateral to the sternum and symptoms of HF
Aortic regurgitation
Px with ejection systolic murmur on the left 2nd ICS just lateral to the sternum that radiates to the left shoulder of infraclavicular area.
Pulmonary stenosis
Symptoms of systemic cyanosis
Px with early-diastolic murmur heard on the left 2nd ICS just lateral t the sternum
Pulmonary regurgitation
Symptoms of right sided heart failure
Px with mid-late diastolic murmur, with opening click on the apex.
Mitral stenosis
Symptoms of heart failure
Px with pan-systolic murmur on the apex that radiates to the axilla.
Mitral regurgitation
Symptoms of Congestive HF (edema and ascites)
Px with diastolic rumble murmur on the 4-5th ICS over the left sternal border and discomfort on the neck.
Tricuspid stenosis
Fluttering and discomfort on the neck
Px with pan-systolic murmur heard on the 4th-5th ICS over the left sternal border.
Tricuspid regurgitation
Symptoms of right-sided heart failure.
Pathogenesis of mitral stenosis
Stenosis impedes left ventricular filling –> increased left atrial pressure which leads to left atrial hypertrophy (CXR shows straight left side heart border) –> blood returns back to lungs –> pulmonary congestion –> right ventricular failure (hepatomegaly, ascites, oedema)
Features of Mitral stenosis
Mid-late diastolic murmur (best heard on expiration) “low-pitched”
Loud S1, opening snap
Atrial fibrillation
Low volume pulse
Malar flush
Left heart murmurs are better heard on…
Right heart murmur are better heard on…
LEft on Expiration (mitral and aortic)
rIght on Inspiration
tricuspid and pulmonary
How does dilated cardiomiopathy affects ejection fraction and wall thickness?
↓ ejection fraction
↓ septal wall thickness
How does hypertrophic cardiomiopathy affects ejection fraction and wall thickness?
↑ Ejection fraction
↑ Septal Wall Thickness
Causes of dilated cardiomyiopathy
Alcohol (improves with tiamine)
Postpartum
Hypertension
Inherited (1/3 of pxs; autosomal dominant)
Previous MI
Infections (Coxsackie B, HIV, diphtheria, parasitic)
Endocrine (hyperthyroidism)
Infiltrative (haemochromatosis, sarcoidosis)
Neuromuscular (Duchenne muscular dystrophy)
Nutritional (Kwashiorkor, pellagra, thiamine/selenium deficiency)
Drugs (doxorubicin)
Patient with SOB, severe dizziness, chest pain and HR > 150 with tachycardia
UNSTABLE!
Any unstable tachycardia = Cardioversion
Stokes Adam attack
Intermittent complete heart block that causes a slow or absent pulse resulting in syncope.
Preterm baby with continuous or machinery murmur
PDA
Patent Ductus Arteriosus
Cyanotic baby with ejection systolic murmur
TOF
Tetralogy of Fallot
The systolic murmur is due to pulmonary stenosis which is one of the 4 major features of TOF
The four major defects in Tetralogy of Fallot
VSD (ventricular septal deffect)
Pulmonary stenosis
Right ventricular hypertrophy
Overrriding aorta
Progressive (severe) cyanosis + poor feeding + holosystolic (pansystolic) murmur along the left sternal border
Tricuspid Atresia
Acyanotic with pan-systolic murmur
VSD (ventricular septal deffect)
May present poor feeding and poorly gaining weight.
Cyanotic Congenital Heart Disease (R→L)
5 Ts, 1 to 5
Truncus arteriosus, vessels join to make 1
Transposition of great vessels, 2 major vessels switched
Tricuspid atresia, 3=tricuspid
Tetralogy of Fallot, 4 defects
Total anomalous pulmonary vascular return, 5 letters TAPVR
Acyanotic Congenital Heart Disease (L→R)
Atrial septal defect (ASD)
Ventricular septal defect (VSD)
Patent ductus arteriosus (PDA)
Coarctation of aorta (CoA)
Causes of falls (4)
Cardiac cause (arrythmia) > Stokes Adam attack, hot and flushed after recovery = 12 lead ECG
Postural (Orthostatic) hypotension > follow a standing position from a sitting position, dizziness before the fall
Hypoglycemia> sweaty and dizzy before the fall, does not recover until glucose is administered
Seizure> post ictal features like confusion and drowsiness, a witness describes the episode, recovers completely.
Preterm baby with continuous or machinery murmur
PDA (persistent ductus arteriosus)
Cyanotic baby with ejection systolic murmur
TOF (tetralogy of fallot)
The ejection systolic murmur is due to pulmonary stenosis
Progressive (severe) cyanosis + poor feeding + holosystolic “pansystolic” murmur along the left sternal border
Tricuspid atresia
Acyanotic + pansystolic murmur
VSD (ventricular septal defect)
or poor feeding and poorly gaining weight
Patent ductus arteriosus (PDA)
Congenital heart defect
Acyanotic
Connection between pulmonary trunk and descendeing aorta
Common in premature babies
May close spontaneously
Features of PDA (patent ductus arteriosus) and dx
Left subclavicular thrill (sometimes rough systolic murmur along the left sternal border)
Continuous machinery murmur
Large volume, bounding, collapsing pulse
Wide pulse pressure
Dx> echocardiogram
Management of PDA (permanent ductus arteriosus)
Indomethacin/ibuprofen (NSAIDs) inhibits prostaglandin synthesis, closes the connection in the majority of cases
Remember ind/end= closes the duct
If associated with another congenital heart defect amendable to surgery then prostaglandin E1 is useful to keep the duct open until surgery.
Tetralogy of Fallot presents typically at around…… months
1-2 months
The most common cause of cyanotic congenital heart disease.
However at birth, transposition of the great arteries is more common lesion as patients with TOF present symptoms later.
Can be picked up until the baby is 6 months old.
TOF is a result of anterior malalignment of the aorticopulmonary septum.
Features of TOF (tetralogy of Fallot)
Cyanosis (the severity is determined by the right ventricular outflow tract obstruction)
Causes right to left shunt
Ejection systolic murmur due to pulmonary stenosis (VSD doesn’t usually cause a murmur)
A right sided aortic arch is seen in 25% of pxs
Chest X ray shows a boot-shaped heart
ECG shows right ventricular hypertrophy.
Management of TOF
Surgical repair is often undertaken in 2 parts (shunt then surgical repair)
Cyanotic episodes may be helped by beta blockers to reduce infundibular spasm
Familiar hypercholesterolemia genetics
Autosomal dominant
When to suspect familiar hypercholesterolemia?
Cholesterol > 7.5 (normal <5mmol)
Family history of MI in 1st degree relative before the age of 60 or 2nd degree below 50
1st degree parents and siblings
2nd degree grandparents aunts and uncles
While in a hospital, an elderly patient was found unresponsive, no pulse and no breathing. Management?
IN THIS ORDER!
Ring the emergency bell and call the resuscitation team
Start CPR 30:2
Get defibrillator
Commence ALS when resuscitation team arrives.
Acute treatment of congestive heart failure with pulmonary oedema (desaturation, dyspnea, orthopnea, crepitations)
MONF Morphine Oxygen Nitrates Furosemide
History of Rheumatic fever and pansystolic murmur at the apex
Mitral regurgitation
Secondary to rupture of papillary muscles or rheumatic fever
It leads to right sided heart failure (ascites, pulmonary oedema)
Difference between mitral stenosis and mitral regurgitation?
Stenosis- Mid late dyastolic murmur, with opening click
At the apex (5th ICS MCL)
Symptoms of HF
Regurgitation- pansystolic murmur
At the apex (5th ICS MCL) radiates to the axilla
Symptoms of congestive HF (oedema, ascites)
An elderly px presented a syncope, he is transferred to A&E and is now fully conscious. ECG shows irregular rhythm. What is the next BEST investigation?
Echocardiogram
Holter ECG is not beneficial as the ECG already shows irregular rhythm (no point in using it again)
Echo will identify the underlying cause of the irregular rhythm.
Aortic stenosis is the most common valvular heart disease that causes syncopal attacks.
If the syncope was during or shortly after exertion then Exercise ECG
This px likely has AF causing TIA (syncope+ irregular rhythm)
Causes of AF
Endocardium- endocarditis, mitral valve disease
Myocardium- cardiomyopathy
Pericardium- Constrictive pericarditis
HF, HTN and MI
Hyperthyrroidism, excessive alcohol intake, chronic lung disease.
What should be done prior prescribing amiodarone?
Request serum electrolytes and urea
It is a class III antiarrhythmic agent used in the tx of atrial, nodal and ventricular tachycardias. It blocks potassium channels which inhibit repolarisation and prolongs the action potential.
Thyroid and liver functions prior and every 6 months
ECG every 12 months
Adverse effects of amiodarone
Thyroid disfunction (hypothyroidism and hyperthyroidism)
Corneal deposits
Pulmonary fibrosis (the most serious pneumonitis!)
Liver fibrosis/hepatitis
Peripheral neuropathy, myopathy
Photosensitivity
Slate-grey appearance (grey skin)
Thrombophlebitis and injection site reactions (usually given via central veins)
Bradycardia
Prolonged QT interval
A px with history of alcholism presents with a racing heart. Management?
Reassurance
It is not serious or harmful and it is a common phenomenon in alcoholics.
A px with history of TOF who underwent surgery in his childhood will present with what murmur decades later and why?
The corrected pulmonary stenosis can be complicated into PULMONARY REGURGITATION (diastolic murmur at the left upper sternal border)
Young adult with history of asthma presents recurrent palpitations, light headedness and tachycardia and paroxysmal supraventricular tachycardia in the ECG. Management?
ADENOSINE IS CONTRAINDICATED IN ASTHMATICS!
Valsalva manoeuvre and carotid massage
Verapamil (CCB)
Cardioversion
Digoxin toxicity features
GIT (most common)- nausea, vomiting and anorexia
Neurological- Hallucinations and confusion
Visual- Yellow green vision (yellow haloes) and blurred vision
Arrhythmias- bradycardia, V tach, premature contractions.
Digoxin toxicity management
Order digoxin level
Digibind (DigiFab) = digoxin immune FAB
Correct arrhythmia
monitor K
Aspirin toxicity features
Earliest symptoms include ringing ears (tinnitus) and impaired hearing
More clinically significant signs and symptoms include hyperventilation, vomiting, fever, dehydration, double vision and feeling faint.
Common adverse effects of Thiazide like diuretics?
Postural hypotension
Hypokalemia and Hyponatremia
Gout (hyperuricemia)
Dehydration
impaired glucose tolerance
Impotence
Thiazide diuretics can cause hypercalcaemia and hypocalciuria
Side effects of calcium channel blockers (CCB)
Ankle swelling
and
Gingival hyperplasia
Diltiazem, amlodipine, verapamil, nifedipine.
Heart disease in alcoholics?
Ankle swelling and orthopnea
Alcoholic cardiomiopathy (enlarged on x ray) which causes AF
may cause flutter but AF is more common. (holiday heart syndrome= irregular heartbeat after bouts of acute bringe drinking)
Palpitations, dyspnea, dizziness, syncope, chest discomfort or pain, stroke or TIC, irregularly irregular pulse.
Blood transfusion is indicated if…
Hb <80g/L + symptoms of anemia
OR
Hb < 70g/L + with or without symptoms of anemia
Recurrent fainting episodes \+ Prolonged QT intervals on ECG \+ History of similar ECG during childhood
Congenital long QT syndrome
The most common arrhythmia associated is V tach
Risk of VF so some use long term beta blocker treatment
