Cardiovascular conditions 1 Flashcards
Arrhythmias and intrinsic conditions
What is Atrial fibrillation/flutter?
Supraventricular tachyarrhythmias, characterised by uncoordinated atrial activity on the surface ECG with fibrillatory waves of varying shapes, amplitudes and timing associated with an irregularity irregulat ventricular response when atrioventricular conduction is intact
What causes atrial fibrillation/flutter?
Cronary artery disease Heart failure Valvular disease Diabetes Thyroid disorders COPD Obstructive sleep apnoea advanced age
What are the risk factors for atrial fibrillation/flutter?
Increasing age Diabetes mellitus Hypertension Congestive heart failure Valvular heart disease Coronary artery disease Other atrial arrhythmias Cardiac or thoracic surgery Hyperthyroidism Hypoxic pulmonary conditions Alcohol intoxication Obesity Smoking Inflammatory disorders
What are the symptoms of Atrial fibrillation/flutter?
Palpitations Dizziness SOB Syncope Chest discomfort
What are the signs of atrial fibrillation/flutter?
Irregular pulse rate Hypotension Elevated JVP Added heart sounds (Gallop rhythm in HF, pericardial rub in pericarditis) Rales (Present in HF) Evidence of stroke
What investigations are done for Atrial fibrillation/flutter?
ECG (diagnostic - could be not detected)
TFTs (Raised)
FBC (Anaemia)
U&Es (Abnormal K+ can potentiate arrhythmias, especially if on digoxin)
TTE, do a TOE in those with an abnormality on TTE
How do you manage Atrial fibrillaiton/flutter?
Control arrhythmia and thromboprophylaxis to prevent strokes
Treat underlying cause
Treatment associated with heart failure
Need lifestyle changes e.g. avoid precipitating factors
Rate/ rhythm control
Left atrial ablation if drugs cant control it
What is used to maintain Rate in atrial fibrillaiton/flutter?
Standard Beta blocker or a rate-limiting CCB (ditliazem/verapamil)
Consider digoxin for those with paroxysmal AF if sedentary
Combo of: Beta-blocker, ditliazem, digoxin
DO NOT offer amiodarone for long-term rate control
What drugs are used for rhythm control in atrial fibrillaiton/flutter?
Cardioversion if lasts longer than 48 hrs
Amiodarone for 4 weeks, before cardioverson and up to a year after
Long term:
Beta blocker
Dronedarone for maintenance of sinus rhythm after successul cardioversoin in people with paroxysmal or persistent AF
Amiodarone for those with left ventriuclar impairment or heart failure
What scoring system is used to assess stroke risk in those with AF or at risk of arrhythmia?
CHA2DS2-VASc score
What is the CHA2DS2-VASc score?
1 point for each: - Heart failure - Diabetes - Hypertension - Vascular disease - Aged >65 - Female 2 points for: - Prior TIA/Stroke/thromboembolism - >/= 75 years old Males: Score 1 or more - oral anticoagulation Females: Score of 2 or more - consider oral anticoagulation
What anticoagulation is used in atrial fibrillation/flutter?
Apixaban (Prevent stroke and systemic embolism in people with non-valvular AF who have had a stroke or TIA)
Rivaroxaban (Congestive heart failure, HTN, 75+, DM, stroke or TIA)
How would someone manage acute atrial fibrillaiton/flutter?
Emergency electrical cardioversion without delay if haemodynamic instability
If use cardioversion: offer flecainide or amiodarone with evidence of structural heart damage
If >48 hrs, delay cardioversion until on therapeutic anticoag for minmum 3 weeks
Do not offer magnesium or CCB for pharmacological cardioversion
Anticoagulation (heparin)
Other management options: Cryoablation or high intensity focused ultrasound ablation
What are the complications of atrial fibrillation/flutter?
Acute stroke
Myocardial infarction
Congestive Heart failure
What is cardiac arrest?
Sudden cardiac arrest is a sudden state of circulatory failure due to a loss of cardiac systolic function.
What are the 4 cardiac rhythm disturbances?
Ventricular fibrillation
Pulseless ventricular tachycardia (Torsades de pointes is a sub-group of polymorphic VT)
Pulseless electrical activity
Asystole
What causes cardiac arrest?
Ischaemic heart disease, cardiovascular disease, cardiomyopathy/dysrhythmia
VT, VF most commonly IHD and acute MI
Most common cause of PEA = Myocardial ischaemia/infarction, hypovolaemia, hypoxia and PE
What are the Risk factors for cardiac arrest?
Coronary artery disease Left ventricular dysfunction Hypertrophic cardiomyopathy Arrhythmogenic left ventricular dysfunction Long QT syndrome Meds that prolong QT interval Acute medical or surgical emergency Illicit substances Brugada syndrome Valvular heart disease Smoking History of eating disorders
What is Brugada syndrome?
A rare, dangerous condition affecting potassium and sodium cell entry in cardiac cells - causing very fast heart beats
What are the signs and symptoms of Cardiac arrest?
Unresponsive patients
Absence of normal breathing
Absence of circulation
Disturbed rhythm disturbance
What investigations are done for cardiac arrest?
Continuous cardiac monitoring FBC (Low Hct in haemorrhage) Serum electrolytes (Hyper/hypokalaemia) ABG Cardiac biomarkers (positive/elevated) Echo (valvular abnormalities)
What are the reversible causes of cardiac arrest?
4H's and 4T's Hypoxia (Give oxygen) Hypovolaemia (Correct with IV fluids) Hypothermia (Consider in those drowning) Hyperkalaemia Tension pneumothorax Tamponade Toxins Thromboembolism
How do you manage cardiac arrest?
If responsive: Call ambulance If unresponsive: ABCD and call ambulance A: Airway - head tilt, chin lift B: Breathing - Look for chest movements C: Circulation (30:2) D: Defibrillation!
Further considerations:
- Amiodarone (150mg followed by infusion of 900mg, lidocaine if no amiodarone)
- Consider Ca2+ in case of PEA (hyperkalaemia, hypocalcaemia, OD on CCBs or magnesium)
- Consider magnesium sulphate
- Bicarbonate, 50mmol in arrests with hyperkalaemia or tricyclic antidepressants
Transfer to ITU for monitoring of breathing, circulation and ventilation
What are the complications of Cardiac arrest?
Death - highly likley Rib and sternal fractures Anoxic brain injury Ischaemic liver injury Renal acute tubular necrosis Recurrent cardiac arrest
What is Heart block?
It is a cardiac electrical disorder defines as impaired (delayed or absent) conduction from the atria to the ventricles
What are the classifications of heart block?
First degree Second degree (Mobitz I and Mobitz II) Third degree (complete) block
What causes heart block?
Fibrosis and calcification of the conduction system, CAD and medication such as:
AV-nodal blocking agents (beta blockers, CCBs, digitalis, adenosine), Anti-arrhythmics (sotalol and amiodarone)
Others include: Vagal tone, cardiomyopathy, calcification from valvular calcification
What are the Risk factors for heart block?
Age-related degenerative changes Increased vagal tone AV-nodal blocking agents Chronic stable CAD Acute coronary syndrome Chronic heart failure Hypertension Cardiomyopathy Left ventricular hypertrophy Recent cardiac surgery Myocarditis Sarcoidosis Infective endocarditis Blunt cardiac injury
What are the symptoms of heart block?
1st degree - asymptomatic
Mobitz I - asymptomatic
Mobitz II and 3rd degree cause stokes-adams attacks (syncope caused by ventricular asystole)
- May cause: Dizziness, palpitations, chest pain and heart failure
What are the signs of heart block?
Often normal
Complete heart block: Slow large volum pulse, JVP shows cannon A waves
Reduced CO
What investigations are done for heart block?
ECG Serum troponin (Raised) Serum potassium (Very low or very high) Serum calcium (very low or very high) Serum pH (Very low or very high) Serum digitalis (Normal to high)
What is seen on ECG for first degree heart block ?
Prolonged PR interval but prolonging is the same
What is seen on ECG for second degree heart block (Mobitz type I)?
Progressive prolonging PR until there is a P wave without a QRS
What is seen on ECG for second degree heart block (Mobitz type II)?
PR interval same but regular/intermittent lack of QRS
What is seen on ECG for third degree heart block?
Total dissociation of P wave and QRS complexes
- QRS initiated in: Bundle of His (narrow complex) or More distally (Wide complex and slow rate)
How do you manage heart block?
1st degree or Mobitz I Asymptomatic: - Monitoring Symptomatic: 1st: Discontinue Medications 2nd: Infrequently PPM or cardiac resynchronicsation therapy
Mobitz II or 3rd-degree
Asymptomatic:
- 1st: Condition specific management and discontinuation of AV node-blocking drugs
- 2nd: PPM or cardiac resynchronisation therapy +/- ICD placement
Symptomatic:
- 1st: Condition-specific management, discontinuation of AV nodal blocking drugs, and temporary
- 2nd: PPM or cardiac resynchronisation therapy +/- ICD placement
What are the complications of Heart block?
Pacemaker implantation sequelae
Asystole
Cardiac arrest
Heart failure
What is Supraventricular tachycardia?
SVT is any tachydysrhythmia arising from above the level of the bundle of His, usually the atria or AV node. These typically produce a narrow complex tachycardia.
There are 2 main types: Atrioventricular nodal re-entry tachycardia and Atrioventricular re-entry tachycardia
What causes AVNRT?
The most common type of SVT, due to a reentry that forms around the AV node, which conducts to the ventricles faster than normal conduction pathways
What is AVNRT?
Reentrant tachycardia with an anatomically defined circuit that consists of 2 distinct pathways
What causes AVRT?
Occurs when normal AV conduction is present as well as accessory pathways. Forming a re-entry between atria and ventricles
What are the risk factors for SVT?
Nicotine Alcohol Caffeine Previous MI Digoxin toxicity
What are the symptoms of SVT?
May have minimal symptoms or may present with syncope
Palpitations
Light-headedness
Polyuria (due to increased atrial pressure causing ANP release)
Abrupt onset and termination of symptoms
Other symptoms: Fatigue, chest discomfort, dyspnoea, syncope
What are the signs of SVT?
Normal except tachycaridia
What investigations are done for SVT?
ECG
24hr ECG monitoring required with paroxysmal palpitations
Cardiac enzymes (Check for MI)
Electrolytes (Can cause arrhythmias)
Digoxin level
Echocardiogram (check for structural disease)
What can be seen on ECG for AVNRT/AVRT?
Tachycardia
Narrow QRS
No P waves
Decreased PR interval
How can you tell the difference between AVNRT and AVRT?
Acutely you cannot tell the difference!
Once tachycardia has resolved, you can see delta waves on ECG in AVRT
What is the management of SVT?
Unstable:
DC cardioversion
Stable:
Vagal manouevres (valsalva, carotid massage)
If valsalva doesnt work:
- Adenosine 6mg bolus (increase to 12) [contraindicated in asthma, use verapamil insted]
- Wait 2 mins, no change adenosine 12mg
- Same again after 2 mins
- wait 2 more mins, no change, IV metoprolol/amiodarone/digoxin/ DC cardiovert
If unresponseive to chemical cardioversion or tachycardia or adverse signs (low BP, heart failure, low consciousness) - sedate and synchronised / DC cardioversion
- Ongoing management: Radiofrequency ablation of slow apathy, beta blockers, alternatives: Fleicanide, propafenone, verapamil
What are the complications of SVT?
Haemodynamic collapse
DVT
Systemic embolism
Cardiac tamponade
What is vasovagal syncope?
Loss of consciousness due to a transient drop in blood flow to the brain caused by excessive vagal discharge
What causes vasovagal syncope?
Very common cause of fainting
Precipitated by: Emotions (e.g. fear, severe pain, blood phobia) and Orthostatic stress (e.g. prolonged standing, hot weather)
What are the symptoms of vasovagal syncope?
Loss of consciousness lasting a short time
Patients may experience vagal symptoms (Sweating, dizziness, light-headidness) before passing out
There may be twitching of limbs during blackout
Recovery is normally quick
What are the signs of vasovagal syncope?
None
What are the investigations for vasovagal syncope?
ECG (Check for arrhythmia)
Echo (Check for outflow obstruction)
Lying/standing blood pressure (Check for orthostatic hypertension)
Fasting blood glucose (check for DM/hyperglcaemia)
What is Ventricular fibrillation?
Cause of cardiac arrest and sudden cardiac death. Ventricular muscle fibres contract randomly causing a complete failure of ventricular function.
What causes Ventricular Fibrillation?
Ventricular fibres contract randomly causing complete failure of ventricular function
Most cases occur in patients with underlying heart disease
What are the Risk factors for ventricular fibrillation?
Coronary artery diseae AF Hypoxia Ischaemia Pre-excitation syndrome Drugs Electrolyte imbalance
What are the signs and symptoms of Ventricular fibrillation?
History of: Chest pain, fatigue and palpitations Known pre-existing conditions: - CAD - Cardiomyopathy - Valvular heart disease - Long QT syndrome - Wolff-Parkinson white syndrome - Brugada syndrome
What investigations are done for ventricular fibrillation?
ECG (Chaotic irregular deflections of varying amplitude)
Cardiac enzymes (troponin)
Electrolytes (Derangements cause arrhythmias)
Drug levels and toxicology screen
TFTs
Coronary angiography
How do you manage ventricular fibrillation?
Defibrillation and cardioversion
Full assessment of LVF, myocardial perfusion and electrophysiological stability
Most need an ICD
Beta blockers
May be treated with radiofrequency ablation
CABG prevents recurrent VF if ejection fraction is normal and ischaemia was the cause of the arrest
What are the complications of Ventricular fibrillation?
CNS Ischaemic injury Myocardial injury Post-defibrillaiton arrhythmias Aspiration pneumonia Defibrillation injury to self or others Injuries from CPR and resuscitation Skin burns Death
What is Ventricular tachycardia?
A broad complex tachycardia originating from a ventricular ectopic focus.
What defines ventricular tachycardia?
3 or more ventricular extrasystoles in succession at a rate of more than 120bpm
Accelerated idioventricular rhythm refers to ventricular rhythms with rates of 60-100 bpm
What are the types of VT?
Monomorphic VT
Non-sustained VT (<30secs)
Sustained VT
What is Sustained VT associated with?
Late phasemyocardial infarction Cardiomyopathy Right ventricular dysplasia Myocarditis Drugs (flecainide and disopyramide)
What are the types of VT?
Fascicular tachycardia
Right ventricular outlflow tract tachycardia
Torsades de pointes
Polymorphic ventricular tachycardia
What is Fascicular tachycardia?
Not usually associated with underlying structural heart disease
Originates from left bundle branch
Produces QRS complexes of short duration (often misdiagnosed as SVT)
QRS has right bundle branch block pattern
What is Right ventricular outflow tract tachycardia?
Originates from right ventricular outflow tract
ECG typically shows right axis deviation, with a LBBB pattern
Tachycardia provoked by catecholamine release, sudden changes in heart rate and exercise
Responds to alpha blockers or calcium anatagonists
What is polymorphic ventricular tachycardia?
Same ECG as torsades de pointes but in sinus rhythm
ECG tract similar to AF with pre-excitation
Less common than torsades de pointes
Leads to cardiogenic shock
Occur in acute MI and deteriorate into VF
What causes ventricular tachycardia?
Ischaemic heart disesae
Underlying non-ischaemic cardiomyopathy
Chagas disease
What are the Risk factors for ventricular tachycardia?
Coronary artery disease Acute MI Left venrticular systolic dysfunction Hypertrophic cardiomyopathy Long/Short QT syndrome Brugada syndrome Ventricular pre-excitation Arrhythmogenic right ventricular cardiomyiopathy Electrolyte imbalance Drug toxicity Chagas disese Family history of sudden death Mental or phsyical stress
What are the symptoms of Ventricular tachycardia?
Chest pain
Palpations
Dyspnoea
Syncope
What are the signs of Ventricular tachycardia?
Respiratory distress Bibasal crackles Raised JVP Hypotension Anxiety Agitation Lethargy Coma
What investigations are done for Ventricular tachycardia?
ECG Electrolytes Level of therapeutic drugs (e.g. digoxin) Evaluate for MI CXR Arrhythmia
What is seen on ECG on Ventricular tachycardia?
Rate >100 bpm Wide QRS complex Presence of AV dissociation Fusion beats Retrograde ventriculoatrial conduction
How do you manage ventricular tachycardia?
ABCs of resuscitation and provide basic and advanced life support
Pulseless VT - treat as if VF
Unstable VT (Reduced cardiac output) - Unsychronised defibrillaiton, respond to low levels of energy. Amiodarone often used for haemodynamically unstable VT, replenish electrolyte imbalance
Refractory VT - after 300mg amiodarone, followed by infusion of 900mg over 24hrs
When is an implantable cardiac defibrillatory used for?
Sustained VT causing collapse
Sustained VT with ejection fraction <35%
Previous cardiac arrest due to VT/VF
MI complicated by non-sustained VT
What are the complications for Ventricular tachycardia?
Congestive cardiac failure and cardiogenic shock
VT deteriorates to VF`
What is Wolff-Parkinson white syndrome?
Congenital abnormality which can result in SVTs that use an accessory pathway.
It is a pre-excitation syndrome
Early activation of the ventricles due to impulses bypassing the AB node via an accessory pathway
What causes wolff-parkinson-white syndrome?
The accessory pathway (Bundle of Kent) is likely to be congenital Associated with: - Congenital cardiac defects - Ebstein's anomaly - Mitral valve prolapse - HOCM
What is Ebstein’s anomaly?
Congenital malformation of the heart characterised by displacement of septal and posterior tricsupid leaflets
What are the signs and symptoms of WPW?
SVT in early childhood
Often asymptomatic
Symptoms: Palpitations, light-headidness, syncope
Paroxysmal SVT followed by polyuria, due to atrial dilatation and release of ANP
Sudden death - if SVT deteriorates into VF
Clinical features of associated cardiac defects
What are the investigations for WPW?
ECG normal if condition speed of the impulse along the necessary pathway matches the conduction speed down bundle of His
ECG (Short PR interval, Broad QRS complexes, Delta waves)
May be in SVT (AVRT)
Bloods - check for electrolyte imbalance
Echocardiogram - check for structural anomalies of heart
What is Cardiac failure?
Clinical syndrome characterised by:
Breathlessness, fatigue, ankle swelling, tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised JVP, peripheral oedema, hepatomegaly
What are the different types of Cardiac failure?
Acute vs Chronic
Systolic vs Diastolic
High and Low output
What causes cardiac failure?
Valvular heart disease
Heart failure to secondary myocardial disease
High output heart failure
Which valvular disease causes cardiac failure?
Aortic stenosis Aortic or mitral regurgitation Atrial septal defect Ventricular septal defect Tricuspid incompetence cause excessive preload
What heart failure issecondary to myocardial disease?
Coronary heart disease
Hypertension
Cardiomyopathies
Drugs (beta blockers, CCBs, anti-arrhythmis, cytotoxic)
Toxins (alcohol, cocaine, mercury, cobalt, arsenic)
Endocrine (Diabetes, cushing’s, hypothyroidism, adrenal insufficiency)
Nutritional (thiamine, selenium, obesity, cachexia)
Infiltrative (Sarcoidosis, amyloidosis, haemochromatosis, connective tissue disease)
Infective (Chaga’s disease, HIV)
What are the causes of high output heart failure?
Anaemia Pregnancy Hyperthyroidism Paget's disease of the bone Arteriovenous malformations beriberi
What are the symptoms of Left heart failure?
Dysonoea Orthopnoea Paroxysmal nocturnal dyspnoea Fatigue Poor exercise tolerance Nocturnal cough +/- pink frothy sputum Wheeze Nocturia Cold peripheries Weight loss Muscle wasting
What are the symptoms of acute left ventricular failure?
Dyspnoea
Wheeze
Cough
Pink frothy sputum
What are the symptoms of right heart failure?
Swollen ankles Fatigue Increased weight (Due to oedema) Reduced exercise tolerance Anorexia Nausea
What are the signs of left heart failure?
Tachycardia
Tachypnoea
Displaces apex beat (LV dilatation)
Bilateral basal crackles
S3 gallop (caused by rapid ventricular filling)
Pansystolic murmur (due to functional mitral regurgitation)
What are the signs of acute left ventricular failure?
Tachypnoea Cyanosis Tachycardia Peripheral shutdown Pulsus alternans Arterial pulse waveforms showing alternating strong and weak beats Signs of left ventricular systolic impairment Gallop rhythm Wheeze Fine crackles throughout lung
What are the signs of right heart failure?
Raised JVP Hepatosplenomegaly Ascites Ankle/sacral pitting oedema Signs of functional tricuspid regurgitation Facial engorgement Epistaxis RV heave (Pulmonary hypertension)
What are the investigations for cardiac failure? (with a previous MI)
Overall LV dysfunction Diastolic function LV wall thickness Valvular disease Estimation of pulmonary artery systolic pressure
What are the investigations for cardiac failure? (without a previous MI)
Serum Naturietic peptides (if high, >400, referral and assessment made within 6 weeks) FBC U&E and creatinine LFTs Glucose Fasting lipids TFTs CXR Urinalysis Lung function tests Cardiac MRI Exercise testing Radionuclide imaging
What can be seen on CXR for cardiac failure?
Cardiomegaly Ventricular hypertrophy Prominent upper lobe veins Peribronchial cuffing Diffuse interstitial or alveolar shadoing Fluid in fissures Pleural effusions Kerley B lines
How do you stage heart failue?
Class I: NO symptoms
Class II: Slight limitation of physical activity by symptoms
Class III: Less than ordinary activity leads to symptoms
Class IV: Inability to carry out any activity without symptoms
What indicates a 2 week referral for special assessment and echo?
People with previous MI
People with history of MI with high levels of BNP (>/=400)
People with severe symptoms
Women who are pregnant
What indicates a 6 week referral?
No history of MI BNP 100-400 Suspicion of heart failure Another condition suspected ECG abnormal ECG normal but still strong suspicion of heart failure
What drugs are used for heart failure?
ACE inhibitors unless contraindicated (angio-oedema, B/L renal artery stenosis, hyperkalaemia) Diuretics Beta blockers Angiotensin-II receptor antagonists Mineralocorticoid/aldosterone receptor anagonists Ivabradine Digoxin Opiates or opioids
What drugs are used to treat cardiovascular comorbidity?
Anticoagulants
Statins
Which drugs are contra-indicated in heart failure?
Pro-anti-arrhythmics with negative ionotrope effects
CCBs
TCAs
Lithium
NSAIDs and COX-2 inhibitors
Corticosteroids
Drugs prolonging QT interval and potentially
What is cardiomyopathy?
Primary disease of the myocardium
What are the types of cardiomyopathy?
Dilated
Hypertrophic
Restrictive
What are the Risk factors for cardiomyopathy?
Majority idiopathic Dilated cardiomyopathy - Post viral myocarditis - Alcohol - Drugs (e.g. doxorubicin, cocaine) - Familial - Thyrotoxicosis - Haemochromatosis - Peripartum or postpartum - Hypertension - AI - Congenital [X-linked] Hypertrophic cardiomyopathy - up to 50% are genetic - AI dominant Restrictive cardiomyopathy - Amyloidosis - Sarcoidosis - Haemochromatosis - Scleroderma - Loffer's eosinophilic endocarditis - Endomyocardial fibrosis
What are the symptoms of dilated cardiomyopathy?
Symptoms of heart failure (fatigue, dyspnoea)
Arrhythmias
Thromboembolism
Family history of sudden death
What are the symptoms of hypertrophic cardiomyopathy?
No symptoms Syncope Angina Arrhythmias Dyspnoea Palpitations Family history of sudden death
What are the symptoms of Restrictive cardiomyopathy?
Dyspnoea Fatigue Arrhythmias Ankle or abdominal swelling Family history of sudden death
What are the signs of dilated cardiomyopathy
Raised JVP Displaced apex beat Functional mitral and tricuspid regurgitations Third heart sound Tachycardia Hypotension Pleural effusion Oedema Jaundice Hepatomegaly Ascites AF
What are the signs of hypertrophic cardiomyopathy?
Jerky carotid pulse
Double apex beat
Ejection systolic murmur
Systolic thrill at lower left sternal edge
What are the signs of restrictive cardiomyopathy?
Raised JVP (Kussmaul's sign) Palpable apex beat Third heart sound Ascites Ankle oedema Hepatosplenomegaly
What is Kussmaul’s sign?
Paradoxical rise in JVP on inspiration due to restricted filling of ventricles
What investigations are done for Cardiomyopathy?
CXR (Cardiomegaly, heart failure) ECG Echocardiography Cardiac catheterisation Endomyocardial biopsy Pedigree or genetic analysis
What is seen on ECG in cardiomyopathy?
All of them: - Non-specific ST changes - Conduction defects - Arrhythmias Hypertrophic: - Left axis deviation - Signs of LVH - Q waves in inferior and lateral leads Restrictive: - Low voltage complexes
What is seen on echocardiogram in cardiomyopathy?
Dilated
- Dilated ventricles with global hypokinesia and low ejection fraction
- Mitral regurgitation, tricuspid regurgitation and 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
What is constrictive pericarditis?
Chronic inflammation of the pericardium with thickening and scarring of the pericardial layers. It limits the ability of the heart to function normally, as it is encased in a right pericardium
What causes constrictive pericarditis?
Often under diagnosed, difficult to distinguish restrictive cardiomyopathy and other causes of RHF Can occur after any pericardial disease process - Idiopathic - Virus - TB - Mediastinal irradiation - Post-surgical - Connective tissue diseases
What are the symptoms of constrictive pericarditis?
Early subtle symptoms with slow progression of:
- Dyspnoea
- Ascites
- Oedema
- Advanced symptoms (Jaundice, cachesxia)
What are the signs of constricitve pericarditis?
Raised JVP + Kussmaul's sign Pulsus paradoxus Diastolic pericardial knock Quiet heart sounds Pulsatile hepatomegaly Splenomegaly
What investigations are done for constrictive pericarditis?
CXR (small heart +/- calcification of pericardium)
Echo (Diagnostic and distinguishes from constrictive and restrictive)
MRI (allows assessment of thickness of pericardium)
CT (Same as MRI)
Pericardial biopsy (indicated if infective cause)
What is infective endocarditis?
An infection involving the endocardial surface of the heart, including the valvular structures, the chordae tendinae, sites of septal defects, or the mural endocardium
What causes infective endocarditis?
Streptococci (40%) - s. viridans Staphylococcus (35%) - S. aureus Enterococci (20%) - E. faecalis Other organisms - Haemophilus - Actinobacilus - Cardiobacterium - Coxiella burnetti - Eikenella - Kingella - Chlamydia - Histoplasma Others (SLE, malignancy)
What are the risk factors for infective endocarditis?
Abnormal valves Prosthetic heart valves Turbulent blood flow Recent dental work/poor dental hygiene [S. viridans] Dermatitis IV injections Renal failure Organ transplantation DM Post-operative wounds Hypertrophic cardiomyopathy
What are the symptoms of infective endocarditis?
Fever/chills Night sweats Fatigue Anorexia Weight loss Myalgias Weakness Arthralgias Headache SOB Chest pain Back pain
What are the signs of infective endocarditis?
Meningeal signs Cardiac murmur Janeway lesions Osler nodes Roth spots Splinter haemorrhages Cutaneous infarcts Palatal petechiae
What investigations are done for infective endocarditis?
FBC (Anaemia, leucocytosis) Serum chemistry panel with glucose Blood cultures Rheumatoid factor ESR Complement levels CT (Valvular abnormalities) MRI (Cerenral lesions) ECG (prolonged PR interval, non-specific ST/T wave abnormalities, AV block) Echocardiogram Urinalysis (RBC casts, WBC casts, proteinuria, pyuria)
How do you manage infective endocarditis?
ABx for 4-6 weeks
Blind therapy of native valve (Amoxicilin +/- gentamicin)
Blind therapy of prosthetic valve (Vancomycin + Gentamicin + Rifampicin)
On clinical suspicion: Benzylpenicillin + Gentamicin
Staphylococci (Flucloxacillin/vancomycin + gentamicin)
Enterococci (Amoxicillin + gentamicin)
Culture negative (Vancomycin + gentamicin)
What are the complications for infective endocarditis?
Congestive heart failure Systemic embolisation Anterior mitral valve vegetation >10mm Valvular dehiscence, rupture or fistula Splenic abscess Mycotic aneurysms
What is Ischaemic heart disease?
Angina with acute coronary syndrome (unstable angina, STEMI and NSTEMI)
What is angina pectoris?
Stable ischaemic heart disease and low-risk unstable angina are most commonly caused by atheromatous plaques int he coronary arteries that obstruct blood flow.
Anginal symptoms are clinical manifestations of ischaemia
What causes angina pectoris?
Atheromaous plaque leading to obstruction of coronary blood flow in the most common cause
Damage to the arterial wall produces an inflammatory response and the development of atheromatous plaques
What are the risk factors for angina pectoris?
Advancing age Smoking Hypertension Elevated LDL cholesterol Isolated low HDL cholesterol Diabetes Inactivity Obesity Family history of premature IHD Illicit drug abuse Male sex Hypertriglyceridaemia Mental stress/depression Plasma biomarkers Polluted air Aortic stenosis Hypertrophic obstructive cardiomyopathy
What are the symptoms of angina pectoris?
Central chest tightness or heaviness brought on by exertion and relieved by rest
May radiate to one or both arms, neck, jaw or teeth
Dyspnoea
Nausea
Sweatiness
Faintness
What are the signs of angina pectoris?
Dyspnoea
Tachycardia
Hypoxia
Xanthoma or Xanthelasma
What are the investigations for angina pectoris?
Resting ECG Lipid profile (elevated LDL) Fasting glucose (Raised in diabetes) FBC LFTs (baseline pre-statins) TFTs Cardiac enzymes Echo
How do you manage angina pectoris?
Modify CVS risk factors:
GTN for symptomatic relief
Offer a beta blocker or CCB
If not controlled, switch to other option or combo of both
Consider adding: long acting nitrates, ivabradine or Ranolazine
IF using CCB with a beta blocker/ivabradine - use slow release (Nifedipine, amlodipine or felodipine)
IF cannot tolerate Beta blocker or CCB, consider long-acting nitrate, ivabradine or ranolazine
If not contraindicated: Aspirin (Or clopidogrel)
If stable angina + Diabetes [Ace inhibitor]
Stains should be prescribed for all patients with stable angina due to atherosclerotic disease
What is done if they have a poor response to medical therapy?
If poor response to medical therapy, can do percutaneous transluminal coronary angioplasty
Prinzmetals - treat with CCBs +/- long actin nitrates - aspirin and B blockers worsen it!
Syndrome X - CCB
What is Prinzmetal angina?
Variant angina - temporary increase in coronary vascular tone (vasospasm) causing a marked, but transient reduction in luminal diametes
What are the complications of angina pectoris?
Unstable angina Chronic heart failure Myocardial infarction Acute stroke Depression
What is Unstable angina?
Absence of Biochemical evidence of myocardial damage. Characterised by specific clinical findings of prolonged angina at rest
What are the causes of unstable angina?
Coronary artery disease underlying in nearly all patients with acute MI
Coronary artery narrowing caused by a thrombus that develops on a disrupted atherosclerotic plaque and is usually non-occlusive
Less common causes: Intense vasospasm of a coronary artery (Prinzmental’s angina)
What are the risk factors for unstable angina?
Female sex Personal history Increasing age Family history of CAD Hypertension Smoking DM Hyperlipidaemia Peripheral vascular disease Chronic kidney disease Elevated CRP Mediastinal radiation Obesity/lack of exercise High altitude
What are the symptoms of unstable angina?
Angina type pains randomly, occurs at rest
What are the signs of unstable angina?
Pulse high or low Arrhythmias BP disturbances New heart murmurs Signs of complications (HF, shock) Signs of HF: Increased JVP, S3, basal crepitaitons Pericadial friction rub
What are the investigations for unstable angina?
FBC U&Es CRP Glucose Lipid profile Cardiac enzymes (not raised) ECG (ST depression or T wave inversion) CXR Echo (Rest/stress) Coronary angiography
What is the management of unstable angina/NSTEMI?
Admit to coronary care unit
Oxygen, IV access, motor vital signs and serial ECG
GTN
Morphine
Metoclopramide (counteract nausea from morphine)
Aspirin
Clopidogrel
LMWH (Enoxaparin)
Beta blocker
G1pIIb/IIIA inhibitors considered (e.g. tirofiban) in patients: Undergoing PCI or high risk
Glucose-insulin infusion of Blood glucose >11
Antiplatelet therapy + statin w/ beta blocker, ACEi + cardiac rehab
What are the complications of unstable angina?
Of treatment (Bleeding and thrombocytopenia)
Congestive heart failure
Ventricular arrhythmia
What is the definition of NSTEMI?
Acute ischaemic myocyte necrosis. The initial ECG may show ischaemic changes such as ST depression, T wave inversions of transient ST elevation
What are the cuases of NSTEMI?
Transient or near-complete occlusion of a coronary artery or acute factor that deprives the myocardium of oxygen
What are the risk factors for NSTEMI?
Atherosclerosis Diabetes Smoking Dyslipidaemia Family history of premature CAD Age >65 Hypertension Obesity and metabolic syndrome Cocaine use Physical inactivity Depression Stent thrombosis or restenosis CKD Surgical proceduees Sleep apnoea
What are the symptoms of NSTEMI?
Chest pain Diaphoresis Recurrent PCI or CABG SOB Weakness Anxiety Nausea Vomiting Abdominal pain Emotional
What are the signs of NSTEMI?
Hypertension
Hypotension
Arrhythmias
S3/S4
What are the investigations of NSTEMI?
FBC U&Es CRP Glucose Lipid profile Cardiac enzymes (Raised) BNP (Raised >400) ECG (Depression or t-wave inversion) CXR (HF, pulmonary oedema)
What are the complications of NSTEMI?
Cardiac arrhythmias Congestive heart failure Cardiogenic shock Ventricular rupture or aneurysms Acute mitral regurgitation Post-MI pericarditis (Dressler syndrome) Venous thromboembolism Depression In-stent thrombosis
What is Dressler syndrome?
Secondary form of pericarditis that occurs in the setting of cardiac injury e.g MI
What is a STEMI?
Acute MI, is myocardial cell death that occurs becuase of a prolonged mismatch between perfusion and demand. Caused predominantly by complete atherosclerotic occlusion of the artery
What causes a STEMI?
Myocardial O2 demand excess O2 supply
Usually due to atherosclerosis
Rarer causes: Coronary artery spasm, artheritis, vasculitis and emboli
What are the risk factors for STEMI?
Male DM Family history Hypertension Hyperlipidaemia Smoking Age Obesity Sedentary lifestyle Cocaine use
What are the symptoms of STEMI?
Acute onset chest pain >20 mins
Central, heavy, tight crushing pain
Radiates to arm, neck, jaw or epigastrium
Occurs at rest
More severe and frequent pain that previously occurring stable angina
Associated with: Breathlessness, sweating, palpitations, nausea and vomiting
What are silent infarcts?
Occur in elderly and diabetic patients.
Present with syncope, pulmonary oedema, epigastric pain and vomiting
What are the signs for STEMI?
May be no clinical signs Pale Sweating Restless Distress Low-grade pyrexia Check both radial pulses to rule out aortic dissection Pulse high or low Arrhythmias Disturbances of BP New heart murmurs Signs of complications Signs of heart failure Pericardial friction rub or peripheral oedema
What are the investigations for STEMI?
FBC (Anaemia) U&Es (Can be normal, high or low) Glucose Lipid profile (normal or elevated) ECG (STEMI) Cardiac troponin (Raised) ABG (<90%) CXR (Pulmonary oedema, widened mediastinum, cardiomegaly, pacemaker, sternal wires, clear lung fields) Transthoracic echo (L ventricular regional wall motion abnormalities, valvular defects, Right ventricular function, pericardial effusion)
What is the management of STEMI?
Clopidogrel
- 600mg if PCI
- 300mg if underlying thrombosis and <75 yo
- 75 mg if underlying thrombosis and >75
- Maintenance of 75mg a day for a year
If undergoing primary PCI:
- IV heparin
- Bivalirudin (antithrombin)
Thrombolysis:
- Fibrinolytics e.g. streptokinase and tPA (alteplase)
- Considered if within 12 hrs of chest pain with ECG changes and not contraindicated
- Rescue PCI may be performed if continued chest pain or ST elevation
What drugs are used for secondary prevention?
Dual antiplatelet therapy (Aspirin + Clopidogrel) Beta blockers ACE inhibitors Statins Control Risk Factors
What are the complications of STEMI?
Death Arrhythmias Rupture Tamponade Heart failure Valve disease Aneurysm Dressler's syndrome Embolism Reinfarction
How do you measure prognosis of STEMI?
TIMI score or Killip classification
What is TIMI score?
Age >/= 65 >/= 3 CAD risk factors (HTN, hypercholesterolaemia, diabetes, family history of CAD, smoking) Known CAD ASA use in past 7 days Severe angina EKG ST changes Positive cardio marker
What is Killip classification?
Class I: No evidence of heart failure
Class II: Mild to moderate heart failure
Class III: Overt pulmonary oedema
Class IV: Cardiogenic shock
What is myocarditis?
Acute inflammation and necrosis of cardiac muscle
What causes myocarditis?
50% idiopathic
Viruses (Coxsackie B, EBV, CMV, Adenovirus, Influenza, Hepatitis, Mumps, Rubella, Polio, HIV)
Bacteria (Post-streptococcal, TB, Diphtheria, Clostridia, meningococcus, mycoplasma, brucellosis)
Fungal (Candidiasis)
Protozoal (Trypanosomiasis (chaga’s disease))
Helminths (Trichinosis)
Non-infective (Systemic: SLE, Sarcoidosis, polymyositis, sulphonamides)
Drugs (chemo, penicillin, chloramphenicol, sulphonamides, methyldopa, spironolactone, phenytoin, carbamezapine)
Others (Cocaine, heavy metals, radiation, toxins, vasculitis)
What are the symptoms of myocarditis?
Prodromal flu-like illness (Fever, malaise, fatigue, lethargy)
Breathlessness
Palpitations
Sharp chest pain
What are the signs of myocarditis?
Signs of pericarditis Tachycardia Soft S1 S4 gallop Signs of complications (e.g. HF, arrhythmia)
What are the investigations for myocarditis?
FBC (Leucocytosis) U&E ESR/CRP raised Cardiac enzymes - raised Negative antimyosin scintigraphy excludes acute myocarditis Tests to identify cause ECG (non-specific T wave and ST changes, atrial arrhythmias, transient AV block, PERICARDITIS - saddle-shaped ST elevation) CXR (Normal, may show cardiomegaly) Pericardial fluid drainage Echo Myocardial biopsy
What is Pericarditis?
inflammation of the pericardium. Acute form defined as new-onset inflammation. Either fibrinous (dry) or effusive with a purulent, serous or haemorrhagic exudate
What is the cause of pericarditis?
Can be idiopathic or due to systemic conditions e.g. SLE
90% of cases either idiopathic or due to viral infections (e.g. Coxsackie virus, mumps, Ebv, cytomegalovirus, varicella, rubella, HIV)
Systemic AI disease (Rheumatoid arthritis, systemic sclerosis, reactive arthritis IBD)
Bacterial, fungal and parasitic infections
What are the risk factors for Pericarditis?
Male sex Age 20-50 years Transmural MI Cardiac surgery Neoplasm Viral and Bacterial infections Uraemia or on dialysis Systemic AI disorders Pericardial injury Mediastinal radiation
What are the symptoms of pericarditis?
Dull, sharp, burning or pressing
Either barely perceptible or up to a severe level
Felt in substernal or precordial region
Radiaitng to the neck, trapezius ridge (usually left) or shoulders
Aggravated by inspiration, swallowing, coughing and lying flat
Relieved by sitting and leaning forward
Non-productive cough, chills and weakness
If cardiac tamponade, present with Beck’s triad
What is Beck’s triad?
Hypotension
Elevated systemic venous pressure
Muffled heart sounds
What are the signs of pericarditis?
Pericardial friction rub on auscultation Tachypnoea Tachycardia Fever Dyspnoea & Orthopnoea noticeable when cardiac tamponade develops Abdominal pain in children
What are the investigations for Pericarditis?
FBC U&Es ESR/CRP Cardiac enzymes (normal) Blood cultures ASO titres ANA Rheumatoid factor VIral serology CXR (Normal, may be globular)
What is the management for Pericarditis?
NSAIDs (Naproxen) Colchicine with significantly fewer recurrences PPI with High-dose NSAIDs Cessation of possible drug causes Treat with antimicrobials appropriately Uraemic pericarditis
What are the complications of pericarditis?
Pericardial effusion with or without cardiac tamponade
Chronic constrictive pericarditis
What is Rheumatic fever?
An inflammatory multisystem disorder, occurring following group A beta-haemolytic streptococci (GAS) infection
What are the causes of rheumatic fever?
Pharyngeal infection with lancefield group A beta-hemolytic streptococci triggers Rheumatic fever 2-4 weeks later
Antibody to the carbohydrate cell wall of the streptococcus cross-reacts with valve tissue (antigenic mimicry) and may cause permanent damage to the heart valves
What are the risk factors for rheumatic fever?
Genetic susceptibility
Malnutrition
Poverty
What are the symptoms of Rheumatic fever?
2-5 weeks after pharyngeal infection
General (malaise, fever, anorexia)
Joints (Painful, swollen, reduced movement/function)
Cardiac (Breathlessness, chest pain, palpitations)
What are the signs of Rheumatic fever?
Diagnosis made using Jones’ criteria.
Evidence of recent strep infection + 2 major criteria / 1 major and 1 minor criteria
Need evidence of GAS infection
- Positive throat culture
- Rapid streptococcal antigen test positive
- Elevated/rising streptococcal antibody titre
- Recent scarlet fever
What are the major Jones’ criteria?
CArol SES
- Carditis (Tachycardia, murmur, pericardial rub, cardiomegaly, conduction defects)
- Athritis (Usually large joints)
- Subcutaneous nodules (Small firm painless nodules on extensor surfaces)
- Erythema marginatum (rash with red, raised edges and clear centre, mainly on trunk and proximal limbs)
- Syndenham’s chorea (Rapid involuntary, irregular movements with flowing/dancing quality)
What are the Minor Jones’ criteria?
- Pyrexia
- Raised ESR/CRP
- Arthralgia
- Prolonged PR interval
- Previous rheumatic fever
What investigations are done for Rheumatic fever?
FBC
ESR/CRP
Rising antistreptolysin O tire
Throat swab (Culture for GAS, rapid streptococcal antigen test)
ECG (Saddle-shaped ST elevation and PR segment depression, arrhythmias)
Echocardiogram (Pericardial effusion, myocardial thickening or dysfunction, valvular dysfunction)
How can you tell where a MI is on ECG?
ST elevation in different leads:
Anterior/septal - V1-4
Lateral - V5, V6, I
Inferior - II, III, aVF
