Cardiovascular 2 Flashcards
Ventricular tachycardias
Broad complex - VT and VF
Monomorphic - MI
Polymorphic - Torsades de Pointes - Precipitated by prolonged QT
Management if stable…
- IV amiodarone
- IV lidocaine
VF / Pulseless VT management
Shockable!
- DC cardioversion - 200, 300, 360
- Resume CPR for 2 minutes
- Assess rhythm
- Repeat shock
+ IV amiodarone after 3 shocks
+ IV adrenaline every 3-5 minutes
Prevention - BB or ICD
Torsades de Pointes
Twisting of peaks
Polymorphic VT with long QT
Management - IV magnesium sulphate
Long QT aetiology
Delayed ventricular repolarisation
Drugs
- Antipsychotics
- Amitriptyline
- Ondansetron
- SSRIs
- Amiodarone
- Erythromycin
- Haloperidol
SAH
Electrolyte imbalance - HYPO-C/K/M
Acute MI / Myocarditis
Hypothermia
Brugada syndrome
Sodium channelopathy
AD inheritance
Young
South-East asian
Presentation - Syncope
ECG findings
- J-point elevation in V1
- ST elevation
- RBBB
Management - ICD
Asystole
Non-shockable
CPR
Reassess rhythm every 2 minutes
IV adrenaline every 3-5 minutes
Long QT features
Incidental finding - Routine ECG Long QT1 - Exertional syncope - Swimming Long QT2 - Emotional stress Long QT3 - At night / at rest Sudden cardiac death
Long QT management
BBs
ICD
Atrial flutter aetiology
Increasing age
Structural heart disease
Recent cardiothoracic surgery - Surgical / post-ablation scarring of atria
HF
Hyperthyroid
COPD
Asthma
Pneumonia
Atrial flutter clinical features
Worsening HF Pulmonary symptoms Palpitations Fatigue Syncope
Atrial flutter ECG findings + investigations
Sawtooth appearance - II, III, aVF
2:1 block - 150bpm
Flutter waves visible following carotid sinus massage or adenosine
TFTs
Serum electrolytes
CXR
Atrial flutter management (acute)
Haemodynamically unstable - Synchronised cardioversion
Haemodynamically stable - Rate control - BB, CCB, Amiodarone - Synchronised cardioversion - Pharmacological cardioversion - Ibutilide \+ Heparin
Atrial flutter management (ongoing)
Catheter ablation of cavotricuspid isthmus
Rate control - BB or CCB
Anticoagulation - Warfarin
Hypertrophic obstructive cardiomyopathy pathophysiology
AD - Disorder of muscle tissue
Mutation in B-myosin heavy chain protein
Predominantly diastolic dysfunction
LVH - Decreased compliance - Decreased CO
Myofibrillar hypertrophy with chaotic disorganised myocytes and fibrosis
HOCM clinical features
Asymptomatic
Exertional dyspnoea
Syncope - Following exercise
Sudden death - Ventricular arrhyhtmias
Jerky pulse
Large A waves
Double apex beat
Murmur - Ejection systolic
- Increased with valsalva
- Decreased on squatting
HOCM ECG findings
LVH
T-wave inversion
Deep Q waves
AF
HOCM echo findings
MR SAM ASH
MR - Mitral regurgitation
SAM - Systolic anterior motion of anterior mitral valve leaflet
ASH - Asymmetric hypertrophy
HOCM management
ABCDE
Amiodarone BBs - Verapamil Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis
Contraindicated in HOCM
Nitrates
ACE-I
Inotropes
Dilated cardiomyopathy aetiology
Autosomal dominant
Myocarditis
IHD
HTN
Drugs - Doxorubicin, Cocaine ± Alcohol
Peripartum
Haemochromatosis / Sarcoidosis
Hyperthyroid
Duchenne’s
Wet beri beri
Dilated cardiomyopathy pathophysiology
Dilated heart
Predominantly systolic function
All 4 chambers dilated - LV > RV
Eccentric hypertrophy - Sarcomeres added in series
Dilated cardiomyopathy presentation
HF symptoms
Arrhythmias
Emboli
Mitral regurgitation
Dilated cardiomyopathy examination
S3 gallop
Systolic murmur
JV distension
Peripheral oedema
Bibasal crackles
Hepatomegaly
Dilated cardiomyopathy investigations
ECG
- LVH
- Wide QRS
- LBBB
- P-wave abnormalities - Atrial enlargement
CXR - Balloon appearance
Echo
- Decreased wall thickness
- LV dilatation
- Poor systolic function
FBC - Anaemia
BNP ^^^
Dilated cardiomyopathy management
Lifestyle - Same as HF!
ACE-I / ARB
BB
Diuretics
Digoxin
Aspirin
Warfarin
LVAD
Pacemaker
ICD
Heart transplant
Takotsubo cardiomyopathy
Broken heart syndrome
Non-ischaemic cardiomyopathy
Transient apical ballooning of myocardium - Octopus pot
Presentation - Triggered by stress
- Chest pain
- HF symptoms
- ST elevation
Management - Supportive
Peripartum cardiomyopathy
Last month of pregnancy to 5 months post-partum
More common in older women
Increased risk with greater parity and multiple pregnancies
Cardiac conditions considered severe risk in pregnancy
Pulmonary HTN
Systemic left heart obstruction
Systemic ventricular impairment - Ejection fraction < 30%
Marfan’s syndrome with aortic root diameter > 47mm
Aortic aneurysm aetiology
True - All 3 layers
False - 1 layer
Arterial disease - HTN, DM, smokers, etc.
Connective tissue disease
Age ^
Male - Increased prevalence
Female - Increased risk of rupture
Aortic aneurysm clinical features
Palpable pulsatile mass
Abdo/back/groin pain
Hypotension - Rupture?
Aortic aneurysm investigations and management
Abdominal USS
Ruptured or symptomatic - Urgent surgical repair
Aortic aneurysm screening
< 3cm - Normal width
3-4.4cm - Small - Rescan every 12 months
4.5-5.4cm - Medium - Rescan every 3 months
> 5.5cm - Large - Referral < 2 weeks + Endovascular repair
Aortic dissection aetiology
Smoking
Family history
Atherosclerosis
HTN
Connective tissue disorder
Bicuspid aortic valve
CoA
Aortic dissection presentation
Marfan's / ED Acute severe chest pain = Tearing, radiates to the back Left/right BP differential Pulse deficit Diastolic murmur
Aortic dissection investigations
ECG - ST depression or elevation
CXR - Widened mediastinum
Cardiac enzymes - Negative
CT angiography - Intimal flap
TOE if unstable
Aortic dissection management
Analgesia
Control BP!
- Labetalol
- Nitroprusside
Type A - Surgical repair
Type B - Conservative
On discharge - Anti-HTN
PVD aetiology
Age > 40
Smoking
Sedentary lifestyle
DM
HTN
Hyperlipidaemia
Atherosclerosis
PVD clinical features
Asymptomatic?
Intermittent claudication
Thigh or buttock pain on exertion - Relieved at rest
Diminished or absent pulse
Erectile dysfunction?
6 Ps of acute limb ischaemia
Pale Pulseless Painful Paralysed Paraesthesia Perishingly cold
PVD investigations and management
Ankle/Brachial pressure index < 0.9
Antiplatelet therapy - Aspirin/Clopidogrel
Analgesia - Opioid
Anticoagulation - Heparin
CV risk factor management
Endovascular or surgical revascularisation
Shock
Life-threatening
Acute circulatory failure
Inadequate oxygen delivery to cells
Shock risk factors
History of sepsis
Recent MI
Surgery, trauma, haemorrhage
Exposure to known allergens
Change in medication
Significant comorbidities
Shock clinical features
Hypotension
Tachycardia
Skin changes - Cyanosis
Oliguria < 0.5ml/kg/hr
Altered mental state - GCS
Shock investigations
ABG - Metabolic acidosis with raised lactate
Glucose ^ FBC - Anaemia WCC - Infection? Urea - GI bleed? Clotting screen - DIC - Septic shock CRP - Inflammation - Sepsis? ECG - Cardiogenic cause?
Shock complications
Multiple organ dysfunction
End-organ damage
Death
Reversible causes of cardiac arrest
4 Hs
- Hypoxia
- Hypovolaemia
- Hypo/hyperkalaemia
- Hypothermia
4 Ts
- Thrombosis - Coronary or pulmonary
- Tension pneumothorax
- Tamponade
- Toxins
