Cardiovascular Flashcards
What is Atrial fibrillation
Rapid, chaotic and ineffective atrial electrical conduction.
Permanent
Persistent
Paroxysmal
What are the causes of Atrial fibrillation
May be no cause
Systemic:
- Thyrotoxicosis
- HTN
- Alcohol
Cardiac:
- Mitral valve disease
- IHD
- Rheumatic heart disease
- Cardiomyopathy
- Pericarditis
- Sick sinus syndrome
- Atrial myxoma
Lung:
- Cancer
- PE
- Pneumonia
What are signs and symptoms of Atrial fibrillation
Mainly asymptomatic
Palpitations
Syncope
Irregularly irregular pulse
What are the appropriate investigations for Atrial fibrillation
ECG - Absent P waves + Irregularly irregular QRS complex
Atrial Flutter = Saw tooth
Check Thyroid - Low TSH in Thyrotoxicosis
Check Valves - Echo
Check U&Es
How is Atrial fibrillation treated
Acute
Haemodynamically unstable Under 48hrs - DC Cardioversion or chemical cardioversion (Flecainide)
Over 48hrs - Anticoagulant for 3/4 weeks and then cardioversion
Chronic
Otherwise
- Anticoagulant or antiplatelet: - NOAX (Rivaroxaban, Apixaban, Dabigitran), Warfarin, Aspirin
Rate control (Aimed rate is 90bpm and below):
- Beta-blocker - Propranolol
- Digoxin (Glycoside - Positive inotropic affect but negative chronotropic - Good in CHF with AF but not CHF with sinus rhythm)
- CCBs - Verapamil (Negative Inotropic and chronotropic affect)
Prophylaxis:
Amiodarone - Antiarrhythmic used in tachyarrhythmias as it prolongs ventricular and atrial muscle contraction
Anticoagulant depends on stroke risk stratification (CHADS-VASc): Low risk (<2) = Antiplatelet High risk (>2) = Anticoagulant
What are the complications of Atrial fibrillation
- Thromboembolism - Risk of stroke 4% per year
Increased risk with left atrial enlargement or left ventricular dysfunction
- Worsening of existing HF
What are the reversible cause of Cardiac arrest
4 Hs:
- Hypothermia
- Hypoxia
- Hypovolaemia
- Hypokalaemia/Hyperkalaemia
4 Ts:
- Toxins
- Thromboembolic
- Tamponade
- Tension pneumothorax
What are the signs and symptoms of Cardiac arrest
Potentially preceding:
- Fatigue
- Pre-syncope
Unconsciousness
Not breathing
Absent carotid pulse
What are appropriate investigation for Cardiac arrest
Cardiac monitor: Allows classification of rhythm
Bloods:
- ABG
- U&Es
- FBC
- X-Match
- Clotting
- Toxicology
- Blood glucose
What is the treatment for Cardiac arrest
BLS - CPR & Rescue Breaths
ALS - If pulseless VT or VF then defibrillate once + Administer Adrenaline (1mg IV) every 3-5 minutes - Repeat
If pulseless electrical activity or systole then administer adrenaline and atropine (3mg IV once only) if <60bpm
Treatment of reversible causes: - Hypothermia - Warm slowly - K - Correct imbalance - Hypovolaemia - IV colloids, crystalloids and blood products - Tamponade - Pericardiocentesis - Tension pneumothorax - Aspiration/Chest drain - Thromboembolism - Treat as PE or MI Toxins - Use antidote
What is HF?
This is the inability of the cardiac output to meet the body’s demands despite normal venous pressure
What are the causes of low output HF (Reduced CO)
LHF:
- IHD
- HTN
- Cardiomyopathy
- Aortic valve disease
- Mitral regurgitation
RHF:
- Secondary to LHF (Called CHF)
- Infarction
- Cardiomyopathy
- Pulmonary hypertension/Embolus/Valve disease
- Chronic lung disease
- Tricuspid regurgitation
- Constrictive pericarditis/pericardial tamponade
Biventricular failure
- Arrhythmia
- Cardiomyopathy
- Myocarditis
- Drug toxicity
What are the causes of high output HF (Increased demand)
- Anaemia
- Beri-Beri
- Pregnancy
- Paget’s disease
- Hyperthyroidism
- Arteriovenous malformations
What are symptoms of HF
LHF:
- Dyspnoea/Orthopnoea/PND
- Fatigue
Acute LHF:
- Dyspnoea
- Wheeze/Cough
- Pink frothy sputum
RHF:
- Swollen Ankles
- Fatigue
- Increased weight
- Reduced exercise tolerance
- Anorexia
- Nausea
What are the signs of HF
LHF:
- Tachycardia
- Tachypnoea
- Displaced apex beat
- Bilateral basal crackles
- S3 Gallop (Rapid ventricular filling)
- Pansystolic murmur
Acute LHF:
- Tachycardia
- Tachypnoea
- Cyanosis
- Pulsus alternans
- Wheeze
- Bilateral basal crackles
- S3 Gallop
RHF:
- Raised JVP
- Hepatomegaly
- Ascites
- Peripheral oedema
- Tricuspid regurgitation
Class 1: Exertional
Class 2: With daily tasks
Class 3: Less than daily tasks
Class 4: Rest
What are the investigative findings in HF
Troponin
BNP >500
CXR
- Alveolar shadowing (Bat-winging)
- Kerley B lines
- Cardiomegaly
- Upper lobe Diversion
- Pleural Effusion
ECG
- Potential ischaemic changes
Echocardiogram
- Assess ventricular contraction
- Systolic Vs Diastolic (Systolic LVEF <40%)
Catheterisation
How is acute HF treated
Sit up
Oxygen
Stable:
- Furosemide
- GTN
If hypotensive:
- Dobutamine
If malignant hypertension (>180/110):
- IV BB - Metoprolol
- GTN
How is chronic HF treated
- BB + ACEi/ARB(Valsartan)
- Reduced Salt + Reduced Fluid
Class 2 + AA (Spironolactone)
Class 3 + Vasodilators (Isosorbide Dinitrate + Hydralazine)/Diuretic (Furosemide
Class 4 + Inotrope (Digoxin)/Ivabrandine
LVEF <35% = ICD –> Transplant
LVEF <3O% = CRT biventricular pacemaker
What are complications and prognosis for HF patients
Respiratory failure
Cardiogenic shock
Death
50% die within 2 years
What are causes of DVT
Vessel wall damage
- Surgery
- Trauma
- Previous DVT
- Central venous catheterisation
- Cancer
Stasis
- Varicose veins
- Paralysis
- COPD
- GA
- Long-haul flights
Hyper-coagulability
- HRT + Increased Oestrogen
- Pregnancy
- Inherited thrombophilia
What are signs and symptoms of DVT
Calf swelling
Localised pain
Oedema
- Unilateral calf swelling (Difference between legs >3cm = bad)
- Oedema
- Tenderness along deep vein
- Homan’s sign: Forced passive dorsiflexion of the ankle causes deep calf pain
- Pratt’s Test: It involves having the patient lie supine with the leg bent at the knee, grasping the calf with both hands and pressing on the popliteal vein in the proximal calf. If the patient feels pain, it is a sign that a deep vein thrombosis exists.
- Phlegmasia cerulea dolens (Painful blue swelling)
What are the investigative findings in DVT
Wells score 2 + = Duplex
D-Dimer - High sensitivity
Proximal duplex US
Monitor:
- FBC
- U&Es
- LFTs
- Coag
What are the criteria in Well’s criteria
Active caner Bedridden/surgery Calf swelling >3cm Collateral veins present Entire leg swollen Localised tenderness Pitting oedema Paralysis Previous DVT
What is the treatment of DVT
No bleeding/PE
- Anticoagulant: Heparin and Warfarin
- Gradient stockings
Pregnant
- Dalteparin instead
- Gradient stockings
Bleeding
- IVC filter
What are complications of DVT
PE
Bleeding
HIT - Heparin induced thrombocytopenia
Osteoporosis
What are the 3 classifications for Heart block
1st Degree AV Block: Prolonged conduction through the AV node
2nd Degree AV Block:
Mobitz Type 1: Progressive prolongation of AV node conduction culminating in one atrial impulse failing to be conducted through the AV node. The cycle then repeats
Mobitz Type 2: Intermittent or regular failure of conduction through the AV node. Defined by the number of normal conductions per failed or abnormal one (2:1, 3:1, etc.)
3rd Degree (Complete) AV Block: No relationship between atrial and ventricular contraction. Failure of conduction through the AV node leads to ventricular contraction generated by a focus of depolarisation within the ventricle
What are the causes of Heart block
- MI or IHD (Most common)
- Infection (Rheumatic heart or IE)
- Drugs - Digoxin
- Metabolic (Hyperkalaemia)
- Infiltration of conducting system (Sarcoidosis)
- Degeneration of the conducting system
What are signs and symptoms of Heart block
1st and 2nd degree are usually asymptomatic
Mobitz 2 and 3rd degree may cause Stokes-Adams attacks (Syncope caused by ventricular asystole)
+ Chest pain, HF, Palpitations, Pre-syncope, Hypotension
In 3rd degree there is:
- A slow large volume pulse
- JVP may show cannon a waves - Atria and ventricle contract at the same time
What are the investigative findings in heart block
ECG - Gold standard
- 1st Degree: Fixed PR interval (0.2s)
- Mobitz Type 1: Progressively prolonged PR interval - Dropping QRS
- Mobitz Type 2: intermittently a P wave is NOT followed by a QRS. There may be a regular pattern of P waves not followed by QRS (e.g. 2:1 or 3:1)
- Complete: No relationship between P waves and QRS complexes. If QRS is initiated in the bundle of His then there will be a narrow complex. If it is more distally then there will be a wide complex and slow rate
CXR - Cardiomegaly/Pulmonary Oedema
Bloods - TFTs/Digoxin/Cardiac enzyms/ Troponin
Echo - Wall motion abnormalities/Aortic valve disease/Vegetations
What is the treatment for Heart block
Chronic Block
- Permanent pacemaker is recommended for: Complete/Mobitz 2/Symptomatic Mobitz 1
Acute Block
- IV atropine
- Temporary (External) pacemaker
What are the complications of Heart block
- Asystole
- Cardiac arrest
- Heart failure
- Complications of any pacemaker instead
What is an AAA
This is the permanent dilation of the aorta (>3cm or 1.5x expected on AP film for sex and body size)
What are risk factors for AAA
Smoking
FHx Increasing age Male Female (Rupture) Connective tissue disorder Hyper lipidaemia COPD Atherosclerosis HTN Tall Central obesity Non-diabetic
What are the signs and symptoms of AAA
Normally incidental findings
Rupture:
- Abdominal, back and groin pain
- Palpable expansile abdominal mass
- Hypotension
- Fever if infectious
What are the investigative findings in AAA
Abdominal US - Diagnostic
CTA - Diagnostic for rupture
ESR/CRP
FBC
Blood culture
What is Aortic dissection and what are the different classifications
Separation of the tunica intimacy leads to blood flow between the inner and outer layers of the tunica media creating a false channel
Stanford A: Ascending or Arch Stanford B: Descending DeBakey I: Ascending + Arch DeBakey II: Ascending DeBakey III: Descending
Most affect the ascending aorta
What are the causes of Aortic dissection
- Atherosclerotic aneurysmal disease
- HTN
- Connective tissue disorders
- Bicuspid aortic valve
- Annulo-Aortic ectasia
- Coarctation
- Smoking
- FHx
What are the signs and symptoms of Aortic dissection
- Tearing chest pain radiating to the back
Potentially:
- Syncope
- Weakness/Paraplegia/Paraesthesia
Signs:
- BP difference between limbs
- Diastolic Decrescendo murmur
What are the appropriate investigations for Aortic dissection
ECG - ST Depression rarely elevation
CXR - Widened mediastinum
D-Dimer - May be raised helps with differentials
Diagnosis:
- CT Angiography
Operating theatre/ICU:
- Trans-Thoracic Echo or Trans-Oesophageal Echo
What are the most common causes of Aortic regurgitation
Worldwide: Rheumatic heart disease
Developed countries: Bicuspid valve
Connective tissue disease
Aortic dissection
Infective endocarditis
AS, TA, RA
What are the signs and symptoms of Aortic regurgitation
Acute:
- Signs of Pulmonary Oedema and Cardiogenic Shock
- MI
Chronic:
- Palpitations
- Exercise intolerance
- CHF
- Wide PP
- Early Diastolic murmur
- Severe: Austin-Flint Mid-Late diastolic rumbling
- Collapsing pulse
- S3 +/- S4 (LVH)
Eponymous signs of haemodynamic instability: Quincke's - Nail bed pulsation Corrigan's - Visible carotid pulse de Musset's - Head nodding Muller's - Uvula pulsations Traube's - Pistol shot over femoral Becker's - Retinal artery pulsations
What are the appropriate investigations for Aortic regurgitation
Echo - Diagnostic
2D Echo - Valvular Anatomy
Doppler Echo - Severity
ECG - Left axis deviation
What are the most common causes of Aortic stenosis
Most common: Age related calcification
Bicuspid valve calcification
Rheumatic fever
What are the signs and symptoms of Aortic stenosis
Reduced exercise tolerance
On exertion:
- Dyspnoea
- Angina
- Syncope
Signs of:
- LVH
- CHF
- Ejection systolic murmur (Crescendo Decrescendo)
- S2 diminished
- Slow rising pulse
- Narrow PP
- S4 (LVH)
What are the appropriate investigations for Aortic stenosis
Echo
ECG - LVH, Absent Q, Block
What are the characteristics of Arterial ulcers
Temperature: Cold Pain: Painful Site: Bony (Dorsum, Ankle, Toes) Depth: Deep Border: Well defined (Punched out) Base: Dry +/- infection
Delayed capillary refill
Hairlessness
Absent pulse
Pain relieved dangling leg off bed
What are the causes of Arterial ulcers
PVD
Vasculitis DM Renal failure HTN Sclerosis
What are the investigations of Arterial ulcers
Ankle Branchial Pressure Index <0.9
What are the characteristics of Venous ulcers
Temperature: Warm Pain: Mildly? Site: Gaiter - Medial Malleolus Depth: Shallow Border: Bigger poorly defined Base: Granulation tissue (Wet)
What are the causes of Venous ulcers
Venous valvular defect
DM CHF PVD DVT VV Pregnancy Obesity
What are the investigations of Venous ulcers
Duplex US - Retrograde or reversed flow, valve closure time >0.5 seconds
How are Venous ulcers treated
Graded compression stockings
Debridement to make the wound heal acutely
Extreme cases: Surgical graft
What is Cardiomyopathy
It is primary disease of the myocardium
- Dilated
- Hypertrophic
- Restrictive
What are the causes of Cardiomyopathy
Majority idiopathic
Dilated
- Post viral
- Alcohol
- Drugs
- Familial
- Thyrotoxicosis
- Haemochromatosis
- Peripartum
Hypertrophic
- 50% genetic
Restrictive
- Amyloidosis
- Sarcoidosis
- Haemochromatosis
What are symptoms of Cardiomyopathy
Dilated
- Symptoms of heart failure – fatigue, dyspnoea
- Arrhythmias
- Thromboembolism
- Family history of sudden death
Hypertrophic
- Usually NO SYMPTOMS
- Syncope
- Angina
- Arrhythmias
- Dyspnoea
- Palpitations
- Family history of sudden death
Restrictive – similar to constrictive pericarditis
- Dyspnoea
- Fatigue
- Arrhythmias
- Ankle or abdominal swelling
- Family history of sudden death
What are signs of Cardiomyopathy
Dilated RHF - Functional mitral and tricuspid regurgitations - Hypotension - AF
Hypertrophic
- Jerky carotid pulse
- Double apex beat
- Ejection systolic murmur
- Systolic thrill at lower left sternal edge
Restrictive
- RHF
- Kussmaul Sign - paradoxical rise in JVP on inspiration due to restricted filling of the ventricles
- Palpable apex beat
How is Cardiomyopathy investigated
CXR:
- May show cardiomegaly
- May show signs of heart failure – pulmonary oedema
ECG: All Types - Non-specific ST changes - Conduction defects - Arrhythmias
Hypertrophic
- Left-axis deviation
- Signs of left ventricular hypertrophy
- Q waves in inferior and lateral leads
Restrictive
- Low voltage complexes
Echocardiography:
Dilated
- Dilated ventricles with global hypokinesia and low ejection fraction
- MR, TR, LV thrombus
Hypertrophic
- Ventricular hypertrophy (asymmetrical septal hypertrophy)
Restrictive:
- Non-dilated non-hypertrophied ventricles
- Atrial enlargement
- Preserved systolic function
- Diastolic dysfunction
- Granular or sparkling appearance of myocardium in amyloidosis
Cardiac Catheterisation
What are the causes of Pericarditis
Usually Idiopathic
- Viral - Coxsackie B virus
- Dressler syndrome - Post MI
- Uraemic
- Autoimmune - RA, SLE, SS
- Cancer + Radiation therapy
- Medication
What are the signs and symptoms of Pericarditis
- Pleuritic chest pain - Sharp central, radiates to neck or shoulders (Relieved by sitting forward)
- Dyspnoea
- Nausea
- Fever
- Pericardial friction rub
- Faint HS due to effusion
Tamponade
- Beck triad (Raised JVP, Hypotension, Muffled HS)
- Tachycardia
- Pulsus paradoxus
Constrictive = RHF signs
What are the investigations in Pericarditis
ECG - Widespread saddle-shaped ST elevation
Echo
How is Pericarditis treated
Pain = NSAIDS
Treat cause
Recurrent = Low dose steroids/Immunosuppressants
What is Constrictive pericarditis
This chronic pericarditis leading to thickening and scaring of the pericardium
What are signs of Constrictive pericarditis
RHF signs
What are investigations for Constrictive pericarditis
Echo - Diagnostic
CXR - Calcification of pericardium
Pericardial biopsy
How is Hypertension diagnosed
Stage 1 >140/90 in clinic and ambulatory/home readings over 135/85
- Treat <80 + LVH, CKD, Hypertensive retinopathy, CVD, Renal disease, DM
- <40 seek specialist advice for secondary cause
Stage 2 >160/100 in clinic and ambulatory/home readings over 150/95
- Treat all
Generally for under 80 target is
What are the symptoms of accelerated Hypertension
Visual field loss Blurered vision Headache Seizures N&V Acute HF
What are the signs of Hypertension
Retinopathy - Keith-Wagner Classification 1 - Silver wirings 2 - AV nipping 3 - Flame haemorrhages + soft exudates 4 - Papilloedema
What are the investigations for Hypertension
FBC - Polycythaemia U+E - Hypokalaemia/Renal function ECG - LVH Urinalysis Fasting glucose Lipids
Ambulatory BP monitoring or Home readings
How is Hypertension treated
Stop smoking/Lose weight/Reduced salt/Reduce alcohol
1st line
Under 55 - ACEi/ARBs
Over 55 or Black - CCBs/Thiazide diuretic
2nd line
ACEi/ARBs + CCBs/Thiazide diuretic
3rd line
+ Thiazide diuretic/CCB (whichever wasn’t previously given)
4th line
+ Alpha/beta blockers
What are important secondary causes of Hypertension
Phaeochromocytoma Cushing's Conns Acromeglay Renal artery stenosis Co-arctation of the aorta
What are the causes of Infective endocarditis (IE)
Most common cause is Streptococcus Viridans then:
- Staph. Aureus
- Strep. Bovis
- Enterococci and Coxiella Brunetii
Rarely HACEK (Gram -ve): - Haemophilus - Actinobacillus - Cardiobacterium - Eikenella - Kingella
What are risk factors for IE
- Abnormal valves (Congenital, calcification, rheumatic heart disease)
- Prosthetic heart valves
- Turbulent blood flow - Patent ductus arteriosus
- Recent dental work/poor dental hygiene - Source of S. Viridans
- IVDU - Source of S. Aureus
What are the signs and symptoms of IE
Fever Headache Weakness Arthralgia Dyspnoea on exertion
Cutaneous infarcts
Chest pain
Back pain
Subacute (Weeks to months):
- Janeway lesions
- Osler nodes
- Roth spots
- Splinter haemorrhages
- Clubbing
- Petechiae on pharyngeal and conjunctival mucosa
New regurgitant murmur:
Mitral > Aortic > Tricuspid > Pulmonary
How is IE diagnosed
FBC - Anaemia of chronic disease, Leukocytosis
U&Es - Normal or elevated urea
Urinalysis - RBC casts; WBC casts; Proteinuria; Pyuria
Blood cultures - Bacteraemia; fungaemia
ECG - Prolonged PR; Non-specific ST/T wave abnormalities; AV block
Echo - Diagnostic- Valvular, mobile vegetations
Duke classification - A method of diagnosis IE based on findings of the investigation and the symptoms/signs
- RF
How IE treated
Antibiotics for 4‐6 weeks
Empirical treatment
- Benzylpenicillin, Gentamicin
Streptococci - Benzylpenicillin, Gentamicin
Staphylococci - Flucloxacillin, vancomycin, Gentamicin
Enterococci - Ampicillin, Gentamicin
Culture Negative - Vancomycin, Gentamicin
Surgery - Urgent valve replacement may be needed if there is a poor response to antibiotics
What are the complications of IE
- Valve incompetence
- Intracardiac fistulae or abscesses
- Aneurysm
- Heart failure
- Renal failure
- Glomerulonephritis
- Arterial emboli from the vegetations shooting to the brain, kidneys, lungs and spleen
What are the 4 diseases that come under Ischaemic heart disease
Stable angina
Unstable angina
NSTEMI
STEMI
What are the 3 diseases that come under Acute coronary syndrome
Unstable angina
NSTEMI
STEMI
What is Stable angina and what are the causes
Chest pain resulting from Myocardial ischaemia that is precipitated by exertion and relieved by rest
The main cause is atherosclerotic disease
Rare causes:
- Decubitus - When lying down
- Prinzmetal - Coronary spasm
- Coronary syndrome X - Normal exercise tolerance and normal coronary angiograms
What are the symptoms of Stable angina
- Constricting discomfort in the chest or neck, shoulders, jaw and arms
- Precipitated by exercise
- Relived by rest or GTN after 5 minutes
Typical = All 3
Atypical = 2 features
Likely to be non-anginal pain = 1
How may Stable angina be investigated
Resting ECG is often normal so an exercise ECG may help show differences.
Hb
Lipids
Blood glucose
How is Stable angina treated
Conservative:
- Smoking cessation
- Lose weight
- Exercise
Medical:
- Anti-anginals (BB/CCB)
- Symptomatic (GTN)
- Risk factor reduction (Aspirin, statins, ACEi)
if medical treatment is ineffective then consider PCI or CABG
What are the symptoms of Acute coronary syndrome
- Acute-onset central, crushing chest pain
- Radiates to arms/neck/jaw
- Pallor
- Sweating
Silent infarcts in elderly and diabetics
How is Acute coronary syndrome diagnosed
ECG:
- STEMI - ST elevation, Hyperacute T waves, New-onset LBBB
- Unstable angina/NSTEMI - ST depression, T wave inversion
Troponins:
- Elevated troponin suggest myocardial injury (NSTEMI/STEMI)
- High sensitivity - 0-3hrs
- Previous generation - 3-6hrs
- CK-MB - 8-12hrs
- If there has been a previous infarction in the last 10-14 days then CK-MB or Serum myoglobin should be used as cardiac markers instead
- The gold standard diagnostic investigation is Coronary angiogram
Which ECG leads would be affected in different sites of infarction
- Inferior (Right coronary artery) - II, III, aVF
- Anterior (LAD) - V1-5
- Lateral (Left circumflex) - I, aVL, V5/6
- Posterior (Posterior descending): Tall R wave + ST depression in V1-3
How is Acute coronary syndrome treated
MONA BASH
Morphine
Oxygen - Saturating below 90
Nitrates (GTN)
Antiplatelets (Aspirin + Clopidogrel)
Beta-blockers (Bisoprolol) - Indefinitely with Reduced LVEF, HF
ACEi - LVEF <40, DM, HTN, CKD
Statins - All patients
Heparin (LMWH) - If coronary angiography is planned
Fondaparinux - If low bleeding risk and no coronary angiography is planned within 24hrs of admission
For a STEMI you want to give them a PCI
- Access to PCI in 90 minutes - Perform PCI - 120 minutes latest!
- No access to PCI in 90 minutes but under 12 hours since onset - Thrombolysis (Alteplase) followed by PCI in high risk patients (Ongoing chest pain, haemodynamically, mechanically or electrically unstable) - If thrombolysis is contra indicated then do a PCI
- No access to PCI in 90 minutes and over 12 hours since onset - If symptoms persisted then PCI is still indicated especially is a coronary angio is done first to determine patient condition. If the patient is stable then there is no evidence that PCI is beneficial.
What is the GRACE score
This is the risk stratification score used to estimate mortality of patients up to 6 months after admission
High risk patients should be given - GlpIIb/IIIa Inhibitor - Tirofiban and coronary angiography within 72 hours
What are the complications to Acute coronary syndrome
Death Arrhythmia Rupture Tamponade HF
Valve disease Aneurysm Dressler's syndrome Embolism Reinfarction
What is Supraventricular tachycardia
A regular, narrow-complex tachycardia with no p waves and a supraventicular origin
What are symptoms of Supraventricular tachycardias
Palpitations
Syncope
Dyspnoea
Chest discomfort
What are the different types of Supraventricular tachycardia
Atrioventricular nodular re-entry tachycardia (AVNRT)
- Local circuit form around AV node
Atrioventricular re-entry tachycardia (AVRT)
- A re-entry circuit forms between the atria and ventricles due to the presence of an accessory pathway (Bundle of Kent)
How is an Supraventricular tachycardia diagnosed
ECG
- During the tachycardia - Regular, narrow complex tachycardia with absent P waves
- After termination of SVT - AVNRT - Normal but AVRT - Delta wave (Slurred upstroke on QRS complex)
Presence of an accessory pathway resulting in a delta wave on ECG - Wolff-Parkinson-White syndrome
How is Supraventricular tachycardia treated
Step 1: Is the patient haemodynamically stable
No - DC Cardioversion
Yes - Step 2
Step 2: Vagal manoeuvres - did it work?
Yes - Great
No - Step 3a
Step 3a: IV adenosine 6mg - Did it work?
Yes - Great
No - 3b then 3c - IV adenosine 12mg (Try twice) - Then step 4
Step 4:
1 - BB/CCB (Diltiazem/Esmolol/Verapamil/Metoprolol)
2 - Amidarone/Ibutilide
3 - Flecainide/Propafenone/DC Cardioversion
What is Wolff–Parkinson–White syndrome (WPW)
The presence of an accessory pathway connecting the atrium to the ipsilateral ventricle
What are causes of WPW
Accessory pathway (AP) is a development cardiac defect
An increased rate of stimulation causes increase AP conduction but decreased AV conduction leading to an AVRT
- Ebstein’s anomaly (most common) - Displacement of septal and posterior tricuspid leaflets
- Mitral valve prolapse
- Cardiomyopathies (HOCM)
What is the different between a WPW Pattern and WPW
A WPW pattern is asymptomatic but with the same ECG abnormalities as normal WPW
Who is usually affected by WPW
2x in Men
Younger patients - Prevalence decreases with age
What are the signs and symptoms of WPW
Often asymptomatic
Potential:
- Palpitations
- Syncope
- Light-headedness
- SOB
- Chest pain
- Sudden cardiac death
Paroxysmal SVT may be followed by a period of polyuria due to Atrial dilation and release of ANP
How is WPW diagnosed
ECG - Delta waves if the AP conducts anterogradely (If it conducts retrograde-only then there will be no delta wave), Short PR interval, Broad QRS complex, Intermittent pre-excitation
Echo - Cardiomypoathy/Valve defects
What is Vasovagal syncope
This is LOC due to a transient drop in blood flow to the brain caused by excessive vagal discharge
What are causes of Vasovagal syncope
- Emotions (Fear, severe pain, blood phobia)
- Orthostatic stress (Prolonged standing, hot weather)
How does Vasovagal syncope present
- LOC lasting short time
- Patients may experience sweating, dizziness, light-headedness before hand
- There may be some twitching of limbs during the blackout
- Recovery is normally very quick
Ventricular fibrillation
This is an irregular broad-complex tachycardia that can cause cardiac arrest and sudden cardiac death
It is the most common arrhythmia identified in cardiac arrest patients
What are risk factors of Ventricular fibrillation
- Coronary artery disease
- AF
- Hypoxia
- Ischaemia
- Pre-excitation syndrome
- Cardiomyopathy
- Valvular heart disease
- Long QT syndrome
- Brugada syndrome
What are the signs and symptoms of Ventricular fibrillation
Chest pain
Fatigue
Palpitations
How is Ventricular fibrillation diagnosed
ECG - Random lines
- Cardiac enzymes to check for infarction
- Electrolytes check for derangement
- Drug levels and toxicology screen
- TFTs
- Coronary angio if survived
How is Ventricular fibrillation treated
- VF requires urgent defibrillation and cardioversion
- Full assessment of LV function and perfusion
- Most survivors need and implantable cardioverter defibrillator (ICD)
- Empirical BBs
- Radiofrequency ablation treatment in some cases
What is Ventricular tachycardia
A regular broad-complex tachycardia originating from a ventricular ectopic focus. The rate is usually >120bpm
What are risk factors of Ventricular tachycardia
- Coronary heart disease
- Structural heart disease
- Electrolyte deficiencies (K,Ca,Mg)
- Use of stimulant drugs - Caffeine, cocaine
What are the symptoms of Ventricular tachycardia
- Chest pain
- Dyspnoea
- Syncope
- Palpitations
What are signs of Ventricular tachycardia
Respiratory distress Bibasal crackles Raised JVP Hypotension Anxiety Agitation Lethargy Coma
How is Ventricular tachycardia diagnosed
ECG - Rate >100, Broad QRS complex, AV dissociation
- Cardiac enzymes to check for infarction
- Electrolytes check for derangement
- Drug levels and toxicology screen
- TFTs
- Coronary angio if survived
How is Ventricular tachycardia treated
ABC approach
Pulseless VT - ALS
Unstable VT - Reduced cardiac output
Pulseless VT and VF require defibrillation, but other VTs can be treated with synchronised cardioversion
Correct electrolytes abnormalities
Amiodarone - Anti-ar
Stable VT - Same as above + DC cardioversion if amiodarone is unsuccessful
ICD - Implanted cardioverter defibrillator - Consider if:
- Sustained VT causing syncope
- Sustained VT with LVEF <35%
- Previous cardiac arrest due to VT/VF
- MI complicated by non-sustained VT
What is Gangrene
Tissue necrosis either, wet with superimposed infection, dry or gas gangrene
What are causes of Gangrene
- Tissue ischaemia and infarction
- Physical trauma
- Thermal injury
- Gas gangrene is caused by Clostridia perfringens
What are risk factors for Gangrene
Diabetes Peripheral vascular disease Leg ulcers Malignancy Immunosuppression Steroid use Puncture/surgical wounds
What are the symptoms of Gangrene
Painful area = Erythematous region around gangrenous tissue
Gangrenous tissue = Black because of haemoglobin break down products
Wet - Tissue becomes boggy with associated pus and a strong odour caused by the activity of anaerobes
Gas - Spreading infection and destruction of tissues causes overlying oedema, discolouration and crepitus
How is Gangrene diagnosed
Diagnosis is clinical
May include: Wounds swab, pus, fluid aspiration - MC&S X-Ray for Gas gangrene CRP Na - Low in 100% patients
What are causes of Mitral regurgitation
Leading cause is mitral valve prolapse which is when the heartstrings rupture - Due to myxomatous degeneration
Rheumatic heart disease
IE
Connective tissue disease
What are signs and symptoms of Mitral regurgitation
Acute MR - LVF Chronic - Asymptomatic or - Exertional dyspnoea - Palpitations if in AF - Fatigue
- Pulse - AF
- Laterally displaced apex beat - LVD
- Pan/Holosystolic murmur - Loudest at apex beat - radiates to the axilla
- Soft S1
- S3 Galloping - Rapid ventricular filling
- Mitral valve prolapse - Mid-systolic click - Closer to S1 when standing and further when lying down
How is Mitral regurgitation diagnosed
ECG - Normal - May show AF or P mitrale
CXR
- Acute = LVF
- Chronic = Cardiomegaly + LVF
Echo - Performed every 6-12 months in moderate-severe MR
- Diagnostic
What are causes of Mitral stenosis
Main cause: Rheumatic heart disease (90%)
- Congenital mitral stenosis
- SLE
- Rheumatoid arthritis
- Endocarditis
- Atrial myxoma
What are signs and symptoms of Mitral stenosis
May be asymptomatic
- Fatigue
- SOB
- Orthopnoea
- Palpitations - AF
- Peripheral cyanosis
- Malar flush
- Pulse - AF
- Apex beat undisplaced
- Parasternal heave due to RVH secondary to pulmonary hypertension (cor pulmonale)
- Loud S1
- Mid-diastolic murmur
- Evidence of pulmonary oedema
How is Mitral stenosis diagnosed
ECG - Normal - May show AF or P mitrale
CXR
- Cardiac enlargement
- Pulmonary congestion
- Mitral valve calcification
Echo - Diagnostic
What is Myocarditis
Acute inflammation and necrosis of cardiac muscle
What are causes of Myocarditis
Most common in Europe and USA: Coxsackie B virus
Most common in South America: Chagas disease - Trypanosoma Cruzi
Viruses: EBV, CMV, Adenovirus, Influenza Bacteria: Post-Strep, TB, Diphtheria Fungal: Candidiasis Helminths: Trichinosis Non-infective: SLE, Sarcoidosis, Polymyositis, Hypersensitivity, sulphonamides Other: cocaine, heavy metals, radiation
What are the signs and symptoms of Myocarditis
Fever
Malaise
Fatigue
Lethargy
SOB
Palpitations
Sharp chest pain
Signs of pericarditis
Signs of complications
How is Myocarditis diagnosed
ECG - Non-specific T wave and ST changes
Pericarditis - widespread saddle shaped ST elevation
CXR - CHF
Cardiac enzymes - CK, CK-MB, Trop - Elevated
BNP - Elevated in CHF
2D Echo - Diagnostic
Gold standard but rarely required - Endomyocardial biopsy
What is Pulmonary hypertension
This is an increase in mean pulmonary arterial pressure which can be caused by or associated with a wide variety of other conditions
What are causes of Pulmonary hypertension
Idiopathic - Rare
Problems with smaller branches of the pulmonary arteries
LVF
Lung disease (COPD, Interstitial lung disease)
Thromboses/Emboli in the lungs
What are the signs and symptoms of Pulmonary hypertension
Progressive SOB
Weakness/tiredness
Exertional dizziness and syncope
Angina and tachycardia
Parasternal heave Loud pulmonary S2 Murmur - pulmonary regurgitation Tricuspid regurgitation Raised JVP Peripheral oedema Ascites
How is Pulmonary hypertension diagnosed
CXR - Exclude lung disease ECG - RVH and strain PFTs - Spiro LFTs - Liver disease - Portal hypertension Echo - Asses right ventricular function
Right heart catheterisation - directly measure pulmonary pressure and confirm the diagnosis
What are causes of Tricuspid regurgitation
Congenital
- Ebstein’s anomaly
- Cleft valve in osmium primum
Functional
- Consequence of right ventricular dilation
- Valve prolapse
Rheumatic heart disease
IE - Most common
Carcinoid, Trauma, Cirrhosis, Iatrogenic
What are the signs and symptoms of Tricuspid regurgitation
Fatigue SOB Palpitations Headaches Nausea Anorexia Epigastric pain made worse by exercise Jaundice Peripheral oedema
Pulse - AF Raised JVP - Giant V waves Parasternal heave Pansystolic murmur - Louder on inspiration Loud P2 component of S2 Pleural effusion Hepatomegaly Ascites Pitting oedema
How is Tricuspid regurgitation diagnosed
ECG - Normal - May show AF or P pulmonale due to right atrial hypertrophy
CXR
- Cardiac enlargement
Echo - Diagnostic
Valve prolapse and right ventricular dilation
Right heart catheterisation - Rarely necessary but may be useful for assessing pulmonary artery pressure
What are causes of Varicose veins
1o - Due to genetic developmental weakness in the vein wall results in increased elasticity, dilation and valvular incompetence
2o
- Venous outflow obstruction - Pregnancy, Pelvic malignancy, Ovarian cysts, Ascites, Lymphadenopathy, Retroperitoneal fibrosis
- Valve damage (After DVT)
- High flow (Arteriovenous fistula)
RFs:
Age, Female, FHx, Caucasian, Obesity
What are the symptoms of Varicose veins
Patient may complain about the cosmetic appearance
- Aching in the legs
- Aching is worse towards the end of the day or after standing for long periods of times
- Swelling
- Itching
- Bleeding
- Ulceration
- Infection
What are the signs of Varicose veins
Inspect with patient standing
- Tap test - Tapping over saphenofemoral junction will lead to an impulse felt distally (Valve incompetence)
- Palpation of a thrill or auscultation of a bruit would suggest an AV fistula
- Trendelenburg test - Allows localisation of the sites of valvular incompetence - Hand over saphanofemoral junction - Lift leg, place hand, lower leg, observe filling, remove hand, observe filling
What are the signs of venous insufficiency
Varicose eczema Haemosiderin staining Atrophie blanche Lipodermatosclerosis Oedema Ulceration
How is Varicose veins investigated
Duplex US of legs - Allows exclusion of DVT
How are Varicose veins treated
Conservative:
- Exercise - Improves skeletal muscle pump
- Elevation of legs at rest
- Support stockings
Plus
- Stab avulsion
- mechanical avulsion
- Laser scleropathy
- Microinjectino scleropathy
What are complications of Varicose veins
Venous pigmentation Eczema Lipodermatosclerosis Superficial thrombophlebitis Venous ulceration
Complications of treatment:
Scleropathy - Skin staining, local scarring
Surgery - Haemorrhage, infection, recurrence, Paraesthesia, Perineal nerve injury
What is Peripheral Vascular Disease (PVD)
Narrowing of arteries other than those supplying the brain/heart. Most commonly seen in the legs
What are the different types of PVD
- Intermittent claudication - Calf pain on exercise
- Critical limb ischaemia - Pain at rest (Most severe manifestation)
- Acute limb ischaemia - A sudden decrease in arterial perfusion in a limb due to thrombotic or embolic causes
- Arterial ulcers
- Gangrene
What are risk factors for PVD
Smoking Dibetes HTN Hyperlipidaemia Physical inactivity Obesity
Male
Age
What are the signs and symptoms of PVD
Intermittent claudication - Cramping pain in calf, thigh or buttock after walking for a given distance (claudication distance) and relieved by rest - Calf claudication indicates femoral disease. Buttock claudication indicates iliac disease
Critical limb ischaemia:
- Ulcers
- Gangrene
- Rest pain
- Night pain - Relieved by dangling leg over edge of bed
Leriche syndrome (aortoiliac occlusive disease):
Buttock claudication
Impotence
Absent/weak distal pulses
What is the Fontaine classification of PVD
Asymptomatic
Intermittent claudication
Rest pain
Ulceration/Gangrene
What are the signs of acute limb ischaemia
6 Ps Painful Pale Pulseless Perishingly cold Paralysis Paraesthesia
Often hairless, atrophic skin, punched-out ulcers, colour change when raising leg (to Buerger’s angle)
How is PVD investigated
ABPI - When BP in ankles is lower than brachial pressure indicates PVD (Vessel calcification - False negatives - DM, dialysis) >0.90 - Normal 0.5-0.90 - Claudication 0.3-0.5 - Rest pain <0.3 - Critical ischaemia
TBI - <0.6
Doppler US - Non-invasive and cheap - Poor visualisation below the knee
MR Angio - Gold standard for demonstrating anatomy
What are prognostic signs in Acute limb ischaemia
Viable – No neurological signs + audible doppler at ankle
Threatened – Sensory loss, tense calf, no audible doppler
Dead – Complete neurological deficit, fixed mottling
Of the 6 Ps - Profound deficits showing Paraesthesia and Paralysis indicate a non-viable limb
