Cardiology by Dr. Cintia Flashcards
Pulmonary Embolism Clinical Features
Pleuritic Chest pain: Aggravated by cough and deep inspiration, worse with lying flat, relieved by sitting up.
Shortness Of Breath
Pulmonary Embolism
First Investigations (3)
Fist: Chest pain-ECG (S1Q3T3) Diagnostic
Second: SOB-CXR—> Rule out pulmonary pathology
Pregnancy (Doppler USD of legs)
Pulmonary Embolism
Best Investigations
Wells Score:
- Low: D dimer
- High: CTPA (Gold standard)
V/Q (Pregnancy or ♀< 45 yo)
Wells Score for PE (7 criteria)
Clinical symptoms of DVT (leg swelling, pain with palpation) 3
Another diagnosis less likely than pulmonary embolism 3
Heart rate >100 1.5
Immobilization (≥3 days) or surgery in the previous four weeks 1.5
Previous DVT/PE 1.5
Hemoptysis 1
Malignancy 1
Wells Score Probability for PE
Wells criteria
High >6.0
Moderate 2.0 to 6.0
Low <2.0
Modified Wells criteria
PE likely >4.0
PE unlikely ≤4.0
PERC rule (8 criteria)
- Aged <50 years
- Pulse <100 bpm
- SaO ≥95%
- No haemoptysis
- No oestrogen use
- No surgery or trauma requiring hospitalisation within 4 weeks
- No prior venous thromboembolism
- No unilateral leg swelling
RESULT: IF ALL YES RULE OUT PE
Pulmonary Embolism
Management
ABCD/Oxygen/Morphine
Stable:
- LMWH.
- Renal disease –> Unfractionated
Unstable: Thrombolysis
Acute Pulmonary Oedema (APO) Clinical Features
Sudden-onset of SOB with tachypnea
Diaphoresis and cyanosis
Productive cough: pink or white frothy sputum
Crackles and Wheezes (Kettle boiling)
- Hypotension: Cardiogenic shock
Acute Pulmonary Oedema (APO) Most common causes
- Acute Mitral and Aortic Regurgitation
- LV Systolic Dysfunction: anterolateral MI
- AF with rapid ventricular response
Acute Pulmonary Oedema (APO) Initial investigation
- CXR
- ECG
- Troponin
- FBE
- TTE
Acute Pulmonary Oedema (APO) Best investigation
Arterial/Venous Blood Gases to assess the severity of hypoxemia.
Acute Pulmonary Oedema (APO) Treatment
- O2
- IV line
- NGT spray or SL / IV is preferred to Morphine (BP > 100)
- Furosemide IV
- Morphine IV (chest pain)
- CPAP
APO + AF = BB
APO + AF + CHF = Digoxin inf
Infective Endocarditis Clinical Features
Fever (Most common)
New murmur (AI-most common)
NOT A CRITERIA FOR DIAGNOSE
Osler’s nodes (toes/fingers)
Petechiae including “nail bed
splinter hemorrhages”
Mitral and Aortic valves most frequently affected
Janeway lesions: Irregular painless erythematous macules on palms, soles, thenar and hypothenar eminence —> S. aureus!!!
Order of most common microorganisms that cause infective endocarditis
- Staphiloccocus Aureus
- Streptococci
- Enterococci (at least 90% faecalis)
Infective Endocarditis RISK FACTORS
Artificial heart valves.
Congenital heart defects.
A history of endocarditis.
Damaged heart valves: rheumatic fever
History of intravenous (IV) illegal drug use.
Immunocompromised patient.
Infective Endocarditis Diagnose
Modify Duke’s criteria:
DEFINITIVE Infectious Endocarditis:
2 Major Criteria
OR
1 Major + 3 Minor Criteria
OR
5 Minor Criteria
POSSIBLE Infectious Endocarditis:
1 Major Criteria + 1 Minor criteria
3 Minor Criteria
In POSSIBLE Management: Repeat TTE + TOE
Modify Duke’s Major criteria
TWO MAJOR CRITERIA
- Positive blood cultures for infective endocarditis:
Typical microorganisms for infective endocarditis: Coxiella burnetii, Viridans streptococci, Streptococcus bovis, and HACEK group
OR
Community-acquired Staphylococcus aureus or enterococci in the absence of a primary focus.
NOTE: 2 blood cultures drawn 12 hours apart or all of 3 or most of 4 or more separate blood cultures, with the first and last drawn at least one hour apart
OR
- Evidence of endocardial involvement:
Positive echocardiogram for infective endocarditis
OR
Cardiac Vegetation
OR
Cardiac Abscess
OR
New partial dehiscence of prosthetic valve
OR
New valvular regurgitation
Modify Duke’s Minor criteria
FIVE MINOR CRITERIA
- Predisposing heart condition or intravenous drug user
- Fever: 38°C
- Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions
- Immunologic phenomena:
Glomerulonephritis
Osler nodes
Roth spots
Rheumatoid factor (+) - Microbiologic evidence: positive blood culture but not meeting major criterion as noted previously or
echocardiography findings consistent with infective endocarditis but not meeting major criteria as noted previously
Infective Endocarditis Initial Investigations
- Blood culture: Diagnostic
- FBE: leucocytosis with neutrophilia and anemia.
- ECG: Cardiac monitoring
- CXR: Signs suggestive of heart failure.
NOTE: 2 blood cultures drawn 12 hours apart or all of 3 or most of 4 or more separate blood cultures, with the first and last drawn at least one hour apart
Infective Endocarditis Best Investigations
Transesophageal echo (TOE)
BUT:
- If HACEK: CT angio
- If arrhythmias: ECG
- If spread: CT/MRI (brain, thorax, and abdomen)
HACEK group
Slow-growing, fastidious gram-negative organisms
- Haemophilus species: Aggregatibacter aphrophilus, H. Paraphrophilus.
- Aggregatibacter actinomycetemcomitans
- Cardiobacterium hominins
- Eikenella corrodens
- Kingella kingae
COMPLICATED Infective Endocarditis include
Large vegetation
Perivalvular abscess
Multiple emboli
Secondary septic events
Infective Endocarditis Empirical Treatment
Benzylpenicillin + Gentamicin + Flucloxacillin IV
Infective Endocarditis Staphylococcus Aureus Treatment
Methicillin-susceptible:
Flucloxacillin x 6 weeks
Methicillin-resistant (MRSA):
Vancomycin IV x 6 weeks
ATB treatment is usually at least 2 weeks IV and oral until completing 4-6 weeks
Infective Endocarditis Streptococcus ADULTS Treatment
UNCOMPLICATED:
Benzylpenicillin + Genta IV x 2 weeks
OR
Benzylpenicillin IV x 4 weeks
OR
Ceftriaxone IV x 4 weeks
COMPLICATED:
Add gentamicin IV x 2 weeks
ATB treatment is usually at least 2 weeks IV and oral until completing 4-6 weeks
PROSTHETIC valve Streptococcus endocarditis Treatment
Benzylpenicillin x 6 weeks
Complicated: Add gentamicin IV
ATB treatment is usually at least 2 weeks IV and oral until completing 4-6 weeks
Infective Endocarditis Streptococcus CHILDREN Treatment
Uncomplicated or complicated:
Benzylpenicillin x 4 weeks
Infective Endocarditis Enterococcal Treatment
Two-drug regimen:
Benzylpenicillin IV
OR
amoxicillin IV
OR
Ampicillin IV
PLUS Gentamacin IV x 4-6 weeks
Staphylococcus Aureus Infective Endocarditis in ABORIGINAL Patient Treatment
Benzylpenicillin IV (No ATB resistance)
CONSIDER vancomycin treatment in Infective Endocarditis for
MRSA
Hospital Acquired infection
Prosthetic valve
Infective Endocarditis Early Surgery Indications
Prosthetic valve endocarditis (PVE)
Native valve endocarditis (NVE) with heart failure: severe Ao or mitral insufficiency or stenosis with refractory pulmonary edema.
Refractory ATB treatment in NVE.
Management of persistent uncontrolled infections.
Prevent embolism
Fungal infection.
Infective Endocarditis Profilaxis Indications
Prosthetic cardiac valve
Previous infective endocarditis
Congenital heart disease: Unrepaired Cyanotic - Acyanotic defects (VSD; Ao-Mi defect; TOF; PDA)
Repaired congenital heart defect with prosthetic material/device <6 months after procedure.
Cardiac Transplantation recipients who develop cardiac Valvulopathy.
Rheumatic heart disease in indigenous Australians
Procedures that require Infective Endocarditis prophylaxis
- Dental procedures
- Invasive respiratory procedures with incision or biopsy of respiratory mucosa (including tonsillectomy and adenoidectomy)
- Incision and drainage (I&D) of local abscesses
- Surgery procedures through infected skin (cellulitis)
NOTE: Antibiotic cover for genito-urinary or gastrointestinal procedures is NOT recommended for prophylaxis of endocarditis
Infective Endocarditis Prophylaxis ATBs
ORAL: Amoxycillin 2 g 1 hour before
OR
IM: Amoxy/Ampi 2g 30 mins before
OR
IV: Amoxy/Ampi 2g just before
If allergic – clindamycin or vancomycin
Pericarditis Clinical Features
Chest pain+SOB+viral infection
Kussmaul sign.
S4 Gallop: Cardiac Tamponade
Pericarditis Duration: Chronic & Acute
Acute (<6w) Chronic (>6w).
Kussmaul sign phisical exam
Paradoxical: ↑ JVP with insp and ↓ JVP with exp)
Means: constrictive and/or cardiac tamponade.
Pericarditis Causes
- Viral infection: Coxsackie B, CMV, influenza, EBV, COVID, HIV
- After a major heart attack or heart surgery: Dressler syndrome.
- Systemic inflammatory disorders: Lupus, rheumatoid arthritis.
- Trauma
Pericarditis Complications
Constrictive pericarditis.
Cardiac tamponade
Pericarditis Initial Investigations
- ECG:
- ST elevation except in AVR & V1
- Reciprocal PR - CXR:
- Pericardial fluid
- Pulmonary congestion - Echocardiogram: Is diagnostic! Chest FAST scan should be done ASAP.
- Cardiac CT
Pericarditis Best Investigation
Echocardiogram with drainage and culture (Pericardiocentesis)
Pericarditis Medical Treatment
Mild to moderate Pericarditis
- AAS/Ibuprofen (7 to 10 days)
- Colchicine x 3 months. Indication: Recurrent symptoms (Side Effects: Diarrhea, abd pain)
- Prednisone
If infection: ATBs and drainage
Pericarditis Surgical Treatment
Severe Pericarditis, include admision
- Cardiac tamponade: Pericardiocentesis
- Severe, Recurrent or Constrictive:
Pericardiectomy
Beck’s triad = Cardiac Tamponade
Low blood pressure (weak pulse or narrow pulse pressure)
Muffled heart sounds
Raised jugular venous pressure.
Pericarditis Physiopathology
Restrictive Cardiomyopathy
Diastolic Dysfunction with impaired filling – relaxation
Normal Ejection fraction + S4 gallop
Dressler’s Syndrome definition
Pericarditis in the context of major heart attack or heart surgery
Dressler’s Syndrome risk factors
- Young age
- B-negative blood type
- Prior history of pericarditis
- Prior treatment with prednisone
Dressler’s Syndrome investigations
Gold Standard: Echocardiogram
UNSTABLE patient: bedside ultrasonographic (E-FAST)
ECG: Same pattern as pericarditis (global ST segment elevation and T wave inversion)
Dressler’s Syndrome Treatment
1st LINE: NSAIDs in high doses (aspirin, ibuprofen, naproxen) tapered over 4 to 6 weeks.
2nd LINE: Corticosteroids (prednisone) tapered over a 4-week period
3rd LINE: Colchicine.
Dressler’s Syndrome COMPLICATION
Cariac Tamponade
Myocarditis Clinical Features
- Chest pain
- S3 Gallop (Systolic Disfuntion)
- Dyspnoea
- Viral infection
- Fever
- Arrhythmia
Myocarditis Infective Causes
- Virus: Coxsackie, adenovirus, human herpes virus 6, Parvovirus B19, Epstein-Barr virus, COVID-19 HIV, hepatitis B and C.
[pediatric eruptive and STDs virus] - Protozoa: Toxoplasmosis
- Bacteria: Legionella, staphylococci, Salmonella, Shigella, streptococci, Clostridium, tuberculosis
Myocarditis Non-Infective Causes
- ALCOHOL!!!! —> Reversed with abstinence
- Collagen vascular diseases
- Systemic diseases: Rheumatic Fever, sarcoidosis, giant cell arteritis
- Cardiotoxic drugs: Clozapine
Myocarditis Investigation
- Urgent transthoracic
echocardiogram (TTE)
Myocarditis Physiopathology
Dilated Cardiomyopathy
Impaired contractility with thin weak heart muscle - systolic dysfunction
Decreased Ejection Fraction + S3 gallop
Myocarditis Treatment
- Correct underlining cause (alcohol, infection)
- Same tratment that CHF
Mediastinitis Clinical Features
Dysphagia
Chest pain
Fever
Respiratory distress
Mediastinitis Causes
- Tracheal or esophageal rupture:
- After an endoscopic procedure
- Boerhaave syndrome
- Foreign body aspiration - Postoperative mediastinitis (thoracic surgery)
- Traumatic injury
- Spread of pulmonary infection
- Pancreatitis
NOTE: Descending necrotizing mediastinitis caused by neck abscess, Ludwig angina, or dental infections
Mediastinitis Investigations
First: CXR
Mediastinal widening or pneumomediastinum
Best: CT Torax, Mediastinal aspiration
Mediastinitis Treatment
In community:
- Empirical: Amoxi-Clav IV
- If septic shock: Cefazolin+Metro IV
In hospital:
- Piper+Tazo OR Cefepime+Metro
Stable Angina Diagnose
Chest pain < 20 min
Negative ECG
Negative troponin
Negative CK MB
Cardiac Enzymes Measurement in MI
1st line: Troponin I & T
- On arrival.
- If normal (< 0.02): Repeat in 6 - 8 h
- Return to normal in 5-14 days = No suitable for reinfarction diagnosis
2nd line: Total CK & CK-MB (if not troponins available)
- Raise in 4 h.
- Return to normal in 72 h = Usefull for reinfarction diagnosis
NOTE: Troponins can also be elevated in Chronic Renal Failure. Diferencial: CK-MB will be raised in MI but not in CRF
Stable Angina other investigations:
- CXR: CHF sings. Exclude other causes (Ao dissection – lung path)
- Bloods: FBE (anemia) – LFT (dyslipidemia) – RFT– BSL (DM) - Electrolytes
- Echocardiogram
Stable Angina BEST Investigation:
Stress test will confirm the suspected diagnosis
Stable Angina ACUTE Treatment
- Nitrates after 5 mins if pain persists (max. 3 doses) or Nifedipine 5 mg capsule (suck or chew)
- Intolerant or contraindications for nitrates: Aspirin 150 mg oral
Nitrates Contraindications
Phosphodiesterase inhibitors (sildenafil, tadalafil) used in the past 1–5 days
Suspected right-sided/inferior myocardial infarction (hypotension, sweating, vomiting, and sinus brady)
Hypertrophic cardiomyopathy
Stable Angina LONG TERM Treatment
**Aspirin + statin + antiHT **meds (antianginal: BB – CCB + glyceryl
trinitrate)
1st line: BB
2nd line: CCB (Diltiazem, verapamil)
Glyceryl trinitrate
- Short-acting (spray): before exercise that is likely to induce angina
- Long-acting nitrate (transdermal): Recurrent angina.
Tolerance to all forms of nitrate therapy develops rapidly, so allow a nitrate-free period.
Unstable Angina Clinical Features
Clinical Features:
1. Chest pain that has changed or >20 min
- ECG:
- Low Risk: NORMAL
- High Risk: ST Depression - Troponin
- Low Risk: Negative
- High Risk: Positive - CK MB: Negative
Unstable Angina Management
- Admission to coronary unit
- Oxygen 4–6 L/min (PaO2>90%)
- IV line
- Aspirin 150 - 300 mg
- Clopidogrel
- Enoxaparin (1 mg/kg) SC
- Glyceryl trinitrate (patch)
Worsening of Unstable Angina Management
Maximize dose of BB
Consider nifedipine or amlodipine
Consider IV nitrate infusion
If persistent pain (high risk)
- Abciximab (stronger antiplatelets)
- Transfer patient for Percutaneous coronary intervention (PCI)
Non-STEMI Clinical Features:
- Chest pain that has changed or >20 min
- ECG: ST Depression
- Troponin: Positive
- CK MB: Positive
Non-STEMI Management
- Admission to coronary unit
- Oxygen 4–6 L/min (PaO2>90%)
- IV line
- Glyceryl trinitrate
- Aspirin 150 - 300 mg
- Clopidogrel
- Enoxaparin (1 mg/kg) SC or UF Heparin IV 5000 IU bolus followed by infusion 1000 IU/h
Add if necessary: Morphine
Continuous monitoring with ECG and cardiac enzymes
STEMI Clinical Features
Extreme chest pain
ECG: ST Elevation
Troponin: Very high
CK MB: Positive
Acute STEMI Management
- PCI (Gold Standard)
- Optimal: Within 60 minutes of symptom onset.
- Acceptable: 90 min. - Thrombolysis: Within 30
minutes of arrival (most common reteplase, alteplase or tenecteplase)
- Streptokinase: Inappropriate for use in Indigenous patients and those who have received it on a previous occasion (RESISTANCE due to high levels of anti-streptokinase IgG level)
Thrombolysis Side Effects
- Bleeding
- Hypotension
- Reperfusion arrhythmias
- Allergic reactions
- Angioedema
- Anaphylactic shock
NOTE: Streptokinase is most frequently complicated by allergic reactions and hypotension
Absolute Contraindications for Thrombolytic Treatment (9)
- Active Bleeding or bleeding diathesis (excluding menses)
- Suspected aortic dissection
- Significant closed head or facial trauma within 3 months
- Any prior intracranial hemorrhage
- Ischaemic stroke within 3 months
- Known cerebral vascular lesion
- Known malignant intracranial neoplasm
- Recent Intracranial or spinal surgery
NOTE: For streptokinase, previous treatment within six months and ASTI people
Relative Contraindications for Thrombolytic Treatment
- Current anticoagulants (including novel anticoagulant agents)
- Non-compressible vascular puncture
- Recent major surgery (<3 weeks)
- Traumatic or prolonged (>10 minutes) CPR
- Recent internal bleeding (within 4 weeks) / Active Peptic Ulcer
- Suspected Pericarditis
- Advanced Liver Disease / Advanced
- Metastatic Cancer
- History of chronic, severe, poorly controlled hypertension
- Severe uncontrolled hypertension on this presentation (Systolic >180 / Diastolic > 110 mmHg)
- Ischaemic Stroke > 3months ago
- Dementia
- Pregnancy or within 1 week postpartum
POST MI Treatment
- BB (within 12 h)
- ACE inhibitors (within 24 h)
- Dual antiplatelet therapy: Aspirin 75 - 150 mg + Ticagrelor (Clopidogrel or Prasugrel x 12 m)
- Statins
Heart Failure: 3 more important causes
Hypertension
Heart valve disease: rheumatic heart disease
Cardiac arrhythmias
Heart Failure Classification by Left Ventricle Ejection Fraction (LVEF)
LVEF < 40%: Heart failure with REDUCED EF.
LVEF = 50%: Heart failure with PRESERVED EF
NOTE: The CHF management depends on EF.
Heart Failure First Investigations
- CXR
- ECG
Heart Failure Best Investigation
Echocardiogram
Heart Failure Treatment
- Class II (EF 40-50): Mild Symptoms
on activity. Ace Inhs/ARB + BB, On/Off Diuretics (Furosemide) - Class III (EF<40): Severe symptoms
on activity but comfortable at rest: Add Spironolactone - Class IV (EF<35): Severe symptoms
on activity and at rest: Add Digoxin or Entresto (stop ACE inh/ARB)
Hypertrophic Obstructive Cardiomyopathy (HCOM) or Idiopathic Hypertrophic Subaortic Stenosis DEFINITION
Left ventricular outflow tract obstruction (LVOTO) due to hypertrophied ventricular septum
It is the most common genetically transmitted cardiomyopathy (Autosomal Dominant)
DIASTOLIC DYSFUNCTION
Hypertrophic Obstructive Cardiomyopathy (HCOM) Clinical Features
- Family history
- Young athlete with syncope during exercise
- Midsystolic murmur that increases
with Valsalva - Dyspnea, syncope, angina, palpitations, or dizziness
NOTE: Same findings that Ao stenosis Murmur differences: no radiation & exacerbation with Valsalva maneuver
Hypertrophic Obstructive Cardiomyopathy (HCOM) Differential Diagnosis
Prolong QT syndrome (AD)
Dx with ECG – also VT
Hypertrophic Obstructive Cardiomyopathy (HCOM) Initial Management
- Admit to Cardiology
- ECG: Dagger Q waves in left leads
- CXR: CHF findings
- Echocardiogram (THE MOST IMPORTANT BUT NOT THE GOLD STANDARD)
Hypertrophic Obstructive Cardiomyopathy (HCOM) Best Investigation
Cardiac MRI (Gold Standard)
HCOM Management
- Referral:
- Genetic counseling, then genetic testing
- Cardiologist
HCOM Screening
IF POSITIVE FAMILY HISTORY: Echocardiogram
Hypertrophic Obstructive Cardiomyopathy (HCOM) Medical treatment
Symptomatic:
1st line: BB
2nd line: CCB
Contraindicated: Nitrates and ACE inhibitors (↓ preload)
Hypertrophic Obstructive Cardiomyopathy (HCOM) surgical treatment
Septal myectomy: Only in young patients very symptomatic even with medical treatment.
IF Ventricular Tachy: Implantable cardioverter-defibrillator (ICD)
Takotsubo Cardiomyopathy Definition
Transient regional systolic dysfunction of the left ventricle in the absence of angiographically significant coronary artery disease