Cardiology Cases Flashcards
Case
Hx: 60 yo man, chest pain, tight, 4h, nausea and sweating, HTN, DH: amlodipine.
O/E: temp 37, S1 + S2, BP 120/80 (L), 118/75 (R), clear chest, abdomen SNT
What is it?
Pneumonia, Pericarditis, Myocardial infarction, Aortic dissection, Costochondritis
Myocardial infarction
What are the three layers of investigation for MI?
- ECG
- Troponin
- Echocardiogram
Why is an ECG important for MI?
To find out if it is a STEMI or NSTEMI as they have different treatments
What do if troponin comes back as postive or negative?
+ve - coronary angiogram (whether STEMI/NSTEMI)
-ve - exercise tolerance test
Why do an Echocardiogram?
To check for ventricular dysfunction and regional wall motion abnormality, blockage of one of the coronaries can be seen in a territory (RWMA)
Management of STEMI/NSTEMI?
Both you give aspirin and clopidogrel
STEMI - and then send to cath lab to do percutanous coronary intervention to do balloon angioplasty or stenting
NSTEMI - add LMWH and then risk-stratify and sent for an angioplasty
Differential diagnosis of chest pain (cardiac)
Ischaemic heart disease
Aortic Dissection
Pericarditis
Differential diagnosis of chest pain (Respiratory)
Pulmonary embolism
Pneumonia
Pneumothorax
Characteristics of Ischaemic heart disease
radiation to jaw, left arm
pressure-like pain
Associated symptoms: sweating, nausea
Characteristics of Aortic Dissection
Chest pain radiates to back
BP difference in both arms (>20)
Aortic Regurgitation murmur
Characteristics of Pericarditis
pleurtic pain (worse when breathing in, sharp)
relieved when leaning forward
flu-like illness
(young person with no other risk factors)
Characteristics of PE
Pleuritic Sudden SOB Swollen leg Haemoptysis Risk factors: immbolility or pill
Characteristics of Pneumonia
Pleuritics chest pain
cough
sputum
Temp
Characteristics of Pneumothorax
Sudden onset of SOB
Differential diagnosis of chest pain (GI, Musculoskeletal)
GI - Oesophageal spasm
Oesophagitis
Gastritis
Musc - Costochondritis
Cause of pleurtic pain (all Ps)
PE Pericarditis Pneumonia Pneumothorax Pleural pathology Sub-diaphragmatic pathology (could also be due connective tissue disease e.g. sjogren's, SLE or pleurtic tumour)
Cardiac Chest pain associated symptoms
Pain, palpitations, dizziness, breathlessness, ankle swelling
ECG features of Anteriolateral STEMI
ST elevation V2-4, V5,6 + I, aVL
ECG features of inferior STEMI
ST elevation in II, III, aVF
Artery supply of heart anterior, lateral, inferior
Anterior -Left anterior descending
Lateral - Circumflex (branch of left main stem)
Inferior - Right coronary artery
Causes of collapse
Hypoglycaemia
Cardiac - Vasovagal, Arrhythmia, Outflow obstruction, postural hypotension
CNS-seizures
Features of Vasovagal (3P)
Posture
Prodrome
Provoking factors - hot weather, dehydration, cough refelx, micturition reflex
Features of Arrhytmia (causes, requirements etc)
Either brady or tachy
ECG-long QT predisposes to VT - abnormal ventricular repolarisation
Causes: congenital - mutations in K channels (depolarisation porblems), FH of sudden death Acquired: low K/Mg, drugs
Cardiace monitor and 24h tape required to catch an episode
How to measure QT interva
Draw line between two R waves, then draw a line half way and the T-wave shoudl finish before half way point, if not long QT
Examples of Outflow obstruction
Left-Aortic Stenosis, Hypertrophic cardiomyopathy
Right- PE
O/E and Investigations for outflow obstruction
Exam: low volume/slow rising pulse (thrill under fingers on the carotid pulse), ESM
Echo-to see stenosis and pressure gradient across valve
O/E and Investigations for postural hypotension
Lying and standing blood pressure
Differential diagnosis of raised JVP
R-heart failures
Tricuspid Regurgitation
Constrictive pericarditis
Cause of R heart failure
Secondary to left - CCF, previous ischaemic heart disease, MI
Pulmonary hypertension - PE, COPD,
Causes of Tricuspid regurgitations
carcinoid, valve leaflet damage due infective endocarditis, R-ventricle dilation of the valve ring
Causes of Constrictive pericarditis
calcification of the pericardium due TB seen on CX
Infection - TB
Inflammation - Connective tissues disorder lupus, sarcoid
Malignancy
Differential Diagnosis of a Systolic murmur
Aortic Stenosis
Mitral Regurgitation
Tricuspid Regurgitation
Ventricular septal defect
Why could troponin be raised?
MI Sepsis Pneumonia Fall Renal Impairment
3 things an ECG can tell?
Suggests structural problems, conduction problems, ischaemia
4 things ECG can show with a tachycardia/palpitations
Sinus Tachycardia
Supraventricular tachycardia
Atrial fibrillation/Flutter
Ventricular tachycardia
DDx of Sinus tachycardia
Sepsis (hypotension causing reflex tachy)
Hypovolemia
Endocrine: thyrotoxicosis, phaeochromocytoma
Can be physiological
Features sinus tachycardia
Narrow QRS and p waves seen
Features of SVT
missing p wave
fast and regular
QRS-T pattern
narrow complex (<3 sml squares)
DDx of SVT
AVNRT - re-entry circuit at the AV node (in circles)
AVRT (Wolff Parkinson White) - big accessory bundle
Features of AF
Irregular, no p-waves, narrow QRS
Features of Atrial Flutter
Chaotic atrial activity, no p-waves, saw-tooth baseline
DDx of AF/atrial flutter
Metabolic - Thyrotoxicosis. alcohol
Heart (by layer): pericarditis, muscle (CM, IHD, HTN, myocarditis). valves (MS, MR)
Lungs: pneumonia, PE, cancer
Features of a ventricular tachycardia
Broad QRS comples (you can see pink paper between the two limbs if complex)
Regular
DDx of VT
Ischaemia - collapse with MI due to arrhythmia Electrolyte abnormality (Check K, Mg) Congenital: long QT (look at previous old ECG)
Management of SVT
Whatever the rhytmn is if haemodynamically compromised (hypotension) -> DC cardioversion
Otherwise: start with vagal manoeuvres (immers in cold water, valsalva, massage carotid)
Give adenosine with cardiac monitor (contraindication if asthma or pt cold), print rhytmn strp and mark when adenosine given
Management of AF
Treat underlyning cause
Control rate with beta-blockers or digoxin
Prevent stroke (CHADVASC)
Think of complications (anticoagulation - warfarin)
Rhytmn control: if onset >48h, do not perform cardioversion as patietn is of risk of thrombus, which may cause a stroke, hence anticoagulate for 3-4weeks before cardioversion
If less than 48h oppurtunity to do cardioversion
Management of VT
If haemodynamically not compromised, give IV amiodarone (if they are speaking etc)
Look for and treat underlying cause
ICD
if pulseless VT: defibrillate
What is the difference between cardioversion and defibrillation
Cardioversion is synchromised adn defibrillation is not
What is the criteria of left ventricular hypertrophy by ECG
SIR: Deep S waves in V1, V2, tall R waves in V5,V6 ->suggestive of hypertension
S in V1 + R in V5/6 (which ever is bigger) ≥ 7 large squares
DDx of left ventricular hypertrophy
Hypertension - as it is working high resistance
Aortic Stenosis - working against a narrow gradient
(hypertension more common tho)
Features of 1st, 2nd, 3rd degree heart block
1.Prolonged PR interval (> 1 lrg sqr)
2.Missed QRS after P
waves
3. Complete dissociation of atria and ventricles, (broad QRS)
Heart sounds:
S1, S2, fixed wide splitting of S2, S3, S4
S1 - closure of mitral valve
S2 - closure of aortic valve
Fixed wide splitting of S2 - atrial septal defect
S3 - associated with ventricular filling
S4 - associated with ventricular hypertrophy (atria have to constrict against stiff ventricle)
Mangement for acute heart failure
- Sit up
- 60 -100% O2
- Furosemide(IV)- not for diuresis, venodilator as well)
a. Given IV because they have gut oedema they will not absorb the drug orally
b. daily weights needed
4.Treat the underlying cause
GTN spray are only used in rare cases, e.g. if heart failure + MI/angina
Management of chronic heart failure
indicated by reduced exercise-tolerance test
Tx: Beta-blockers
ACEi & spironolactone
Cause of cardiac arrest
Hypoxia Hypothermia Hypovolaemia Hypo/hyperkalaemia Tamponade Tension pneumothorax Thromboembolism Toxins/metabolic disorders: drugs, therapeutic agents, sepsis
Management for VF/pulselessVT
Shock Do CPR for 2min Re-assess rhytmn Adrenaline every 3-5min Amiodarone after 3 shocks Correct reversible causes
Managemenr of asystole/pulseless electrical activity
ECG looks fine bu pt has no pulse
CPR (2min)
Correct reversible causes
Adrenaline every 3-5min
ECg changes for Pericarditis and management
Global saddle-shaped ST elevation, diffuse coronary disease
better when leaning forward
Mx: analgesics and reassurance
