Cardiology & Cardiac Surgery Flashcards
Recite what the CHA2DS2-VASc Score represent
Management for CHA2DS20-VASc Score:
0
1
2 or greater
0 - do not require anticoagulant
1 - low-moderate risk, should consider antiplatelet or anticoagulant
2 or greater - moderate-high risk, anticoagulant (warfarin!)
When do you suspect aortic dissection?
- Sudden onset of thoracic or abdominal pain + sharp, tearing and/or ripping character
- Widened mediastinum or aorta on CXR
- Pulse or blood pressure variation
Aortic Dissection patient with ECG showing acute MI, thrombolyse or not?
Best treatment?
Absolutely NOT due to high risk of bleeding.
Morphine, BB and urgent TOE to confirm diagnosis.
CTA if TOE not available.
Besides acute MI or MI, what else can a dissection that involved the ascending aorta induce?
- Acute aortic valve regurgitation (diastolic decrescendo murmur)
- Acute MI or MI
- Cardiac tamponade and sudden death due to ruction
- SBP variation (>20mmHg) between arms
- Neurologic deficits (stoke/decreased consciousness)
- Horner syndrome (if there is compression of cervical sympathetic ganglion)
- Vocal cord paralysis and hoarseness (compression to left RLNerve)
Dressler’s Syndrome features and best treatment
KEY:
- usually develops 2-3 weeks after acute MI or heart surgery
- patient would suffer from: recurrent fever + chest pain with pleural/pericardial rub
Best treatment: regular aspirin (or steroids if allergic)
In early stages, pleurocentesis and pericardiocentesis are not required yet.
ECG: all T waves, broad QRS complex and prolonged PR interval
Next step?
Hyperkalemia
Next step: IV calcium carbonate 10% 10mL, infused over 2-3 minutes with cardiac monitoring.
Effect lasts for 30-60 minutes
Causes of high troponin levels that is not due to ACS?
Most common:
Renal failure
Myocarditis
AF
Pulmonary thromboembolism
Antibiotic regimen for native valve IE due to streptococci?
Combination of beta-lactam antibiotic + gentamicin
Duration: 2 weeks (uncomplicated) to 6 weeks (enterococcal IE)
Staphylococcal IE antibiotic regimen
Combination of beta-lactam antibiotic + gentamicin + RIFAMPICIN
Signs of constrictive pericarditis
- Paradoxical JVP/Kussmaul’s sign (pulsatile)
- Massive hepatosplenomegaly
- Ascites
- Peripheral oedema
Raised JVP ~ right heart failure
DDX
Superior vena cava obstruction - JVP raised, but no pulsation; no peripheral ankle oedema and ascites.
Budd Chiari syndrome - clot - RUQ pain + mild jaundice + tender hepatomegaly and ascites.
How long should a patient who has received intracoronary drug-eluting stent be on antiplatelet therapy for?
Dual antiplatelet therapy for 12 months.
Aspirin + Ticagrelor/Prasugrel/Clopidogrel
How to confirm hypertrophic cardiomyopathy?
Symptoms?
ECHO
Asymptomatic
Fatigue
Weakness
Chest Pain
Syncope
Midsystolic ejection murmur or LV lift
Commonly cause arrhythmias or death in young athletes
All-first degree relatives of an affected individual be clinically screened for HCM
- physical exam by cardiologist, ECG, TTE
- commercial genetic testing
In which group in Prolong QT syndrome commonly seen?
Syncopal episodes commonly seen in late childhood or adolescence.
During syncope, arrhythmias (VF, Torsades de Pointes) can be noted
May result in death
Congenital Heart Block is related to what disease?
Neonatal Lupus
- rare manifestation of transferred maternal IgG auto-Ab.
- most will self-resolve, but can be permanent in some requiring pacing
Other symptoms: thrombocytopenia, neutropenia, rash, liver dysfunction and congenital HB.
When to refer a child to Paediatric Cardiology for Congestive Heart Failure?
Weak, diaphoretic, poor weight gain, tachypnoeic with retractions.
Lung: crackles, wheezes or both
Cause: congenital heart disease, Kawasaki, metabolic cardiomyopathies, arrhythmias, viral myocarditis
Most effective lifestyle intervention for preventing cardiovascular disease and premature deaths?
Smoking cessation
Ideal Lipid Profile?
Total Cholesterol: < 5-5.5
LDL: < 4
TGL: < 2
HDL: > 1
How often should the absolute CVD risk assessment be done?
Every 2 years in adults aged > 45 y/o OR to be clinically determined high risk
If SBP > 180mmHg or total cholesterol > 7.5, should be considered clinically high risk.
First line investigations in any patient with erectile dysfunction
- Blood glucose
- Free testosterone
- TFT
- Prolactin
- Luteinising
Cardiac Catheterisation as a general term includes…
angioplasty, PCI, balloon angioplasty
Unstable Angina
Low Risk vs High Risk
CK?
Troponin?
ECG?
Low Risk Unstable Angina:
CK normal
Troponin not detectable
ECG normal
High Risk Unstable Angina:
CK normal
Troponin detectable
ECG ST depression
Should be referred to cardiologist for URGENT STRESS ECHO to confirm diagnosis.
If confirmed, to do angiography.
Biomarkers for Heart Failure
That helps predict prognosis
Eg. B-type natriuretic peptide, troponin, ST2, gal-3
What are the initial evaluation of suspected syncope?
- History
- Physical examination (careful carotid sinus massage in older patients)
- Review ECG
- Transthoracic Echocardiogram (TTE) - to evaluate presence or severity of structural heart disease
Once determined, then establish diagnosis.
Usually start by ruling out cardiac causes first, followed by neuro.
Best indicator of myocardial re-infarction?
CK-MB
- short half-life of 12 hours
NSTEMI
CK?
Troponin?
ECG?
CK elevated
Troponin detectable
ECG ST depression, no Q wave
Is anticoagulant required for planned electrical cardioversion?
Yes! If not the risk of embolic event and stroke is very high.
Warfarin for 4 weeks before and maintain therapeutic INR for 4 weeks after the electrical cardioversion.
~ 8 weeks in total!
Managment of Acute Coronary Syndrome (ACS)
STEMI
NSTEMI
UA
Fibrates lowers which component of the lipid profile?
Statins?
Fibrates (fenofibrate or gemfibrozil) - Triglyceride
Fish oil is second line
Statins - LDL or TC
Other lipid-lowering drugs in the market:
Nicotinic acid, bile acid resins (isolated cholesterolaemia), ezetimibe inhibitors, fish oil
When to stop statins?
Transaminase is persistently x3 above upper limit
CK is x 10 the upper limit
Persistent unexplained muscle pain
How often should the following groups repeat their lipids?
Low Risk: ?
Moderate Risk: ?
High Risk: ?
Low Risk: every 5 years
Moderate Risk: every 2 years
High Risk: every year
Most common cause of pericarditis in Australia?
Viral or idiopathic
First line treatment: NSAIDS (7-10 days) + Colchicine (3 months)
Diagnosis of Prosthetic Valve Endocarditis (like IE)
Clinical manifestations
Blood cultures (or other microbiological data)
ECHO - vegetation
Modified Duke’s Criteria
First line treatment for hypertriglyceridemia
- Diet rich in mono- and poly-unsaturated fat
- Diet low in glycaemic index carbohydrates food
- Weight loss by caloric restriction and exercise
- Consider marine omega 3 fatty acids (fish oil) and fibrates
Aim for TG < 1.5 mmol/L
Is antiplatelet therapy recommended for stroke prevention in patient with AF?
NO.
Follow CHA2DS2-VASc Score.
Thrombolytic to avoid in aboriginal?
Streptokinase
Many have high levels of anti-streptokinase IgG level
Resistant to streptokinase reperfusion therapy
Suspected PE with background of renal failure
Investigation?
V/Q scan
CTPA is contraindicated as contrast-induced renal damage will be a problem.
Features of cardiac signs in mitral stenosis
- Increased risk of AF
- Loud first heart sound (S1)
- P2 increased in intensity and widely transmitted as pulmonary HTN develops
- Murmur: low-pitched diastolic rumble (heard at apex, using bell of stethoscope, laying patient at left side)
- Mild MS: murmur in late diastole, just before S1, called presystolic accentuation.
NO THIRD HEART SOUND
Post-viral congestive cardiac failure features
Likely viral myocarditis
Give one dose of frusemide, then
Send to hospital as URGENT TTE is required to rule out cardiomyopathy and heart failure
Most appropriate first line investigation for suspected acute PE?
Management:
ABG or VBG
- to assess severity and need for supported ventilation
Followed by ECG, cardiac troponin, serum BNP level, CXR, FBC, RP, LFT
Morphine
O2
Nitrates
Diuretics
What is heard on lung auscultation for APO?
Pulmonary rales, ronchi; expiratory wheezing
Rheumatic Fever is a sequela of group A streptococcus infectious of the throat or skin (during scabies). Which criteria do we use to diagnose rheumatic fever?
Jones Criteria
Reactive Arthritis
Cannot pee, cannot see, cannot walk.
All inflamed!
Has history of GI or genitourinary infection
Gonococcal Arthritis
Single joint
History of unsafe sex and urethral discharge
Juvenile idiopathic arthritis
Common chronic disease of childhood
At least 6 weeks history of arthritis prior (often with morning stiffness and spiking fevers)
Best prevention for peri operative cardiac event is in those with at least one cardiac risk factor?
Beta Blockers!
Not recommend in those with baseline HR 60 or SBP < 90mmHg or when time is not sufficient for titration
Cardiomyopathy (AKA impaired myocardial function) is the most common cause of heart failure.
What are the most common causes?
Most Common:
Coronary heart disease
Smoking
HTN
Obesity
DM
Valvular heart disease
Routine initial investigations for newly diagnosed heart failure?
Lab tests:
ECG, CBC, urinalysis, serum creatinine, potassium and albumin, and TFT.
ECHO! To identify structural abnormalities and measure EF
Harsh or rumbling murmur
Think of?
AS or MS
Blowing or musical murmur
Think of?
AR or MR
Physical examination features seen in Aortic Stenosis (AS)?
- Ejection clicking in S1 + Harsh, rasping cresendo-decrescendo systolic murmur
- Heard best at second intercostal space at right upper sternal border (radiates to carotid)
- Carotid pulse: small and rises slowly (pulsus parvus et tardus)
- In elderly, commonly heard in the apex, resembling MR
- Paradoxical splitting S2
- Use diaphragm of stethoscope
Acute dyspnea from acute decompensated heart failure (ADHF).
Initial measures?
- Airway and oxygenation assessment and management (SPO2, O2, ventilatory support, vital sings, IV access, seated posture…)
- Initiate tx: prompt diuretic therapy
- Then early vasodilator therapy (for severe HTN, acute MR, or acute AR); later vasodilator use
Nitroprusside lowers arterial tone
Nitroglycerin lowers venous tone - Urine output monitoring
- VTE prophylaxis
- Sodium restriction
- Generally avoid opioid therapy in ADHF patients
Page 130 MPlusX PDF
1st Degree AV Block - delay in conduction through AV node
ECG?
Causes?
Significance?
ECG: PR Interval > 200ms
Causes:
Increased vagal tone (younger patients / athletes)
Fibrosis (elderly patients)
Drugs (AV node blocking agents: BB, CCB, Digoxin)
Normal Variant
Coronary Artery Disease
Mitral Valve Surgery
Electrolyte Imbalance (hypokalaemia, hypomagnesaemia)
Significance:
Usually asymptomatic
Occasional progresses
3x risk of developing AF
If symptomatic, with PR interval > 300ms, pacemakers can be considered
2nd Degree AV Block has two types.
What are they called?
Mobitz 1 = Wenkebach Block
Mobitz 2 = Hay Block
2nd Degree Heart Block
Mobitz 1 (Wenkebach)
ECG?
Causes?
Significance?
ECG:
- Progressively longer PR interval, followed by non-conducted beat
(Due to progressively fatigue of AV cells)
- Cyclical, e.g. 4:3 (P:QRS)
Causes:
Increased vagal tone
Normal variant
Myocardial Infarction (Inferior)
Drugs
Mitral Valve Surgery
Hyperkalaemia
Significance:
Does not usually require treatment
May cause bradycardia and hypotension
- atropine, reduce AV blockers, pacing
2nd Degree Heart Block
Mobitz 2 (Hay)
ECG?
Causes?
Significance?
ECG:
- PR interval constant with intermittent dropped beat
- May have fixed ration P:QRS e.g. 2:1, 3:1
Causes:
Usually structural heart disease (myocardial ischaemia / fibrosis)
** Below Bundle of His in 75% - wide QRS
** Within Bundle of His in 25% - narrow QRS
Significance:
Often symptomatic (syncope, fatigue, chest pain, death)
High risk progression
35% per year risk of asystole
Requires temporary pacing —> pacemaker
Atropine can precipitate Complete Heart Block
3rd Degree AV Block (Complete Heart Block)
No association between atria and ventricle contractions
Junctional/ventricular escape rhythm
ECG?
Causes?
Significance?
ECG: No correlation of P waves and QRS complexes
Number of P waves > QRS complexes
Causes:
Inferior Myocaridal Infarction
AV blocking agents (digoxin/metoprolol)
Degeneration of conduction system
Significance:
Often symptomatic (syncope, fatigue, chest pain, SOB, death)
Atropine (initial treatment), however rarely effective - Dopamine / Adrenaline are other medical options
Transcutaneous/transvenous pacing (treatment of choice) —> pacemaker
Malignant Hypertension
What is it?
Treatment?
- High blood pressure with end organ damage (retinopathy!)
- BP rises rapidly + diastolic BP > 120mmHg
- Histologic changes: fibrinoid necrosis of vessel wall; if not treated, may lead to death from progressive renal failure, heart failure, aortic dissection or stroke
Treatment:
IV sodium nitroprusside
Or infusion of labetalol
Nicardipine
Hydralazine (pregnant women)
Can give frusemide or losartan once diastolic BP is ~ 100mmHg
Long Term Complication of Mitral Stenosis?
Pulmonary Hypertension
Mitral valve stenosis → increase in left atrial pressure → backup of blood into lungs → increased pulmonary capillary pressure → cardiogenic pulmonary edema → pulmonary hypertension → backward heart failure and right ventricular hypertrophy
Heart Failure
Mitral valve stenosis → obstruction of blood flow into the left ventricle (LV) → limited diastolic filling of the LV (↓ end-diastolic LV volume) → decreased stroke volume → decreased cardiac output (forward heart failure)
Best treatment for supraventricular tachycardia (SVT)
Vagal manoeuvres + IV adenosine 6mg
Pulmonary Embolism
What is commonly seen in ECG?
What scoring system do we use to assist us in management?
- Sinus tachycardia
- RBBB
- T-wave inversions
- S1Q3T3 commonly seen in PE
Well’s Score
Most common symptoms/sign a/w IE
Fever!
Followed by
Anaemia
New murmur/worsening of known murmur
Less common ones are
Haematuria
Splenomegaly
Splinter haemorrhages
Janeway lesions (irregular, non-tender Haemorrhagic macules)
Roth spots (white-centred retinal haemorrhages)
Between an abnormal ECHO and positive blood culture, which is more important for the diagnosis of IE?
Blood cultures
At least 3 sets of blood cultures from different venipuncture site must be obtained PRIOR to starting antibiotics (for clinically stable patients) OR empirical antimicrobials therapy (for clinically unstable).
Regardless, blood cultures must be repeated every 2-3 days from the initiation of antibiotics until bacteraemia is cleared.
Which criterion is used for diagnosis of IE?
Modified Duke’s Criteria
Definitive Diagnosis:
2 major criteria
or 1 major and 2 minor criteria
or 5 minor criteria
Possible Diagnosis:
1 major and 1 minor criteria
or 3 minor criteria
Transient monocular blindness in carotid artery disease is most likely due to embolism of which artery?
Central Retinal Artery or one of its branches
Phenomena: amourosis fugax
Cholesterol emboli (Hollenhorst plaques) may be seen on fundoscopic examination even on asymptomatic patients.
Initial management for aortic dissection
IV BB to control HR
IV nitroprusside to control BP (titrate to SBP < 120mmHg)
Diagnose with TEE / MR / CTA
Urgent surgery may be required in proximal type aortic dissection.
Management for haemodynamically stable AF
Rate-control:
- BB
- Diltiazem/verapamil
- Digoxin (if needed to add a second drug)
Usually BB +/- Digoxin is preferred.
Long term management will require anticoagulation as well if CHA2DS2-VASc score is 2 or above to prevent thromboembolism or for planned pericardioversion procedure.
CVP is a helpful determinator in overall haemodynamic assessment.
What increases CVP?
What decreases CVP?
Central Venous Pressure is affected by a variety of factors.
Increase CVP:
Vasoconstrictor drugs
PPV (with/without PEEP)
Mediastinal compression
Hypervolaemia
APO (when clinically significant)
Decrease CVP:
Sepsis (releases vasodilator mediator and loss of intravascular plasma volume)
Which etiologic agent is most likely to evolve into a picture of myopericarditis?
Coxsackievirus B infection
Acute illness with fever and/or flu-like symptoms and painful spasms of chest and upper abdomen due to irritation of the pleura and muscles
Most common cause of viral myocarditis
Case: Cough, sore throat, fever that develops into chest pain after several days
Chief abnormality in Hypertrophic Cardiomyopathy (HCM)
Left ventricular hypertrophy (LVH)
ECG Features of Hypertrophic Cardiomyopathy (HCM)
- LA enlargement (“P mitrale”)
- LVH a/w ST segment / T-wave abnormalities
- Deep, narrow (“dagger-like”) Q waves in the lateral > inferior leads
- Giant precordial T-wave inversions in apical HCM
- Signs of WPW (short PR, delta waves)
- Dysrhythmias: AF, SVT, PACs, PVCs, VT
CTPA is especially contraindicated in those with….
Renal Failure!
Impaired renal function
Low EGFR
What is pulmonary artery occlusion pressure (PAOP)?
How is it performed?
What is most likely to affect its interpretation?
PAOP or wedge pressure: pressure (pulmonary artery waveform) measured by wedging a pulmonary catheter with an inflated balloon (slow injection) into a SMALL pulmonary artery branch.
Pulmonary vein stenosis - most commonly a/w prior radiofrequency ablation procedures for AF in adults
Pulmonary disease and respiratory failure —> cause PAOP/PAWP to exceed the LV end-diastolic pressure due to constriction of small veins in hypoxic lung segments.
Define diastolic heart failure
- Heart failure with preserved ejection fraction/LV function (HFpEF)
- Stiff LV with decreased compliance and impaired relaxation
—> increased end diastolic pressure
DX: Doppler ECHO
Diastolic dysfunction and HFpEF are not synonymous.
Diastolic dysfunction = functional abnormality/abnormal mechanical properties of the ventricle; part of normal human aging; risk factor for developing HFpEF
HFpEF = six of clinical HF in a patient with normal LVEF and LV diastolic dysfunction
What drugs should NOT be used with diastolic dysfunction?
- Diuretics
- Vasodilators (e.g. nitrates)
- Arteriaal vasodilators (hydralazine)
- Digoxin and other inotropic drugs
ECG features of pericarditis
Stage 1:
Diffuse ST elevations
PR segment depression
ST depression in aVR and V1
Stage 2: normalisation of ST changes, generalised T waves flattening (1-3 weeks)
Stage 3: flattened T waves becomes inverted (3 to several weeks)
Stage 4: ECG returns to normal (several weeks onwards)
Other ssx: pericardial friction rub
Cardiac Tamponade Triad on ECG
- Low QRS voltage
- Tachycardia
- Electrical alternans
Bridging therapy prior to surgery for those on warfarin for AF
Stop Warfarin 3-5 days before surgery,
Once INR < 2,
Start bridging with a therapeutic dose of unfractionated heparin or LMWH.
Last dose of LMWH should be given 12-24H before surgery.
Restart Warfarin within 24H of the surgery.
Once INR is at therapeutic range,
Cease heparin.
What is Long QT syndrome?
Most common complication?
A disorder of myocardial depolarisation
ECG: prolonged QT interval
A/W life-threatening cardiac arrhythmias —> Torsades de pointes
[Case: can be caused by tricyclic antidepressants]
Mitral Valve Prolapse
- weak MV leaflets
- weak chordiec tendinae
- poor leaflets gets bowed back (rock hitting leaflet) —> click
- congenital abnormality that frequently manifests in adolescents or later
- common in girls > boys
- autosomal dominant
O/E: Mid-systolic CLICK + apical murmur noted in late systole
DX: ECHO - prolapse of the mitral leaflets during mid-late systole
ECG and CXR usually normal
Others:
- Increased risk of IE
- In Australia, antibiotic prophylaxis is recommended for dental treatment in selected patients
- Most common symptom: non-anginal chest pain.
- Others: palpitations, dyspnea, exercise intolerance, dizziness or syncope, panic and anxiety disorders
- Majority are asymptomatic
- Auscultation + ECHO can diagnose in 10% of population
- Possible complications: SVT and ventricular arrhythmias may result in sudden death
- As clot originates from left atrium, rarely will PE take place, rather the intra-atrial formation may predispose to cerebral or peripheral embolism.
Brain Natriuretic Peptide is elevated in…
- Hypertension
- Pulmonary Hypertension
- Cardiac Hypertrophy
- Congestive Cardiac Failure (x 2 of normal value)
- Renal disease
BNP - used to define cause of fluid overload in patient.
[Not elevated in chronic liver disease]
Amiodarone
Class III antiarrhythmic drug
- used other treat ventricular tachyarrhythmias such as VFib and VT
- conscious patient
If patient loses consciousness, must defibrillate urgently.
Is endoscopy w/ or w/out biopsy a risky procedure for IE?
Low-risk procedure for IE.
Therefore, there is no need for antibiotic prophylaxis.
[Case: has asymptomatic MVP —> still do not need antibiotic prophylaxis]
Electrophysiological Study
Test used to evaluate heart’s electrical system and check for abnormal heart rhythms
Have been used to diagnose those with unexplained syncope
Most common cause of ACS
Acute thrombosis (with primary involvement of platelets)
Give Aspirin immediately to dysfunction platelets from forming the thrombus and preventing further damage
Physiology of Digoxin
- Positive inotrope: heart muscle contracts stronger, raising cardiac output to a normal level and increasing the amount of blood the heart can pump out. Helps organs get the blood and oxygen they need to keep working
- Decreases oxygen consumption
- Binds to and inhibits sodium/potassium-ATPase (sodium pump) within the plasma membrane of cardiac myocytes
- Increases intracellular sodium, which in turn increases the intracellular calcium —> increased cardiac contractility.
Digoxin Toxicity Management
- Cease digoxin
- Correct K according to severity (HYPOKALAEMIA)
- Start cardiac monitoring for any rhythm disturbances and treat any rhythm abnormalities accordingly
- Check digoxin level and other electrolytes in the blood
- In certain cases, (with severe haemodynamic compromise), Fab fragments of digoxin-specific antibodies may be required
Initial ECG: biphasic T-wave
What can happen to a patient on thiazide diuretic and digoxin?
Thiazide diuretic can cause hypokalaemia, making even usual doses of digoxin to cause digoxin toxicity.
After ceasing digoxin, correct K and other measurements, change thiazide diuretic to another potassium-sparing diuretic or antihypertensive drug.
ACE-I and ARB can improve outcomes in…
Only those with LV systolic dysfunction.
Absence of such dysfunction has not been shown to improve outcomes
Best measure to prevent future attacks of acute rheumatic fever
Regularly, monthly injection of penicillin
- should be continued for many years
- to stop only when specialist doctor advice
Cause high risk of redeveloping strep throat —> acute rheumatic fever
Pulmonary embolism can cause right ventricular failure.
What can be seen in right ventricular failure on cardiac examination?
- Elevated JVP
- Prominent a-waves (due to increased atrial contraction pressure in pulmonary HTN often cause by large emboli)
- 4th heart sound (occurs near the end of diastole at the time atrial contraction)
Summary of management based on CVD risk
Contraindication to nitrates for treatment of angina
Sildenafil (PDE-5 inhibitor)
Can only use after 24H of taking sildenafil/vardenafil or after 48H of taking tadalfil.
Use morphine/fentanyl instead.
Patient with drug-eluding stent with ACS, should not do elective procedure for how long?
If possible, at least 12 months.
High risk for stent thrombosis
Requires dual-antiplatelet therapy for at least 12 months.
Clinical Features of Unstable Angina compared to Stable Angina
– A change in the pattern of previously stable angina with increased frequency,
duration or more easily precipitated attacks.
– The onset of angina at rest or with minimal exertion.
– Prolonged episodes fo angina pain, lasting more than 20 minutes.
– The serial troponin levels are not elevated.
Clinical Features of Stable Angina
– Acute central crushing chest pain.
– The pain may radiate the jaw, neck or arms.
– The duration of pain is between 1-15 minutes.
– The pain may be associated with dyspnea, faintness, and relieved by glyceryl
nitrate.
– The ECG is usually normal.
Most common type of primary cardiac tumour
Myxomas
- typically pedunculated, does not involve ventricular myocardium
Treatment of choice for Sustained Ventricular Tachycardia (VT)
Haemodynamically stable vs unstable
Haemodynamically stable:
- IVI Amiodarone 150-300mg over 30 mins —> IVI Amiodarone 900mg over 24H
Haemodynamically unstable:
- Direct current cardioversion
What is the general presentation of Sydenham Chorea?
What is it related to?
Jerky, uncoordinated movement, espeically affecting hands, feet, tongue and face
Movement may disappear during sleep and may get worse when they know they’re being watched.
It’s related to acute rheumatic fever, post streptococcal infection
Differential Cyanosis
Cyanosis and clubbing of the lower extremities with normal upper extremity nail beds
Usually diagnostic of PDA with pulmonary hypertension
An occurrence of right-to-left.
[In contrast, peripheral cyanosis is usually related to reduced extremity blood flow due to small vessel constriction; Seen in severe HF, shock, peripheral vascular disease.]
Drug-Eluting Stent’s effect on mortality and need for subsequent procedures?
Does not affect mortality
Reduces the need for subsequent procedure!
It slowly releases a drug to block cell proliferation, preventing fibrosis and clots (thrombus)
Causes of Long QT Syndrome
- Hypothyroidism
- Hypothermia
- Hypocalcaemia, hypokalaemia, hypomagnesaemia…
- Sotalol
- Methadone
- Antipsychotics: olanzapine, haloperidol, quetiapine, haloperidol and chlorpromazine
- Antidepressants: TCA, SSRI
Drugs that are contraindicated in WPW syndrome:
- Adenosine
- Digoxin
- CCB (verapamil)
- BB (propranolol)
Does CHA2DS2-VASc score apply to valvular AFib cases?
No.
They do require anticoagulants (warfarin).
Nondihydropyridine CCB (Verapamil and Diltiazem) are used to treat AF too
These drugs are generally avoided in which group of people?
Those with decompensated HF or reduced LV systolic function
Patient on warfarin for AF needs to do surgery with high risk bleeding. INR 2.5.
CHA2DS2-VASc score: 1
What to do?
Cease warfarin 2-3 days
Give Vitamin K 12-18 hours before the surgery if INR not < 1.5
Bridging usually not necessary for those with low-risk AF.
If urgent surgery required, can give prothrombinex or FFP to reverse the anticoagulant effect,
Absolute contraindications to cardiac stress test
- Symptomatic severe aortic stenosis
- High risk unstable angina
- Acute MI
- Unstable heart failure
- Acute pulmonary embolism
- Acute aortic dissection
Contraindications for Beta Blockers
ABCDE
- Asthma
- Block (heart blocks)
- COPD
- DM
- Electrolyte (Hyperkalaemia)
Examples of Left-To-Right Shunt
Patient foramen ovale
ASD
VSD
Etc.
Examples of Right-To-Left Shunts
TOF = pulmonary stenosis + overriding aorta + RV hypertrophy + VSD
Transposition of the Great Vessels
Persistent Truncus Arteriosus
Symptomatic Bradycardia
IV Atropine 0.5mg every 3-5 minutes, max dose of 3mg in total
Dopamine and epinephrine may be beneficial
Not improving? Temporary cardiac pacing
Cor-Pulmonale
(Right Ventricular Failure)
Right Herat Failure
- peripheral oedema, raised JVP, positive hepatojugular reflux
Pulmonary Hypertension
- loud P2
Cor-Pulmonale should be suspected in anyone with COPD
- globally decreased air entry
Initial choice of investigation for those suspected to have PE
Chest X-Ray
- first exclude pathologies that mimic PE
- usually normal in PE
- May present with:
Focal oligemia (Westermark’s sign)
Peripheral wedged-shaped density above the diaphragm (Hamptom’s Hump)
Enlarged right descending pulmonary artery (Palla’s Sign)
[CTA - investigation of choice for diagnosis; V/Q scan - second line]
Best time to take cardiac markers (Troponin 1)
Within 4-12 hours after symptoms
If normal after 8-12 hours, unlikely infarct
When do we prefer rhythm-control over rate-control ?
Haemodynamically unstable
Rhythm control first
They’d usually go for electrical cardioversion (first line first), if failed, then go for pharmacological (flecainide)
Treatment of Sydenham Chorea due to suspected acute rheumatic heart disease
Treat the chorea!
Carbamazepine and sodium valproate (preferred over haloperidol)
[Benzodiazepines is for acute anxiety disorders]
Carotid Sinus Hypersensitivity
An exaggerated response to pressure applied to the carotid sinus located in the carotid bifurcation, resulting in bradycardia, vasodilation and hypotension. This response is manifested clinically as syncope or presyncope and can cause fatal consequences.
Primary indications for CABG
- Those with 3VD OR LV dysfunction
- Those with left main coronary artery disease
- Those with comorbid conditions (DM or COPD) and 2VD
[PCI with drug-eluding stents - better reserved for low-risk patients having 1VD or 2VD without the involvement of left main coronary artery]
Causes of high amplitude of peripheral pulses include:
- Paget disease of the bone
- Aortic valve regurgitation (AR)
- Patient ductus arteriosus (PDA)
- AV fistula
- Thyrotoxicosis
- Wet beriberi
- CO2 retention
- Atherosclerosis
- Fever
- Pregnancy
[AS is low volume pulse due to decrease cardiac output secondary to decrease stroke volume]
Beck’s Triad for Cardiac Tamponade
Muffled heart sounds
Hypotension
Raised JVP
Most probable cause of a new systolic murmur a week post/during MI (EF 60%)
Mitral Regurgitation caused by papillary muscle dysfunction
If EF is low, might mean that papillary muscle have ruptured.
Hypokalaemia ECG
- ST depression
- T-wave depression —> becomes progressively smaller with marked hypokalaemia
- U-wave elevation —> becomes increasingly more significant with market hypokalaemia
Hyperkalaemia ECG
(K > 5.5)
- Tall, tented T waves
- Short QT interval
- Prolonged PR interval
- Widening QRS complex with disappearance of P waves if K > 6.5 —> can progress to VFib or asystole
What is usually the first presentations of myocarditis?
Symptoms of heart failure and dyspnea and weakness over few days to weeks
- usually starts after recent viral infection (fevers + myalgia, some may have pleuritic/angina-like chest pain)
AFib on warfarin therapy (INR aim 2-3)
Recently had mild flu, has bruises on skin, INR 9.
What to do?
- Cease the warfarin
- Give IV phytomenadione (Vitamin K) 5-10mg
- Consider Prothrombinex-VF
- Consider Fresh Frozen Plasma
- Assess until INR < 5 (and bruising improves)
Heparin Reversal
Protamine Sulphate
Atherosclerosis stenosis of the superficial femoral artery will likely reuslt in reduce in pulse in…?
Popliteal artery, pedal pulses….
According to anatomy
Peripheral Polyneuropathy
- usually affects distal extremities in symmetric fashion
- manifests at rest and often at night
- frequently a/w paresthesia/hyposthesia and decreased reflexes
Thromboangiitis Obliterans
- young males, heavy smokers
- acute inflammation of the whole neurovascular bundle (arteries, veins, nerves)
- Obstruction of arterial, venous blood flow + nerve involvement
- Often leads to amputation of fingers and toes
Torsades de pointes
Most important cause?
Torsades de pointes: polymorphic VT a/w QT prolongation
Most important cause: Medication (Long list)
Example:
- Antibiotics (erythromycin, clarithromycin, levofloxacin, clindamycin)
- Class 1A and Class 3 antiarrhythmic
- Some antihistamines (astemizole and terfenadine)
- Some antipsychotics
- Cocaine
- Methadone
Colonoscope is a low-risk procedure to contract IE.
There is no indication for antibiotic prophylaxis.
What are the exceptions?
- Prosthetic valve or material used for cardiac valve repair
- Previous IE
- Congenital heart diseases (unrepaired cyanotic defect, completely repaired defect during the first 6 months after the procedure, repaired defects with residual defects)
- Cardiac transplantation with subsequent development of cardiac valvulopathy
- Rheumatic heart disease in Indigenous Australians only.
What is considered a significant stenosis that requires angioplasty (ballooning, atherectomy, stenting, etc.)?
Stenosis > 50%
Erythema Marginatum
of Acute Rheumatic Fever
‘E’ of the
JONES CAFE PAL criteria for ARF
Initial test when suspecting ARF
Confirm by taking throat swab to show preceding GAS infection first and foremost.
(Blood Culture is only for cases where one is unsure or unaware of GAS infection)
Initial tests to exclude PE
ECG FIRST, THEN CHEST X-RAY
DIAGNOSE: CTPA/V/Q SCAN
V/Q scan is preferred over CTPA for:
- Women of reproductive age (< 55 years old)
- Those with poor GFR (< 40) or those with progressively declining renal function
- Those with known allergic reaction to contrast media
Treatment for PE after confirming with V/Q scan or CTPA in
- normal patient
- renal diseased patient
Unfractioned Heparin or LMWH
- renal diseased patient: unfractioned heparin preferred as LMWH is excreted really.
If have to use LMWH, must adjust according to GFR.
After INR reaches 2-3, then warfarin for long term.
Thrombolysis reserved for haemodynamically unstable patients - with no contraindications.
Mediastinal Phaeochromocytoma
- < 2% of all phaemochromocytoma
- Overproduction of catecholamines —> paroxysmal or sustained HTN
- Diagnosis: measure urinary catecholamines and their metabolites
Thymomas
- a/w myasthenia gravis, agammaglobulinemia, red blood cell aplasia
- Tumours are typically cystic, occurring in anterior mediastinum
- Those that are a/w MG are commonly hyperplasticity (rather than neoplastic)
Hyperparathyroidism
- Half the cases have renal stones
- Other related disorders: peptic ulcers, pancreatitis, bone disease, CNS symptoms
- Occasionally, parathyroid adenoma occur in conjunction its neoplasm of other endocrine organs AKA multiple endocrine adenomatosis.
Reed-Sternberg Cells is seen in…?
Hodgkin Disease
Cystic Teratomas (or Dermoid Cysts)
- Cystic, contain poorly pigmented hair, sebaceous material and occasionally teeth
- Dermoid Cysts include endodermal, ectodermal, mesodermal; occur in the gonads and CNS and mediastinum.
- With rare exceptions, these lesions are benign.
Dizziness can be classified into 4 categories
- Vertigo (spinning sensation / sensation of movement of the environment around the patient)
- Disequilibrium (feeling of imbalance)
- Light-headedness (sensation of giddiness)
- Presyncope (faint)
Orthostatic Hypotension is confirmed by recording both supine and standing BP
A drop of at least 20mmHg in systolic or 10mmHg in diastolic confirms with high certainty
Ventricular Septal Defect (VSD)
- holosystolic murmur at left sternal border
- left-to-right shunt
After Birth:
PVR declines —> RV contracting against pulmonary vascular resistance (PVR) + LV contracting against systemic vascular resistance (SVR) —> pressure difference causes left-to-right shunting.
Small VSDs: usually insignificant
Larger VSDs:
- volume overload and dilation of RV —> excess volume pumped through the lungs and delivered to LA
- Increased left atrial preload —> LA and LV also enlarges
THEREFORE, see enlarged left heart contour and and RV
Eisenmenger Syndrome (Right-to-Left Shunt)
The left-to-right shunt through a large VSD reverses to right-to-left flow
Over years
Causing cyanosis
Pericardial Effusion
- Often secondary to viral pericarditis (+/- pleural effusions)
- ECG: ‘’electrical alternans” (QRS complexes whose amplitudes vary from beat to beat = heart swinging back and forth within an increased quantity of pericardial fluid)
+ Jugular vein distension, muffled heart sounds, borderline low BP developing cardiac tamponade - CXR: Enlargement of cardiac silhouette often seen
- ECHO is confirmatory
Wolff-Parkinson-White Syndrome
- a type of heart arrhythmia caused by an accessory pathway, or an extra electrical conduction pathway, called the Bundle of Kent. It connects the atria and ventricles, or the upper and lower chambers of the heart.
- In WPW, the ventricles start to contract a little bit early, which is called pre-excitation. If the Bundle is on the left side of the heart, it’s called “type A pre-excitation.” If it’s on the right side, it’s called “type B pre-excitation.” Type A is a lot more common.
ECG:
- short PR interval with a delta wave (upsloping just before QRS complex), as well as QRS prolongation.
- This makes sense because the signal is taking the shortcut and contracting the ventricles early.
- Also, the ST segment and T wave (representing repolarization), will often be directly opposite the QRS complex.
Most Common Cardiac Abnormalities in Turner Syndrome (TS) (45,X)
Left-sided cardiac abnormalities (common)
- bicuspid aortic valve
- coarctation of the aorta
- increased risk of aortic root dilation —> aortic dissection or rupture
(+ Hypertension)
Common cardiac defects seen in Down’s Syndrome
AV Canal Defects:
- ASD
- VSD
Cardiac abnormality most prevalent with connective tissue disorders such as Marfan Syndrome, Ehlers-Danlos Syndrome
[Tall statures]
Mitral Valve Prolapse
What happens to the heart of woman with Turner’s Syndrome who becomes pregnant?
Increased blood volume in pregnancy places additional strain on the aorta —> further increases risk of dissection
+ sharp/tearing chest or back pain that radiates to neck or abdomen
+ nerve ischaemia can also lead to extremity tingling
+ asymmetry of pulses of BP, hypotension, aortic regurgitation
Special case for WPW?
AF with WPW
Management
Haemodynamically Unstable: immediate electrical cardioversion
Haemodynamically Stable: Rhythm control with anti-arrhythmic drugs: ibutilide or procainamide is preferred
[AF occurs in 10-30% of AF patients —> bypass AV node —> rapid ventricular response rate —> can deteriorate to VF]
[Should not use AV nodal blocking agents: adenosine, BB, CCB (esp verapamil) and digoxin for AF with WPW —> promotes conduction across accessory pathway —> AF into VF]
Chronic Lymphadema
