Cardiology (Quesmed) Flashcards
What are the main causes of Acute Bradycardia?
Sinus/ AV Nodal Disease
Drug Induced (Beta Blockers, Calcium Channel Blockers)
Electrolyte Abnormalities- hyperkalaemia and hyponatremia
Hypothyroidism
What is the 4 step management of Acute Bradycardia?
What is given if beta blockers are the cause?
Assess via DRABCDE
You do NOT need to treat unless symptomatic
Then ECG Monitoring and identify any reversible causes
If any Adverse Features (Heart Failure, Myocardial Ischaemia, Shock, Syncope),
1) Give 500mcg IV Atropine
If these don’t work,
2) Repeat Atropine up to 3mg
3) Transcutaneous Pacemaker can be given while waiting for Transvenous/ Permanent Pacemaker
4) Give Isoprenaline and Adrenaline
Give GLUCAGON if Beta blockers cause the Bradycardia
What JVP Waveform is seen in Complete Heart Block?
Cannon A waves
What is Acute Myocarditis? What are the signs of Acute Myocarditis?
What kinds of heart sounds (S sounds) may be heard?
It is an inflammatory disease of the Myocardium
Signs
- FEVER
- Cardiac-type Chest Pain
- Fatigue
- Palpitations
- Symptoms of Heart Failure
- PULMONARY OEDEMA
Suspect in young people with a new onset flu-like illness and chest pain with pulmonary edema
Signs of heart failure may be evident along with S3 and S4 gallops. If Pericarditis is associated, Auscultation can reveal a Pericardial Friction Rub
What 5 investigations should be ordered in Acute Myocarditis?
What does the ECHO show in Myocarditis?
What is the gold standard?
1) ECG shows ST Elevation and T wave Changes
Ectopic Beats and Arrhythmias may be present
2) Troponin may be elevated
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3) Echocardiogram reveals Ventricular Dysfunction in the form of Diastolic Dysfunction or Regional Wall Motion Abnormalities
4) Cardiac MRI Findings can help confirm the diagnosis of Myocarditis by showing the presence and extent of the Inflammation
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5) Endomyocardial Biopsy via Cardiac Catheterisation is the GOLD STANDARD diagnostic tool. BUT it is INVASIVE so has its own risks
What is the management of Myocarditis?
*What should be given for viral myocarditis?
Address the Underlying cause- ANTIBIOTICS if bacterial
ITU support may be required as the patients may need VASOPRESSORS
Corticosteroids are sometimes needed if they have Viral Myocarditis
After Recovery- they should limit activity for a few months
What is the management of Narrow Complex Tachycardia?
What is done if there are HISS features?
And if there are no HISS features, what is given if it is regular?
If it is irregular, what is given if there was AF in the last 2 days?
And if AF was >2 days ago?
1) ABCDE
2) If HISS Features- Synchronised DC Cardioversion is needed- UP TO 3
3) If Haemodynamically Stable
- Regular= Carotid Sinus Massage/ Vagal Manouevre, if it fails then 6mg IV Adenosine, then 12mg, then 18mg
- Irregular=
a) AF within last 2 days- Rhythm Control= LMWH and Flecainide if there is no Structural Heart Disease or Amiodarone if there is Structural Heart Disease
b) > 2 days ago Rate Control= BETA BLOCKERS/ Verapamil, or Digoxin (if Heart Failure) AND Anticoagulation
What is Aortic Dissection and what are the 4 risk factors for it?
A tear in the Tunica Intima causes blood to flow between the Inner and Outer Walls of the Aorta
Risk Factors-
- Hypertension
- Connective Tissue Disorder (Marfan’s- Tall with Pectus Excavatum)
- Valvular Heart Disease
- Cocaine/ Amphetamine Use
What are the 2 types of Aortic Dissection?
Type A- Ascending Aorta
Type B- Descending Aorta
What are the signs of Aortic Dissection?
Usually Men over 50 years old
Sudden, Tearing Interscapular Pain Radiating to the back- in the CHEST or UPPER BACK
WEAK or ABSENT PULSE
Can also present with (depending on how far the Dissection Extends):
- Limb/ Bowel Ischaemia
- Renal Failure
- Syncope
1) Radio-radial Delay (Ascending)
2) Radio-Femoral Delay (Descending)
3) Blood Pressure Differences between Arms
What investigations should be ordered in Aortic Dissection?
What is seen on CT?
What is seen in Echocardiography?
What is seen on Chest Xray and ECG?
What is diagnostic?
The following sings MAY or MAY NOT be there:
1) Diagnostic- CT, if not Trans-Oesophageal Echocardiography (TOE)- FALSE LUMEN IS SEEN
2) ECG- Ischaemia in Specific Territories if Dissection extends into the Coronary Arteries- mainly INFERIOR RCA
3) Echocardiography- Pericardial Effusion and Aortic Valve Involvement
4) Chest Xray- Widened Mediastinum
5) Bloods-
- Troponin may be raised
- D-Dimer may be positive
What is the Initial and Definitive Management of an Aortic Dissection?
1) Resuscitation
2) Cardiac Monitoring
3) Strict Blood Pressure Control (IV Metoprolol/ Labetalol) and Opioid Analgesia
Definitive
- Type A- Surgical Management= Aortic Graft
- Type B- Conservatively with Blood Pressure Control UNLESS there is End-Organ Damage, then Surgery may be performed
What are the Complications of Aortic Dissection?
- Death due to Internal Haemorrhage
- Rupture
- End-Organ Damage (Renal or Cardiac Failure)
- Cardiac Tamponade
- Stroke
- Limb Ischaemia
- Mesenteric Ischaemia
What are the 4 AcuteCauses of Aortic Regurgitation?
Which 2 should you remember?
1) Infective Endocarditis (destroys and perforates the valve)
2) Aortic Dissection (impedes valve closure)
3) Traumatic Rupture of Valve Leaflets (blunt chest trauma or deceleration injury)
4) Iatrogenic Causes- Balloon Valvotomy or TAVI
Most Common Causes- Infective Endocarditis and Aortic Dissection
Valve Replacements can be complicated by Aortic Regurgitation- leading to the degeneration of a tissue valve or thrombosis of a mechanical one
What are the Chronic Causes of Aortic Regurgitation?
What are the 2 main causes and the different causes of these causes?
What is the most common cause in the developing and developed world of Aortic Regurgitation?
Valve Disease or Aortic Root Dilatation
Valve Disease
1) Calcific Aortic Valve Disease (Age Related)
2) Myxomatous Degeneration
3) Congenital Disease (Bicuspid Aortic Vale)
4) Rheumatic Heart Disease (Most Common in the Developing World)
5) Infective Endocarditis
6) Rheumatic Causes (Rheumatoid Arthritis, Antiphospholipid Syndrome)
Aortic Root Dilatation
1) Congenital Bicuspid Aortic Valve
2) Genetic Cause- Marfan’s, Ehler’s Danlos
3) Systemic Vasculitides- Giant Cell Arteritis
What are the signs of Acute Aortic Regurgitation?
Sudden Cardiovascular Collapse
Pulmonary Oedema
Pallor
Sweating
Peripheral Vasoconstriction
What are the signs of Chronic Aortic Regurgitation?
If it is severe enough, what can it lead to?
(Usually Asymptomatic for years and then Insidious Presentation)
The Pulmonary Heart Failure Signs
Exertional Dyspnoea
Orthopnoea
Paroxysmal Nocturnal Dyspnoea
If Severe Enough, can lead to Stable Angina even if there are no Coronary Artery Diseases present. This is due to a reduction in diastolic Coronary Perfusion
What are the Examination Findings of Aortic Regurgitation?
What are De Musset’s and Quinke’s signs?
What kind of heart sounds are heard- S sounds?
What is the pulse pressure like?
What investigations should be ordered? What is definitive?
Waterhammer Pulse
De Musset’s Sign- bobbing of Head
Quincke’s Sign- Pulsation of Nail Beds
Traube’s Sign- Pistol Shots heard in Femoral Pulse
Muller’s Sign- bobbing of Uvula
Widened Pulse Pressure due to LOW DIASTOLIC PRESSURE
Early Diastolic Murmur- Heard best when patient is leaning forward and exhaling
Soft S1 and occasionally an Ejection Flow Murmur
Imaging-
- DEFINITIVE Echocardiogram
- Cardiac MRI if Echo isn’t enough
- Invasive Cardiac Catheterisation and Angiography once Non-Invasive tests are inconclusive
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What is the management of Aortic Regurgitation?
What 5 things indicate a TAVI/ surgery?
Medical-
- Beta Blockers AND/OR Losartan- to slow Aortic Dilatation
- If Severe and Asymptomatic, monitor them yearly
Surgical (Surgical Replacement) TAVI unless they are too weak to tolerate the Surgery)
- Indicated if:
1) Significant Enlargement of Ascending Aorta
2) Symptomatic Aortic Regurgitation
3) Asymptomatic Aortic Regurgitation WITH:
- Poor LVEF (<50%)
- Left Ventricular End Diastolic Diameter>70 or Left Ventricular End Systolic Diameter> 50 (S50, D70)
- Infective Endocarditis doesn’t get helped by Medical Therapy
What are the signs of Aortic Stenosis?
What is the pulse pressure?
What is the carotid pulse like?
What is the apex beat like?
What are the Heart Sounds (S sounds) like in Aortic Stenosis?
(End Stage)
1) Heart Failure
2) Angina
3) Syncope
4) Exertional Dyspnoea and Reduced Exercise Tolerance
5) SLOW RISING Carotid Pulse
6) Narrow Pulse Pressure
7) Heaving, Non-displaced Apex Beat
- ABSENT S2
- S4 if SEVERE
EVEN NUMBER HEART SOUNDS affected in Aortic Stenosis
8) Ejection Systolic Murmur (heard best at second intercostal space at the right)- Harsh sound transmitted to the Carotids
9) Ejection Click may be heard
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What are the Investigation Findings for Aortic Stenosis?
These MAY be seen or may not be seen so don’t worry too much
What is a sign of severity that warrants surgery?
1) ECG- Left Ventricular Hypertrophy MAY be seen
- Sokolov-Lyon- S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm
- Left Axis Deviation
- Poor R Wave Progression
2) CXR
- Cardiomegaly or Calcified Aortic Valve MAY be there
3) Echocardiogram
- MAIN TEST for DIAGNOSIS
- Severe if:
- Peak Gradient> 40- SURGERY IF THIS IS THE CASE
- Valve Area<1
- Aortic Jet Velocity>4
Exercise Testing to assess Severity
Cardiac MRI to assess Severity
What are the 5 indications for Intervention in Aortic Stenosis?
2 are also indications for Aortic Regurgitation Surgery
What about the BNP?
Also something about the BLOOD PRESSURE in Aortic Stenosis??
1) Symptomatic
2) Asymptomatic with LVEF<50%
3) Asymptomatic with LVEF>50% but BP falls during exercise (EXERCISE TOLERANCE)
4) High BNP/ Severe Calcification
5) Peak gradient >40
What is the management of Aortic Stenosis?
TAVI or Surgical Aortic Valve Replacement
1) Surgery is preferred if Low Risk and <75 years old
2) TAVI is preferred if High Risk (previous heart surgery, frail, restricted mobility) or >75 years old
How is Aortic Stenosis treated if they can not have the TAVI or Surgical Replacement?
YOU ONLY NEED TO MANAGE IF THEY ARE SYMPTOMATIC or GRADIENT>40- otherwise just observe them for Aortic Stenosis
Heart Failure Treatment- ACE Inhibitors, Beta Blockers, Diuretics
They should be checked on every 6 months
What is Aortic Sclerosis?
An Asymptomatic Condition caused by Senile Degeneration of the Valve causing IRREGULAR VALVE THICKENING and FOCAL INCREASED ECHOGENICITY
ONLY EJECTION SYSTOLIC MURMUR- nothing else is there
- Ejection Systolic Murmur that does NOT radiate to the valves
- Normal S2- (Absent in Aortic Stenosis)
- Normal Pulse Character- is NOT Slow Rising and does NOT have Narrow Pulse Pressure
- Peak DOPPLER VELOCITIES are normal (raised in Aortic Stenosis)
What is Atrial Flutter?
It is when the MacroCircuit within the Right Atrium becomes Aberrant (deviates from the norm)
This activates the AV Node but because this node has a long refractory period it is not able to conduct the impulses down the His-Purkinje System at such a fast rate
Instead there is a degree of block meaning that only 2:1 (2 p waves per 1 QRS complex), 3:1, 4:1 or rarely 5:1 AV Blocks are conducted to the ventricle
What are the causes of Atrial Flutter?
*COPP ATICS
Pulmonary Disease
1) COPD
2) Obstructive Sleep Apnoea
3) Pulmonary Emboli
4) Pulmonary Hypertension
Other causes
1) Alcohol
2) Thyrotoxicosis
3) Ischaemic Heart Disease
4) Cardiomyopathy
5) Sepsis
What are the symptoms of Atrial Flutter?
Asymptomatic
Palpitations
Dizziness
Chest Pain
What are the ECG signs of Atrial Flutter?
What is the HR of a 2:1 Atrial Flutter?
What is the rhythm (regular/ irregular)? What are the QRS complexes like in Atrial Flutter?
Regular Rhythm
Sawtooth Baseline with Repetition at 300bpm (these are atrial flutter waves)
NARROW QRS Complexes
Ventricular Rates which depends on the level of AV Block
- 150bpm if 2:1
- 100bpm if 3:1
- 75bpm if 4:1
- 60bpm if 5:1
Sometimes they may have variable block which makes the rhythm irregular and can make it look like AF
What is the management of Atrial Flutter?
What should be done in septic or dehydrated Atrial Flutter patients which will also fix the Atrial Flutter?
What is the first line? What should be done if this fails? (remember it is similar to Atrial Fibrillation)
What is usually curative?
Similar to AF- so doesn’t really matter if you successfully differentiate them
Haemodynamic Stable-
- Fluid Resuscitation in Septic or Dehydrated Patients can reverse Atrial Flutter into Sinus Rhythm
1) RATE CONTROL- Beta Blocker or Calcium Channel Blocker should be attempted First Line
- If it Fails to Respond then Cardioversion
ELECTRICAL CARDIOVERSION is better
But if contraindicated- PHARMACOLOGICAL CARDIOVERSION
1) Amiodarone
2) Sotalol
3) Verapamil
4) Digoxin
FURTHER MANAGEMENT-
- CURATIVE= Catheter Ablation of the Cavotricuspid Isthmus
- If Symptomatic Despite Rate Control
What are the causes of Atrial Fibrillation? What is the most common cause in the UK? And the most common cause in the developing world?
(Similar to Atrial Flutter)
Cardiac Causes
- Ischaemic Heart Disease (Most common cause in UK)
- Rheumatic Heart Disease (usually of Mitral Valve)- (most common in Less Developed Countries)
- Hypertension
- Peri-Myocarditis
Non-Cardiac Causes (EE PIED)
- Environmental Toxins (Alcohol Abuse)
- Electrolyte Disturbances (Hypokalaemia, Hypomagnesaemia)
- Pulmonary Causes (Pneumonia or Pulmonary Embolism)
- Infective Causes (Sepsis)
- Endocrine Causes (like Hyperthyroidism)
- Dehydration
What are the signs of Atrial Fibrillation?
What is the JVP like
(similar symptoms to Atrial Flutter)
What is the Pulse like?
Palpitations
Chest Pain
Shortness of Breath
Dizziness
Single Waveform on JVP (there is the loss of the A wave which usually represents atrial contraction)
Irregularly Irregular Pulse
APICAL to RADIAL PULSE DEFICIT
What is the Chronic management of Atrial Fibrillation? (no need if CHADSVAS= 0 and no symptoms)
What should be done if there are HISS features?
What should be done in terms of pharmacological management (if <2 days / >2 days)?
What should be done if Electric Cardioversion Rhythm Control is needed (<2 days/ >2 days since onset)?
What are the options for Rate control and Rhythm control?
What is CURATIVE
*4 steps
RATE OR RHYTHM if Onset< 48 hours, otherwise RATE
ABCDE Approach
Assess for HISS Features and DC Cardiovert if present
Consider Reversible Causes-
- Infection- Antibiotics and Fluids
- Dehydration- Fluids
- Replace Abnormal Electrolytes
If there are no reversible causes or if AF persists- Rate Control FIRST/ Rhythm Control/ Cardioversion
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1) Rate Control (MONOTHERAPY remember) -
- Either Beta-blocker (Bisprolol) or Calcium-channel blocker (Dilitiazem or Verapamil) (monotherapy)
- If >7 days and they are sedentary- then Digoxin can be added
2) Rhythm Control-
- Electrical Cardioversion or Pharmacological (Beta blockers, Dronederone, AMIODARONE (if Heart Failure)) Cardioversion
- (if <48 hours- cardiovert asap, if >48 hours- ANTICOAGULATION for 3 weeks then cardiovert
3) Based on CHADVASC- Anticoagulation for 2 months if 0, or for life if >1 (if =1, anticoagulate for males only)
- Anticoagulation for 4 weeks prior to catheter ablation
4) Catheter Ablation is CURATIVE
????????- Ignore this one
What is the Acute management of New-Onset Atrial Fibrillation?
If <48 hours ago- DC cardioversion with sedation
If > 48 hours ago or onset is uncertain- Anticoagulate for 3 weeks then DC Cardioversion (Check ORBIT score to ensure they can have anticoagulation)
- No NEED for management if ASYMPTOMATIC with CHADVAS=0
or They can have a Transoesophageal ECHO to rule out Thrombus in the Left Atrial Appendage before Cardioversion takes place
What are the 3 Specific Drugs given for Atrial Fibrillation?
Give info on Flecainide, Amiodarone and Sotalol
Flecainide
- Can be either given regularly or as a “pill in the pocket” when symptoms come on.
- Is preferred in young patients who have structurally normal hearts because it can induce fatal arrhythmias in structurally abnormal hearts.
- it is the CHOICE for PAROXYSMAL AF
Amiodarone
- Extremely effective drug in controlling both rate and rhythm.
- However it comes with a massive list of significant side-effects so should normally only be given to older, sedentary patients.
Sotalol
- This is a beta blocker with additional K channel blocker action
- Used for those that don’t meet the demographics for either flecainide or amiodarone.
What are the Anticoagulation options in Atrial Fibrillation?
Just remember DOACS are the preferred option
For what specific type of Atrial Fibrillation is Warfarin given for? What must you remember about LMWHs?
1) DOACS are generally preferred
- Do not require monitoring and less bleeding risks than Warfarin
2) Warfarin
- Requires cover with LMWH for 5 days when initiating treatment as Warfarin is initially Prothrombotic
- INR can be affected by a whole host of drugs and foods
- It is the only Oral Anticoagulant licensed for Valvular Atrial Fibrillation (USUALLY MITRAL STENOSIS)
3) LMWH (like Enoxaparin)
- Only if they can’t tolerate Oral
- It needs Daily Treatment Dose Injections
What are the complications of Atrial Fibrillation?
There are technically just 3
Heart Failure
Systemic Emboli- Ischaemic Stroke, Mesenteric Ischaemia, Acute Limb Ischaemia
Bleeding- GI/ Intracranial
What are the contradictions for Warfarin?
Bleeding Disorders
Severe Hypertension
Pregnancy
Peptic Ulcer Disease
What is the CHA2DS2VAS Score?
1- Congestive Heart Failure
1- Hypertension
2- (Age) 75 years old or older
1- Diabetes Mellitus
2- (Stroke) Previous Stroke or TIA
1- Vascular Disease
1- (Age) 65-74 years old
1- (Sex) Female
(Anticoagulation if Males score 1 or more and Females score 2 or more)
What are the ECG features of Ventricular Fibrillation?
Polymorphic Irregular Bord Complex Tachycardias
This is usually Pulseless as well
What is the management of Ventricular Fibrillation?
- Basic Life Support - ABCDE and CPR
- VF is Shockable- so Administer Defibrillation (Unsynchronised Cardioversion using a 200J Biphasic Shock)
- Resume Chest Compressions
- 1mg Adrenaline (10ml 1:10,000) plus 300mg Amiodarone after the 3rd Shock. Then give Adrenaline after every other shock
What are the ECG Features of Ventricular Tachycardia?
Tachycardia (>100bpm)
Absent P Waves (as beats originate in the Ventricles)
Monomorphic Broad QRS Complexes (which means longer ventricular depolarisation)
What is the management of Pulseless Ventricular Tachycardia?
Same as Ventricular Fibrillation lol
- Basic Life Support - ABCDE and CPR
- It is a Shockable Rhythm so a 200J Biphasic Unsynchronised shock should be administered
- CPR should be resumed for 2 minutes before rechecking the Rhythm
- Intravenous Adrenaline (1mg of 10ml 1:10,000 solution) and Amiodarone (300mg) should be administered after the 3rd Shock. Then give Adrenaline every other shock
What is the management of Ventricular Tachycardia with a Pulse with Adverse Features?
(HISS FEATURES)
- DC Shock- How many times? (3 attempts)
- Then Expert Help and then 300mg IV Amiodarone over 20 minutes, followed by 900mg over 24 hours
What is the management of Ventricular Tachycardia with a Pulse and No Adverse Features?
300mg IV Amiodarone over 20 minutes (same as what you give after shocking if pulseless), followed by 900mg over 24 hours
What is Torsades de Pointes?
What type of arrhythmia is it exactly?
What causes it?
QRS Complexes Twisting around the Isoelectric Line
It is a Polymorphic Ventricular Tachycardia caused by QT Prolongation
What are the causes of Torsades de Pointes?
What is the main cause?
What are the 4 drugs causes of Torsades de Pointes? (AA/AA/K)
Which HYPOTHs (2) lead to Torsades de Pointes?
Congenital Long QT Syndrome (Romano Ward Syndrome and Jervell and Lange-Nielsen Syndrome)
Medications (4 As and Ketoconazole)(Antiarrhythmics, Antibiotics (like Erythromycin), Tricyclics, Antipsychotics, Ketoconazole)
Myocardial Infarction
Renal/ Liver Failure
Hypothyroidism/ Hypothermia
AV Block
Toxins
What is the management of Torsades de Pointes in Haemodynamically Unstable Patients?
HISS FEATURES
- Direct Current Shock and IV Amiodarone (so similar to a Pulseless Ventricular Tachycardia)
MINUS the Adrenaline
What is the management of Torsades de Pointes in Haemodynamically Stable Patients?
(Remember the FIRST LINE)
IV Magnesium Sulphate (2g over 10 minutes)
Stop Drugs that Prolong QT and Correct Electrolyte Abnormalities
Isoprenaline Infusion and Pacing may be considered. These may be used in patients with recurrent Torsades de Pointes despite Initial Therapy with Magnesium Sulphate
Which Broad Complex Tachycardia is often seen Post-MI?
So if they say there is a broad complex tachycardia after the patient has had an MI it is most likely….
Ventricular Tachycardia
What is Brugada Syndrome?
Which channel is affected and what is the inheritance of this condition?
How may patients present/ what does it increase the risk of patients getting?
What is it worsened by?
It is a genetic condition caused by Sodium Channelopathies
It is autosomal DOMINANT
Patients may be Asymptomatic or present with Palpitations and Syncope due to Arrhythmias such as AV Nodal Re-entrant Tachycardias (AVNRTs), VT or VF
This is worsened by FEVERS
How is Brugada Syndrome diagnosed?
What is given to make the diagnosis easier?
ECG changes and a clinical sign (Palpitations and Syncope that gets worse AFTER Fever)
- Brugada Sign- ST Elevation (>2mm) in V1-2 and Negative T Waves
Flecainide and Ajmaline can help make the diagnosis easier
What investigations should be ordered for Brugada?
Genetic Testing (as it is genetic- AUTOSOMAL DOMINANT), Family History and Special Provocation Tests (like Ajmaline/ ECG)- also used for diagnosis
Also remember ECG
What can precipitate symptoms in Brugada Syndrome?
What electrolyte abnormalities can cause the symptoms?
1) Fever
2) Excess Alcohol
3) Dehydration
4) Medication-
- Antidysrhythmics like Flecainide
- Verapamil
- Antidepressants like Amitriptyline
5) Electrolyte Abnormalities (HYPOKALAMEIA and HYPOMAGNESAEMIA)
What is the management of Brugada Syndrome?
How can we stop it turning into VF/VT
ICD Defibrillation to reduce the risk of sudden cardiac death due to VT/VF
What is the management of Brugada Syndrome?
How can we stop it turning into VF/VT
Implantable Cardiac Defibrillator (ICD) to reduce risk of death from VF and VT
What are the Indications for Cardiac Catheterisation?
1) Imaging- (Contrast Dye into Coronary Vessels to image anatomy and blood supply)
2) Angioplasty- Ball Dilatation and Stenting (PCI)
3) Valvuloplasty- Transcatheter Aortic Valve Implantation (TAVI)
4) Repair- Transcatheter Repair of Septal Defects
5) Electrophysiology- Studies and catheter ablation (for AF, Atrial Flutter, Wolff-Parkinson-White)
6) Measurement- Pressures within Heart and Great Vessels
7) Biopsy- Endomyocardial Biopsies for Inflammatory or Infiltrative Disorder Diagnosis
What is the role of Cardiac Catheterisation in Coronary Artery Disease and Post-MI?
Cardiac Catheterisation is regularly conducted if Post MI or with Coronary Artery Disease for Diagnostic Purposes and if necessary- PCI and Angioplasty
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What are the complications of Cardiac Catheterisation?
What is the most common complication?
Bleeding is the most common Complication, which occurs due to Arterial Puncture
Arterial Thrombosis causing Occlusion of the Radial or Femoral Artery can cause Ischaemia of the Distal Limb. Loss of Distal Pulse can be caused by Arterial Vasospasm
Arrhythmias can also occur but are Transient and include Ventricular Tachycardia and Ventricular Fibrillation. Bradycardia can also occur
Allergic Reaction to Iodine Contrast or Local Anaesthetic
Perforation of the Great Vessels which leads to Tamponade
What is Cardiac Myxoma?
Myxomas are benign and composed of unspecialised Mesenchymal cells with a Mucopolysaccharide Stroma (which gives it a smooth Gelatinous Appearance)
What are the signs of Cardiac Myxoma?
May be systemic and include FEVER and WEIGHT LOSS
Other signs include-
- Audible Tumour Plop
- Nail Clubbing due to Embolisation
- Symptoms of Mitral Obstruction and Stenosis (like Atrial Fibrillation)
What Investigations should be ordered in Cardiac Myxoma?
Raised ESR and CRP
What is Carney Complex?
What can it cause? (remember the 2 main things it can cause)
Myxomas can occur secondary to Carney Complexes which is an Inherited AUTOSOMAL DOMINANT DISORDER characterised by Myxomas, Schwannomas, Endocrine Tumours (Pituitary, Adrenal, Testicular) and Abnormal Skin Pigmentation
Therefore it can cause Cushing’s Syndrome
What are the 4 types of Cardiomyopathies?
Which is the most common?
Dilated (most common)
Hypertrophic (most common cause of death out of all of these)
Restrictive
Arrhythmogenic Right Ventricular Cardiomyopathy
What are the causes of Dilated Cardiomyopathy?
Ischaemic Changes can over time manifest with Dilated Cardiomyopathy- specifically Post-MI (think of it like heart muscle is losing energy so gets weak and thin)
Hypertension
Genetic
Toxin-related- Alcohol, Cocaine (DCM and Ischaemia)
Infiltrative (-Osis diseases)- Sarcoidosis or Haemochromatosis
Infections- Myocarditis
What are the signs of Dilated Cardiomyopathy?
What type of valve disease is usually seen?
What are the heart sounds (S sounds like)?
Heart Failure symptoms (LEFT SIDED- like Shortness of Breath and Fatigue)
So what you see is the HEART FAILURE that arises basically
Other symptoms due to the consequence of Cardiomyopathy- Arrhythmia, Conduction Disturbances, Sudden Cardiac Death
Displaced Apex Beat
S3 gallop rhythm (rapid ventricular filling)
Mitral Regurgitation (due to Displacement of the Valve Leaflets)
What are the ECG findings of Dilated Cardiomyopathy?
Poor R Wave Progression (From V1 to V6)
Echocardiography is diagnostic
What is Hypertrophic Cardiomyopathy?
What is the inheritance?
Genetic Condition characterised by LVH of varying degree (Autosomal Dominant)
It causes DIASTOLIC DYSFUNCTION (Dilated is systolic)
What are the symptoms of Hypertrophic Cardiomyopathy?
What type of murmur is usually heard?
Double Beef Jerky HOCM
Little to no Symptoms
EXERTIONAL DYSPNOEA
Initial presentation= Syncope, Presyncope or Sudden Death in Young People
Jerky Pulse and Double Apex Beat (DOUBLE BEEF JERKY)
Harsh Ejection Systolic Murmur- LOUDER with VALSALVA and QUIETER with SQUATTING. May also be a PANSYSTOLIC MURMUR
Apical Thrill
What are the 4 ECG Findings of Hypertrophic Cardiomyopathy?
DEEP Q Waves
Deeply Inverted T waves
ST changes (usually depression)
LVH
What is Restrictive Cardiomyopathy?
Non-Dilated Non Hypertrophied Ventricles with Impaired Filling
What are the signs of Restrictive Cardiomyopathy?
What does the ECHO show? What should be suspected if the ECHO appears SPARKLY??
What is used to differentiate between restrictive cardiomyopathy and constrictive pericarditis?
1) Heart Failure- RIGHT SIDED Heart Failure Symptoms- Hepatomegaly and Oedema (Left Sided with Dilated)
2) Symptoms like Constrictive Pericarditis
75% will have Atrial Fibrillation
Diagnosis= Echo shows Thickened Ventricular Walls and Valves. If Sparkly= Amyloidosis (Oedema also seen due to Nephrotic Syndrome and Proteinuria)
Cardiac MRI= Differentiates between Restrictive Cardiomyopathy and Constrictive Pericarditis
Which Heart Sounds are audible in which Cardiomyopathies?
S3= In DCM
S4= In HOCM
Which Cardiomyopathy is the most common cause of Sudden Cardiac Death in Young People?
Hypertrophic Cardiomyopathy
When is CABG preferred over PCI?
there are 4 reasons why you would do CABG over a PCI?
It has a mortality advantage if:
- Over 65 years old
- Diabetes
- 3 Vessel Disease
- Significant LEFT MAIN STEM Stenosis
What scars are seen in CABG?
Mid-line Sternotomy Scar
Longitudinal Graft Scar
What are the 5 causes of Ejection Systolic Murmur?
Aortic Stenosis
Aortic Sclerosis
Flow Murmur (Anaemia, Pregnancy, Thyrotoxicosis)
Hypertrophic Obstructive Cardiomyopathy
Pulmonary Stenosis
What are the 3 causes of Pan Systolic Murmur?
When and where is TR loud?
Mitral Regurgitation- Loudest at the Apex- Radiating to the Axilla- Loudest in Expiration
Tricuspid Regurgitation- Loudest at Left Sternal Edge- Loudest in Inspiration
Ventricular Septal Defect
How does Digoxin work?
What kind of tropicness does it show?
It Inhibits the Sodium/Potassium Pump in the Myocardium and also has Parasympathetic Effects on the AV Node
It is Negatively Chronotropic and Positively Ionotropic- Slows the Heart Rate and Increases Contractility
What are the 4 ECG signs of Digoxin (NOT TOXICITY- just Digoxin)?
Long, Short, T, Tick
Slight PR Prolongation
Shortened QT Interval
T Wave Inversion
Downsloping ST Depression- Reverse Tick
Where do the ECG Leads go?
V1- 4th Intercostal Space- Right Sternal Margin
V2- 4th Intercostal Space- Left Sternal Margin
V3- Halfway between V2 and V4
V4- 5th Intercostal Space Mid Clavicular Line
V5- 5th Intercostal Space Anterior Axillary Line
V6- 5th Intercostal Space Mid Axillary Line
What are the signs of First Degree Heart Block? What are the 4 causes of First Degree Heart block?
What drugs can cause it?
PR>200
1) High Vagal Tone (Athletes)
2) Acute Inferior MI
3) Electrolyte Abnormalities (Hyperkalaemia)
4) Drugs (NHP-CCBs, Beta Blockers, Digoxin, Cholinesterase Inhibitors (dementia medications))
- acute Heart medications aside from ACE inhibitors
What is the management of First Degree Heart Block?
It is benign and does not need to be treated
But treat the cause
What are the signs of Mobitz I (Wenkebach)?
What are the 5 causes of Mobitz I?
PR gets longer and longer until P wave no longer has QRS Complex
1) High Vagal Tone (Athletes)
2) MI (Mainly Inferior)
3) Cardiac Surgery
4) Myocarditis
5) Drugs (NHP-CCBs, Beta Blockers, Digoxin, Cholinesterase Inhibitors)
(SAME as First Degree Heart Block)- but also Cardiac Surgery and Myocarditis can cause it
What is the management of Mobitz I?
Generally Asymptomatic and does not require specific management. So treat the cause
If symptoms do arise
1) ECG monitoring may be needed
2) Removing Precipitating Drugs
3) Atropine if Bradycardic
- Basically similar-ish to First Degree but you give Atropine if there are symptoms
What are the signs of Mobitz II?
What are the 6 causes of Mobitz II?
Constant but Long PR Interval With the occasional solo P Wave (usually regularly)
– Remember the 2 I’s that you keep forgetting- Inflammatory/ Autoimmune and Infiltrations
1) Infarction- Anterior MI which damages the Bundle Branches
2) Surgery- Mitral Valve Repair or Septal Ablation
3) Inflammatory/ Autoimmune- Rheumatic Heart Disease, SLE, Systemic Sclerosis, Myocarditis
4) Fibrosis (Lenegre’s Disease)
5) Infiltrations (Sarcoidosis, Haemochromatosis, Amyloidosis)
6) Drugs (NHP-CCBs, Beta Blockers, Digoxin, Cholinesterase Inhibitors, Amiodarone)
What is the management of Mobitz II?
Permanent Pacemaker as patients are at risk of Complete Heart Block
What are the signs of Complete Heart Block and the 3 causes?
Severe Bradycardia and complete dissociation between P waves and QRS complexes
1) Myocardial Infarctions (usually Inferior)
2) Drugs (Beta Blockers and Calcium Channel Blockers)- so this time it is mainly just TWO DRUGS that can cause it
3) Idiopathic Fibrosis
What is the management of Complete Heart Block?
Permanent Pacemaker
What are the investigations of Hypertension?
Patients with 2 measured BP readings> 140/90 should be offered either Ambulatory BP Monitoring or Home Blood Pressure Monitoring
Assess for End Organ Damage-
- Urine Dip and Albumin: Creatinine Ratio
- Blood Glucose, Lipids and Renal Function
- Fundoscopy for evidence of Hypertensive Retinopathy
- ECG- look for LVH
What is the management of Hypertension?
When should management be offered based on the Hypertension stage?
What is the 4 step pharmacological management?
What is an example of an Alpha Blocker?
Control Risk Factors-
- Weight Loss
- Healthy Diet (less salt and saturated facts)
- Reduce Alcohol and Caffeine
- Reduce Stress
- Stop Smoking
Start Pharmacological management if:
- Stage 1 if<80 years old with End Organ Damage (HEART KIDNEYS DIABETES), CVS Disease, Renal Disease, Diabetes or 10-year CVS risk>10%
- Stage 2 or 3
Pharmacological Management-
1) ACE (Ramipril) if <55 years old or Diabetic OR DHP-CCB (Nefedipine) if >55 years old or Afro-Caribbean
2) Combine ACE and DHP-CCB or Add a Diuretic (A+C/ A+D and C+A/C+D)
3) Then A + C + D
4) Potassium< 4.5= Spironolactone, Potassium>4.5=
- Alpha Blocker (Doxacosin), Beta Blocker (Atenolol), Referral
~~~~
What are the stages of Hypertension?
Stage 1- 1 reading> 140/90 and Average Ambulatory Readings> 135/85
Stage 2- 1 reading> 160/100 and Average Ambulatory Readings> 150/95
Stage 3- 1 reading where Systolic > 180 or Diastolic> 120
What is Malignant Hypertension?
What are the signs?
BP> 180/120
Evidence-
- Papilloedema and/or Retinal Haemorrhages
- New Onset Confusion (Encephalopathy)
- Seizure
- Chest Pain
- Heart Failure
- AKI
What is the management of Malignant Hypertension?
What should you have in mind when managing Malignant Hypertension?
What are the 3 indications for IV management?
CONTROLLED drop in Blood Pressure (to avoid Ischaemic Stroke if Uncontrolled)
1) ORAL Amlodipine or Nifedipine is used first line
- IV only if (Aortic Dissection, Heart Failure, Encephalopathy)
What are the 5 Specific Situations in Hypertension Control?
What do you avoid in Pulmonary Oedema Hypertension?
1) Hypertensive Encephalopathy- IV Labetalol or IV Sodium Nitroprusside
2) Aortic Dissection- IV Labetalol or IV Sodium Nitroprusside (target 100-120 Systolic)
–
3) Pulmonary Oedema- IV Infusion GTN or Sodium Nitroprusside (AVOID BETA BLOCKERS)
–
4) Pregnancy Induced- IV Magnesium Sulphate with IV Labetalol/ Hydralazine/ Methyldopa
–
5) Phaeochromocytoma- IV Phentolamine/ Phenoxybenzamine (Alpha Blockers) before Beta Blockers- PHENS first
What are the causes of Secondary Hypertension?
What is the most common cause?
Kidney Diseases (Most Common)
Cushing’s
Conn’s
Phaeochromocytoma
Hyperthyroidism
Coarctation of aorta
What are the side effects of Calcium Channel blockers?
Ankle Swelling
Gum Hypertrophy
Dizziness
What are the side effects of Statins?
Muscle Aches and Abdominal Discomfort
When are Thiazide Diuretics Contraindicated?
In Severe Renal Failure
- so bear this in mind for blood pressure management!
What is Hypertrophic Cardiomyopathy?
It is the most common Genetic Heart Condition that often causes sudden cardiac death (unexplained syncope is a risk factor) in young people
Autosomal Dominant
What investigations should be ordered in Hypertrophic Cardiomyopathy?
ECG- LVH, Left Axis Deviation, Conduction Abnormalities and Ectopic Activity
Echocardiogram- Septal Hypertrophy
Cardiac MRI- To measure the extent of LVH
Genetic Testing
What is the management of Hypertrophic Cardiomyopathy?
remember ABC and what to avoid
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis
AVOID- ACE inhibitors, Nitrates, Digoxin
Risk stratification and presence of symptoms (OCD for sudden cardiac death patients, exercise restriction, reduction of outflow obstruction (beta blockers, verapamil)
What kind of Murmur is heard in Hypertrophic Cardiomyopathy?
Ejection Systolic Murmur that is Louder with Exercise/ Standing/ Valsalva and Quieter when Supine/ Squatting- due to Left Ventricular Outflow Obstruction
Pansystolic Murmur Loudest at Apex and radiating to Axilla (Mitral Regurgitation)- due to Systolic Anterior Motion
Pulse will be Jerky and Apex Beat will be Displaced, Apical Thrill
What ECG Changes are seen in Hypokalaemia?
1) Long QT
2) Prolonged PR Interval
3) ST Depression
4) T Wave Inversion
5) U Waves
LONG PR and LONG QT
U are DEPRESSed cos there is no T
What are the risk factors for Infective Endocarditis?
Remember the MITRAL VALVE is usually affected, unless IV DRUG use
IV Drug Use (predisposition for Staph Aureus and Right-sided Valve Disease (Tricuspid Endocarditis))
Poor Dentition and Dental Infections
Comorbid Conditions-
- Valvular Disease (Rheumatid Heart Disease, Mitral Valve Prolapse, Aortic Valve Disease)
- Congenital Heart Disease (Bicuspid Aortic Valve, Pulmonary Stenosis, Ventricular Septal Defect)
- Prosthetic Valves
- Previous Endocarditis
- Intravascular Devices (Central Catheters, Shunts)
- Haemodialysis
- HIV Infection
What are the most common Infective Organisms involved in Infective Endocarditis? (4)
1) Staph. Aureus
2) Strep Viridans
3) Strep Bovis- seen in Colorectal Cancer
4) Staph EPIDERMIS if <2 months after valve surgery
What are the signs of Infective Endocarditis?
Fever and Mitral Regurgitation (Fever and Murmur is Infective Endocarditis unless proven otherwise)
What is (may be) seen on ECG and what does it indicate?
What causes the Abdominal Pain?
Abdominal pain due to MESENTETRIC ISCHAEMIA (do CT Angiography)
F - Fever
R - Roth’s spots
O - Osler’s nodes
M - Murmurs (Mitral Regurgitation)
J - Janeway lesions
A - Anemia (Normocytic, Normochromic)
N - Nail bed hemorrhages (Splinter)
E - Emboli (Septic Emboli)
- Anorexia and Weight Loss
- Headache
- Myalgia and Arthralgia
- Night Sweats
- Cough
- Abdominal Pain and Pleuritic Pain
- Microscopic Haematuria and Glomerulonephritis
- PR Prolongation (this is a sign of AORTIC ROOT ABSCESS) or Complete AV Block
On Examination-
- Janeway Lesions (nontender macules on palms and soles)
- Osler Nodes- Tender Nodules on fingerpads and toes
- Roth Spots- Exudative Haemorrhagic Retinal Lesions with pale centres
- Splinter Haemorrhages
What investigations should be ordered in Infective Endocarditis?
What is first line? What is most sensitive?
What bloods should be taken and how many of them?
1) Transthoracic Echocardiogram is First Line
2) Transoesophageal Echocardiogram is most sensitive
/////
At least 3 sets of bloods should be taken at different times from various sites
Blood tests- FBC, U&Es, LFT, CRP
What is the Dukes’ Criteria for diagnosing Endocarditis?
There are 2 MAJOR and 5 MINOR
Infective Endocarditis if 2 Major Criteria OR 1 Major and 3 Minor OR all 5 Minor Criteria
Major Criteria-
1) Blood Cultures= S. Viridans, S. Bovis, S, Aureus- from 2 separate cultures. Single positive culture for Bart, Cox or Chlamydia
2) Imaging= Echo positive for IE- vegetation, abscess, partial dehiscence of prosthetic valve, new valvular regurgitation. Abnormal activity around site of Prosthetic Valve Implantation on PET-CT. Perivalvular Lesions on Cardiac CT- Any imaging that shows that the valves are not normal
Minor Criteria-
1) Fever > 38.0°C
2) Predisposition e.g. predisposing heart condition or intravenous drug use
3) Vascular phenomena e.g. arterial emboli, infarcts, mycotic aneurysms, intracranial or conjunctival haemorrhages, Janeway lesions
4) Immunological phenomena e.g. glomerulonephritis, Osler’s nodes, Roth’s spots, rheumatoid factor
5) Microbiological evidence e.g. blood culture not meeting major criteria, or serological evidence of active infection with organism consistent with IE
What does PR Prolongation in Infective Endocarditis indicate?
Surgery should be done
as this can be due to Aortic Root Abscess
What is the management of Infective Endocarditis?
What are the indications for surgery?
Long Term IV Antibiotics (minimum 6 weeks)
Initially Broad Spectrum but can be changed to more specific ones if the organism is known
Amoxicillin first, then 1) Flucox if Staph and 2) Benzylpenicillin if Strep
Surgery if:
- Haemodynamically unstable
- Severe Sepsis despite antibiotics
- Severe Heart Failure
- Repeated Emboli
- Aortic root abscess (Prolonged PR)
- Persistent Bactraemia
- Infected Prosthetic Valve
- Valvular Obstruction
What is the management of Pulseless Electrical Activity and Asystole?
These are non-shockable
- CPR
- 1mg IV Adrenaline
- 1mg Adrenaline every 3-5 minutes
What are the 4 causes of Mitral Valve Prolapse?
Marfan’s
Ehler’s Danlos
Turner Syndrome
Fragile X
What are the signs of Mitral Valve Prolapse?
Pan systolic murmur and Mid systolic Click
- A non-ejection click (not an early systolic ejection click) which is variable in timing (due to snapping of the mitral chordae during systole when the valve bows into the atrium) (MID SYSTOLIC CLICK)
-A mitral regurgitation (pansystolic) murmur
- Features of a secondary cause may also be noted on examination.
- Symptoms are inconsistent but can include- Chest Pain, Palpitations, Dyspnoea, Exercise Intolerance, Dizziness, maybe even Asymptomatic)
What are the ECG signs of Mitral Regurgitation?
What is the MAIN ECG sign?
P Mitrale (broad notched P wave due to Atrial Enlargement)
Right Ventricular Hypertrophy
Right Axis Deviation
What is Acute Mitral Regurgitation? What may it indicate and how urgent is it?
A Cardiac Emergency (may have sudden onset Pulmonary Oedema, Hypotension and Cardiogenic Shock)
What is seen on the Chest Xray of Mitral Regurgitation?
Pulmonary Oedema (hence why Acute MR is an emergency) and Left Atrial Enlargement (hence the p mitrale)
What is the management of Mitral Regurgitation?
Treat the complications
- Atrial Fibrillation (common cause of MR)
- Thromboembolism
- Heart Failure (caused by MR)
Definitive management for MR- Surgery
- Mitral Valve Repair (Valvuloplasty) is preferred
- Otherwise Mitral Valve Replacement
What are the signs of Mitral Regurgitation?
Pansystolic Murmur
- Loudest at Apex
- Radiates to Axilla
- Louder on Expiration
- Louder on rolling to left
What is Mitral Stenosis and what are its causes?
When do you suspect MS?
It is the impaired opening of the mitral valve which affects blood flow from the left atrium to the ventricle
Suspect if Atrial Fibrillation+ Mid-late diastolic murmur
Caused by:
1) Rheumatic Fever (most common cause)- streptococcal antigens cause the damage
2) Mitral Annual Calcification (Age related)
3) Mucopolysaccharidosis- Metabolic Disorder which affects Connective Tissues
4) Carcinoid Syndrome
5) Systemic Diseases- SLE and Rheumatoid Arthritis
What is the presentation of Mitral Stenosis?
What is the JVP like?
What is the Apex Beat like?
What 2 lung-related signs are seen?
What is seen in the face?
Atrial outflow obstruction like Atrial Myxoma may produced similar Symptoms
- Gradual Exertional Dyspnoea and reduced Exercise Tolerance (seen in 70% of patients)
- Haemoptysis
- Palpitations (Atrial Fibrillation)
- Chest Pain
- Thromboembolism (Cerebral or Systemic)- due to the Atrial Fibrillation
- Hoarseness- the enlarged Left Atrium presses on the Laryngeal Nerve
- Peripheral Oedema/ Hepatomegaly due to Right Heart Failure
- Mitral Face (Malar Flush)
- Elevated JVP (A wave due to high Atrial Pressure)
- Tapping, Non-displaced Apex Beat
- Right Ventricular Heave (due to Pulmonary Hypertension)
- Inspiratory Crepitations (Pulmonary Oedema and other signs of Heart Failure)
What are the Cardiac Auscultation Findings of Mitral Stenosis?
Loud S1- becomes softer with increased calcification
Loud P2 due to Pulmonary Hypertension
Opening Snap Heard at Apex
Mid- Diastolic Murmur-
- Low Pitched Rumble prominent at APEX
- Heard best when lying at Left Side
- Loudest in Expiration
Graham-Steell Murmur- Early Diastolic Murmur- Only if Pulmonary Regurgitation is present- due to Pulmonary Hypetension
What are the ECG, X ray, Echo and MRI signs of Mitral stenosis?
same as MR
ECG-
- P Mitrale (broad notched P Wave due to Left Atrial Enlargement)
- Right Ventricular Hypertrophy
- Right Axis Deviation
- Atrial Fibrillation (due to Left Atrial Enlargement)
CXR- signs of Pulmonary Oedema and Left Atrial Enlargement
Echocardiogram
Cardia MRI- Valvular Vegetations may be present if infective cause (Rheumatic Heart Disease)
What is the management of Mitral Stenosis?
If left Untreated- High Left Atrial Pressures and High Pressures in Pulmonary Vasculature and Right Heart
- If Asymptomatic, Regular Follow Up Echocardiography to assess progression as it can progress to Pulmonary Hypertension and Right Heart Failure
- If Atrial Fibrillation- Anticoagulation and Rate-Controlled
- DIURETICS and BETA BLOCKERS can provide Symptomatic Relief in decompensated states due to illness or for stabilisation prior to surgery
////////
- If Symptomatic (Heart Failure signs), (unless valve area is >1.5 cm)
1) Balloon Valvuloplasty (only appropriate if Valve is pliable and non-calcified)
2) Percutaneous Mitral Valvotomy- if moderate disease
3) Open Valve Repair/ Replacement- severe disease
What are the complications of Mitral Stenosis?
Atrial Fibrillation and Thromboembolism
Pulmonary Hypertension (Dyspnoea and Haemoptysis)
Dilated Left Atrium- affects local structures leading to Hoarseness, Dysphagia and Bronchial Obstruction
Left Atrium dilates and presses on the local structures
What are the 4 causes of NSTEMIs where the patient may not need or benefit from Conventional Treatment?
Severe Sepsis
Hypotension
Hypovolaemia
Coronary Artery Spasm
What is the most important investigation that should be ordered if MI is suspected?
ECG (before Bloods)
What type of MI presents with ST depression in V1-3?
Posterolateral MI (ST elevation in V7-9)
When should Troponin be measured in an MI patient and what would the results indicate?
3 hours after MI
3 groups of Troponin Levels
1) Low- definitely no myocardial death. Patient is not having an MI but may be Unstable Angina
2) Mildly Raised- may be due to other Non-MI Factors. Do another test in 6-12 hours. If raised- then MI, if not raised- then unlikely to be MI
3) Definitely raised- MI confirmed
What are the causes of Raised Troponin?
(Anything that affects the heart p much)
What are the 3 non-cardiac causes?
DPS
Myocardial Infarction
Pericarditis
Myocarditis
Arrhythmias
Defibrillation
Acute Heart Failure
Pulmonary Embolism
Type A Aortic Dissection
Prolonged Strenuous Exercise
Sepsis
What is the Post-MI management of patients? (5)
ALL patients post-MI patients should be started on the following 5 drugs:
1) Aspirin 75mg OM + second anti-platelet (clopidogrel 75mg OD or ticagrelor 90mg OD)
2) Beta blocker (normally bisoprolol)
3) ACE-inhibitor (normally ramipril)
4) High dose statin (e.g. Atorvastatin 80mg ON)
All patients should have an ECHO performed to assess systolic function and any evidence of heart failure should be treated.
All patients should be referred to cardiac rehabilitation.
Patients who have been treated without angiography should be considered for ischaemia testing to assess for inducible ischaemia.
What are the 9 complications of MI?
Which murmur and septal defect are seen?
What 2 things are seen regarding the Left Ventricle?
What 2 Heart ______’s?
What 3 other complications are there? (V.I.D.)
What kind of MI’s lead to Heart Block and Left Ventricular Thrombus/ Aneurysm?
What is the management of Dressler’s and Left/Right Ventricular Rupture?
1) Ventricular Arrhythmias- during cardiac catheterisation or after reperfusion. Most should self-resolve but if VT/VF treat as per guidelines
2) Recurrent Ischaemia, Infarction, Angina. Inserted stents can thrombose which requires Reintervention. This is more common with Unstable Angina
3) Congestive Heart Failure- due to heart muscle ischaemia
4) Heart Block- particularly after Inferior Infarcts. Treat with simple observation, Transcutaneous/ Venous Pacing if Symptomatic or Permanent Pacing if this fails to resolve
5) Left Ventricular Thrombus/ Aneurysm- Aneurysm can occur following Anterior MI where the myocardium can be susceptible to Wall Stress which leads to an Aneurysm. It is definitively diagnosed via ECHO but ECG may show persistent ST Elevation. The Thrombi can embolise which causes Stroke, Limb Ischaemia and Mesenteric Ischaemia
6) Left/ Right Ventricular Free Wall Rupture- Necrosis of the free walls of either ventricle can lead to rupture, causing blood to enter the Pericardial Space. Treatment= Pericardiocentesis and Surgery but prognosis is poor
7) Acute Mitral Regurgitation
8) Ventricular Septal Defect- Shortness of Breath, Chest Pain, Heart Failure, Hypotension, Harsh Pansystolic Murmur at the Left Sternal Border, Palpable Parasternal Heave. Diagnosis via ECHO. Manage with Emergency Cardiac Surgery
9) Dressler’s Syndrome- Pericarditis, presents with pleuritic chest pain and FEVER that happens a few weeks after MI. Symptoms usually resolve after a few days. Treat with NSAIDs
What are the drug causes of Pericarditis?
MA HIPP
- Methyldopa
- Anthracycline Chemotherapy
/// - Hydralazine
- Isoniazid
- Phenytoin
- Penicillin (Hypersensitivity)
What are the ECG changes in Pericarditis?
Remember the 2 main signs
1) Saddle-shaped ST Elevation (Widespread)
2) PR Depression
1-3 weeks= Normalisation of ST changes, T wave flattening
3-8 weeks= flattened T waves become inverted
8+ weeks= ECG returns to normal
What is the management of Pericarditis?
For Viral/Idiopathic and Bacterial?
- Viral and Idiopathic-
1) Exercise Restriction and NSAIDs
1a) Add Colchicine but use with caution if Renal/Hepatic Impairment
2) Corticosteroids if NSAIDs don’t work, or if Non-viral Pericarditis and once infection has been ruled out
//////
- Bacterial-
1) IV Antibiotics and Pericardiocentesis if Purulent Exudate
What are the causes of Pulmonary Stenosis?
Which 3 Congenital conditions and which Congenital infection?
Which of these is the most common cause of Pulmonary Stenosis?
Usually Congenital
1) Noonan Syndrome (Valvular) (most common)
2) Williams Syndrome (Supravalvular)
3) Tetralogy of Fallot (Valvular)
It may also be associated with Congenital Rubella Infection (Valvular)
Can also be due to Carcinoid Syndrome
What is the management of Pulmonary Stenosis?
Valvotomy (if Valvular) or Balloon Angioplasty (if Supravalvular), treatment is considered if Transvalvular Pressure Gradients>50mmHg
What kind of Murmur does Pulmonary Stenosis cause?
Ejection Systolic Murmur, loudest at Pulmonary Area and radiates to Shoulders (not Carotids like AS)
What is Rheumatic Fever?
What pathogen causes it? What kind of infection usually occurs before the fever?
It is a systemic complication of Lancefield group A Beta-haemolytic Streptococcal Infection (typically Pharyngitis) that occurs 2-4 weeks after the infection
Streptococcus Pyogenes
What is needed to diagnose Rheumatic Fever?
- Recent Streptococcal Infection (history of Scarlet Fever, Positive Throat Swabs or High Antistreptolysin O Titre >200U/ml or DNase B Titre)
- Either 2 Major Jones Criteria or 1 Major and 2 Minor Criteria
What are the 5 Major Jones Criteria for Rheumatic Fever?
What is Sydenham’s Chorea like?
What shape does Erythema Marginatum look like in Rheumatic Fever?
APSEN- Remember PANCARDITIS
Arthritis
- Usually the earliest manifestation- typically FLITTING or Migratory Polyarthritis. Commonly affects the knees, ankles, elbows and wrists- so similar in arms and legs
Pancarditis
- Affects all layers of the myocardium, however Endocardial Infection usually dominates- presenting as Valvulitis. It manifests as Tachycardia, a New Murmur or Conduction Defect
Sydenham’s Chorea
- Involuntary Movements with Muscular Weakness and Emotional Disturbance. They usually happen on just one side and stop during sleep
Erythema Marginatum
- Pink/ Red, Non Pruritic Rash involving the trunk, thighs and arms- so within the area where the arthritis starts. The rash usually has sharp, raised outer edges with diffuse clear centre, making a ring
Subcutaneous Nodules
- Firm, mobile painless lesions
What are the 4 Minor Jones Criteria for Rheumatic Fever?
FARP- A/P only if APSEN criteria does not cover it
1) Fever
2) Arthralgia (unless Arthritis meets major Criteria)
3) Raised ESR/ CRP
4) Prolonged PR intervals (Unless a carditis is the major Criteria)
What is the 5 step management of Rheumatic Fever?
What are the 2 first line treatments?
What is given for the Sydenham’s Chorea, Carditis (if Heart Failure)and the Erythema Marginatum?
What must be stopped if Heart Failure occurs?
Remember the First 2 AT Least
1) IV Benzylpenicillin STAT and 10 day course of Phenoxymethylpenicillin
2) Analgesia for Arthritic Symptoms (Aspirin or NSAIDs)- use aspirin with caution in young children due to risk of Reye’s Syndrome
//////
3) If Carditis is complicated by Heart Failure- Glucocorticoids (Prednisolone)- and stop NSAIDs. Diuretic Treatment can also help
//////
4) Sydenham’s Chorea is self-resolving, however Haloperidol or Diazepam can help with distressing symptoms or risk of harm
5) Erythema Marginatum- Antihistamines can help with pruritus, but otherwise no need to treat
Which valves are commonly affected in Rheumatic Heart Disease?
What is the most common?
Mitral Stenosis (most common)
Mitral Regurgitation
Aortic Regurgitation
Aortic Stenosis
Tricuspid Regurgitation or Stenosis
What are the 5 causes of LBBB and 5 causes of RBBB?
I-MADH
AVEN-I
LBBB (it is NEVER normal- always pathological)
1) Ischaemic Heart Disease
2) Myocardial Infarction
3) Aortic Stenosis
4) Digoxin Toxicity
5) Hyperkalaemia
RBBB
1) (Atrial Septal Defect) Congenital Heart Disease
2) (Ventricular) Right Ventricular Hypertrophy
3) (Embolism) Pulmonary Embolism
4) Normal Variant
5) Ischaemic Heart Disease
What does RBBB look like on an ECG?
Bunny ears on V1 (RSR)- R for Rabbit
Slurred S Waves on V6 (QRS is normal though)- Sloping DOOOOOWN S waves
What are the causes of Right Heart Strain?
Pathologies that affect the Pulmonary Vasculature
1) Pulmonary Emboli
2) Pulmonary Hypertension
3) Chronic Lung Disease
4) Pulmonary Stenosis
5) Pneumothorax
What are the ECG Features of Right Heart Strain?
What is the most common feature?
What shows Right Ventricular Strain?
What type of P wave is typically seen and what does it show?
1) Sinus Tachycardia (most common)
2) Right Ventricular Strain (ST Depression and T Wave Inversion in Inferior Leads)
3) RBBB
4) Right Axis Deviation
5) P Pulmonale- shows Right Atrial Enlargement
6) S1 Q3 T3
7) Atrial Arrhythmias
What are the target INRs for different diseases?
- Atrial Fibrillation- 2-3
- Metallic Valve Replacement- 2-3 (if Aortic Valve), 2.5-3.5 (if Mitral Valve)
- VTE (2-3), if recurrent VTE (3-4)
GENERALLY it is 2-3, but if Recurrent VTE then 3-4
What are the signs of Tricuspid Regurgitation? (even though it is usually asymptomatic even if severe)
What kind of JVP waves are seen?
What is the actual murmur like?
Signs of Right Sided Heart Failure (remember Tricuspid is in the Right Heart)- Ascites, Peripheral Oedema, Pulsatile Hepatomegaly
Heart Sounds- Pansystolic Murmur loudest in Left Parasternal Region, Louder on Inspiration
JVP- Prominent V waves
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What investigations should be ordered in Tricuspid Regurgitation?
What are the P waves like in Tricuspid Regurgitation?
ECG- may show Peaked P Waves or incomplete Right Bundle Branch Block
Echocardiography- Used to detect and Quantify the Regurgitation and Heart Function
Cardiac MRI- to evaluate the Right Ventricular Size and Function
Cardiac Catheterisation- to be used BEFORE SURGERY to assess for Coronary Artery Disease
What is the presentation of Ventricular Septal Defects?
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Just remember they show exertional dyspnoea and maybe heart failure signs if it progresses
May be Asymptomatic if they are small
May be incidentally found on examination due to their Pan-Systolic Murmur
Signs-
- Shortness of breath on exertion (like Breastfeeding)
- As the work of breathing is less effective there may be Poor Weight Gain leading to Faltering Growth
- Undetected cases may lead to Heart Failure
How are VSDs diagnosed?
What might the CXR/ ECGs show?
They are definitively diagnosed through an Echocardiogram, where their severity is also graded
Chest X Rays and ECGs may show Enlarged Left Ventricle
What is the management of Ventricular Septal Defects?
How are they surgically managed?
Majority of them will Self-resolve so manage the infant conservatively with increased Calorie Intake and Observation with Follow Up
Large Defects need Closure- Catheter Intervention usually
When should Congenital Valve Diseases be suspected in patients if a murmur is heard?
What is the most common and second most common?
If there is NO MEDICAL history and the murmur is found incidentally
The most common defect is Bicuspid Aortic Valve. The second most common defect are Ventricle Septal Defects
What investigation is typically done if a patient is haemodynamically unstable for Aortic Dissection?
Echocardiogram (TOE) as this can be done bedside- OVER a CT
What are the contraindications for Carotid Sinus Massage?
Cerebrovascular Disease
What should be done in Atrial Fibrillation if a CHA2DS2VAS score suggests that there is no need for anticoagulation?
Do a TRANSTHORACIC ECHO to exclude VALVULAR DISEASE!!!!!
cos even if the CHA2DS2VAS is 0, you NEED anticoagulation if there is valvular disease!
Is Age or Risk of Falls enough to conclude that a patient should not have ANTICOAGULATION???
Nope (do ORBIT score if AF)
Which 2 components of the ORBIT Scoring System for AF risk of bleeding with anticoagulation should you remember?
Anaemia and Renal Impairment (Anemia= 2, Renal Impairment= 1)
What is the first line investigation to be ordered if Pericarditis is suspected?
Transthoracic Echocardiography
What are the 3 signs of Pericarditis?
Pleuritic chest pain relieved by Sitting Forward
NON-productive cough, Dyspnoea, FLU-like symptoms- may also be FEVER
PERICARDIAL RUB
