cardiology

defibrillation vs cardioversion
- elective or emergency
- synchronised or non
- high or low energy
- for which types of patients

defib - emergency, non sync, high energy, for cardiac arrests
cardioversion - elective/emergency. sync to R wave, lower energy, for patients WITH PULSE

ventricular tachycardia is

a broad complex tachycardia ordiginating from a ventricular ectopic focus, regular or fast rhythm, P wave migh be present or absent

symptoms : lightheadedness, palpitations, chest pain

ECG shows broad complex tachycardia,
conscious/semiconscious
atrial activity present
haemodynamically stable

diagnose and treat

ventricular tachycardia, give amiodorone

ECG shows ventricular tachycardia and haemodynamically unstable, (sbp<90), treatment is

cardioversion (shock). he is unstable but has a pulse

patient is unconscious, collapsed or not breathing, no pulse.
it could be _________, management will be ___________

vFib…defibrillation = asynchronised shock

if patient is still conscious and with a felt pulse, it is likely

ventricular tachycardia, not vFib

ventricular tachycardia is managed by ________ if the patient is stable, and by _________ if unstable. if no pulse, ___________

amiodorone…cardioversion…immediate defibrillation

main cause of ventricular tachycardia

hypokalemia (<K)

symptoms and features of aFib
basic management

palpitation, tachycardia, dyspnoea
fibrillatory wave on ecg, irregularly irregular rythm

give BB
if asthmatic give Ca blocker
if haemodynamically unstable give cardioversion
if cardioversion not available give IV amiadarone

symptoms and features of atrial flutter
basic management

fluttering feeling in chest, sawtooth waves on ecg

synchronised cardioversion

sinus bradycardia. definition, symptoms and treatment

Sinus bradycardia is a heart rhythm where your heart beats slower than expected.

normal in young athletes

lightheadedness, hypotension, vertigo, syncope, dizziness

dizziness, unwell → atropine

wpws. definition and ecg peculiarity

Wolff-Parkinson-White (WPW) syndrome is a condition that causes the heart to beat abnormally fast for periods of time.

delta wave on ecg

narrow complex supraventricular tachycardia (SVT)
symptoms, treatment

palpitations, lightheadedness, recurrent, usually in younger patients

initial line : valsava manoeuvre, carotid massage
not improved : iv adenosine

polymorphic (broad complex) ventricular tachycardia = Torsades De Pointes (TDP)
symptoms, treatment

no uniform pattern of ventricular contractions
broad QRS, prolonged QT, fainting episodes
young athletes

IV MgSo

atrial fibrillation is

an irregular and often very rapid heart rhythm.

atrial flutter is

a saw tooth patterned arrhythmia

atrial fibrillation vs atrial flutter
(electrical activity, atrial rate, atrial rhythm, P waves, types)

treatment of aFib on stable patient

BB (atenolol,bisoprolol,metoprolol) - contra for asthma
Ca channel blocker (verapamil,diltiazem) - used for asthma
Digoxin (preferred for patients with coexistent heart failure)

treatment of aFib on haemodynamically unstable patient (SBP <90)

cardioversion (shock)

treatment of aFib on unstable patient (hypotension), aFib has just started and no cardioversion in the option, pick

IV amiodarone

management of atrial flutter

cardioversion (shock)

degrees of heart blocks

first, second (mobitz I,II and 2:1) and third

characteristics of first degree heart block

PR interval > 0.2 seconds (larger than 5 small squares)

characteristics of second degree heart block (type 1)

progressive prolongation of PR interval until a dropped beat occurs

characteristics of second degree heart block (type 2)

PR interval is constant + dropped beat

characteristics of second degree heart block (2:1)

occurs when every other P wave is not conducted through the AV node

characteristics of third degree heart block

no relation between P wave and QRS complex, P>QRS

management of first degree AV heart block and Mobitz type 1

does not require treatment as long as the patient is asymptomatic

management of Mobitz type 2 and complete heart block (3rd degree)

atropine (for symptomatic bradycardia)

transcutaneous pacing

transvenous pacing

permanent pacing (pacemaker)

acute coronary syndrome is

reduced blood flow to the heart

ischemic chest pain could be

unstable angina, STEMI or NSTEMI

STEMI is characterised by

-completely occlusive thrombus
-high troponin level
-elevated ST segments on ECG
-severe symptoms

ACS treatment

MONA (morphine, oxygen therapy, nitrates, aspirin)

clinical picture of MI

-chest pain (left-sided, epigastric, central, anteroseptal)
-irradiate to jaw, shoulder and habd
-’elephant on chest’
-dyspnoea
-paleness
-nausea and vomit

risk factors of MI (modifiable and non)

modifiable (age, male, fam history)
non-modifiable (SMOKING, diabetes, hypertension, hypercholestrolemia, obesity)

diabetic patient with MI may not experience chest pain, it is known as

silent MI

Types of MI

lateral, anterior, inferior and anterolateral MI

lateral MI (ST elevated leads on ECG leads and which artery is most likely occluded)

lead : I, avL, V5,V6
left circumflex artery

inferior MI (ST elevated leads on ECG leads and which artery is most likely occluded)

lead : II, III, avF
right coronary artery

anterior MI (ST elevated leads on ECG leads and which artery is most likely occluded)

lead : V1-V4
LAD artery

anterolateral MI (ST elevated leads on ECG leads and which artery is most likely occluded)

lead : I, avR, V4-V6

LMCA occlusion ECG findings and diagnostics

widespread of ST depression
ST elevated on avR

emergency coronary angiography

gold standard treatment of STEMI

PCI - angioplasty through radial or femoral artery

if PCI is not available for the treatment of STEMI, we prescribe

alteplase > streptokinase

chronic long term management of STEMI

aspirin, ACEi, BB, Clopidogrel, Statin

management of NSTEMI and unstable angina

aspirin + LMWH

LMWH examples

deltaparin, enoxaparin and fondaparinux

LMWH should not be administered for patients with

high risk of bleeding and are having angiography within 24h

unfractioned heparin is administered in patients with

creatinine level >265
angiography in 24h

how are unfractioned heparin and LMWH administered

LMWH & fondaparinux - subcutaneous
unfractioned - IV

atrial myxoma is

primary heart BENIGN tumour (tumor started within the heart)

inherited atrial myxoma is known as

familial myxoma (10%)

75% of atrial myxoma occur in

left atrium ( grown on the inter atrial septum wall)

feature of obstruction of mitral valve

mid-diastolic murmur, dyspnea, syncope, congestive HF

small pieces of atrial myxoma may break off and travel to arteries causing _______ of different parts of body such as
- _____ can cause ________
- _____ can cause ________
- _____ can cause ______ and _______

ischemia

-lung…pulmonary embolism
-brain…stroke
-peripheries…clubbing and blue fingers

diagnostics of atrial myxoma

echo (mass attached to fossa ovalis - inter atrial septum)

treatment of acute limb ischemia which develops ‘sudden painful swollen limb + loss of pulse‘

embolectomy - urgent catheter

how many axis deviation types are there

causes of left axis deviation

causes of right axis deviation

causes of extremer right axis deviation (no man’s land)

congenital heart disease and left ventricular aneurysm

definition of cardiac tamponade

accumulation of pericardial fluid under pressure

berks triad involves

hypotension, heart murmur and jvp

plexus paradoxus

pressure decreases during inspiration

cause of cardiac tamponade

trauma

chest x-ray shows enlarged globular heart, it could be

cardiac tamponade or pericardial effusion.

diagnostic of cardiac tamponade

echocardiogram

pericardial effusion : sign

water bottle sign (cardiothoracic ratio > 0.5)

treatment of cardiac tamponade

oxygenation and ventilation, 1-2L of IV normal saline, pericardiocentesis

symptoms of infective endocarditis are

fever, new onset murmur
+ rigor, malaise

main diagnostic of infective endocarditis is

blood culture → echo

risk factors of infective endocarditis

-history of infective endocarditis

-congenital heart defect

-prosthetic valve

-IV drug use

-rheumatic valve disease

causatives of infective endocarditis

-staph aureus

-staph epidermis

-strept viridans (most comon)

duke criteria for diagnosis of infective endocarditis (how may of majors and minors)

-2 majors

-1 major 3 minor

-5 minor

major duke criteria of infective endocarditis

-positive blood culture

(2 positive for IE specific bacteria : HACEK/Viridans) or

(2 positive taken >12 hours apart or 3-4 positive for less specific bacteria : aureus/epidermis)

-endocardial involvement

positive echo (structure oscillation, dehiscence of prosthetic valve, abscess formation, new valvular regurgitation)

minor duke criteria of infective endocarditis

-predisposing heart condition/IV drug use

-fever > 38

-microbio evidence that dont meet major criteria

-immuno phenomena (glomerulonephritis, osler node and roth spot)

-vascular phenomena (major emboli, splenomegaly, clubbing, splinter haemorrhage, janeways lesion, petechiae/purpura

what is included in the immuno and vascular phenomena of dukes minor criteria for infective endocarditis

-immuno phenomena (glomerulonephritis, osler node and roth spot)

-vascular phenomena (major emboli, splenomegaly, clubbing, splinter haemorrhage, janeways lesion, petechiae/purpura

man presents with fever, confusion and petechiae. what is shown in the picture and most likely the diagnosis? how to diagnose?

janeway’s lesion (painless on soles and palms)

infective endocarditis

blood culture → echo

empirical blind therapy of infective endocarditis

natural valve

-amoxicillin + gentamycin (low dose)

-vancomycin + gentamycin (low dose)
(for sepsis, penicillin allergic and staph aureus resistence)

prosthetic valve

-vancomycin + low dose gentamycin + rifampicin

CHA₂DS₂VASc is used to _____________ in patient who has __________

determine the need to anticoagulants….. aFib

ABCD₂ is used to identify ______________ in patients who have had ___________________

risk of future stroke… a suspected TIA in following 7 days

HAS-BLED score estimates ______________ for patients on ____________ for ____________

the risk of major bleeding… anticoagulation… aFib

DRAGON score predicts _____________ in __________ patients receiving tissue plasminogen activator (tPA) e.g. __________

3 month outcome… ischaemic stroke…. alteplase

QRISK₂ score is used to determine the risk of a ______________________

cardiovascular event in the next 10 years

Patent foramen ovale (PFO) is

a hole between the left and right atria (upper chambers) of the heart. This hole exists in everyone before birth, but most often closes shortly after being born. PFO is what the hole is called when it fails to close naturally after a baby is born.

PFO could lead to

paradoxical embolism → stoke or ischemic attach

paradoxical embolism is

an embolism that travels from the venous (right) side to the arterial (left) circulation. It may lead to stroke or ischemic attack

gold standard diagnostic method of PFO

trans-esophageal echocardiography (TEO) with buble contrast

what are the important complications of MI

cardiac arrest, dressler’s syndrome, chronic heart failure, tachyarrythmia, pericarditis, left ventricular aneurysm, ventricular septal defect, acute mitral regurgitation (MR), acute tricuspid regurgitation

cardiac arrest most commonly occur due to patients developing __________ and is the most common cause of _______ following MI

patients are managed with _________

ventricular fibrillation… death

defib

management of chronic heart failure

-loop diuretics (furosemide)

-BB or ACEi

-persists, the other drug

persiste, spironolactone (AA)

if patient is on ACEi and ARB, what would be an additional med for his chronic heart failure?

BB

if patient is on it, go for spironolactone

tachyarrythmias include _________ and _________
management is __________

ventricular fibrillation and ventricular tachycardia

check the patients pulse, if no pulse → arrest protocol + defib
administer oxygen

pericarditis occurs within ________ after MI.

features are _______________________________

_____________ may develop leading to enlarged globular heart on xray

ecg shows _____________ and _____________

management : __________ and ____________

48h

pleuritic chest pain (lying + inspiration intensifies), fever, pleural pericardial rub

pericardial effusion

saddled concave upwards ST elevation and PR depression

NSAIDS 7-14 days (aspirin/ibuprofen/indomethacin) + Colchicine

dressler’s syndrome is similar to _________ in features but it tend to occur _____________ post MI.

it is an ___________ against __________ formed as myocardium recovers

features are _____________, ___ and ___

ecg shows ___________ and ____________

treated with ____________

pericarditis.. 2-6 weeks

autoimmune reaction…antigenic protein

(same as pericarditis),pericardial effusion, raised ESR

(same as pericarditis - saddled concave upward ST elevation + PR depression)

NSAIDs

left ventricular aneurysm.

the ischaemic damage sustained during a MI episode may weaken the _________ resulting in a ___________, thus _____ forms

a ____________ may form within the _______ increasing the risk of _______, so patients are prescribed with ___________

it usually occurs __________ post MI

ecg shows _________ and __________

x ray shows ______________

echo shows ______________

myocardium…thin muscular wall…aneurysm

thrombus…aneurysm…stroke…anticoagulatives

4-6 weeks

ST elevation + left ventricular failure

enlarged heart with a bulge on the left heart border

paradoxical movement of the ventricular wall

ventricular septal defect (VSD).

rupture of the ___________ occurs during ______ post MI

features are __________________

diagnostic will be __________ to exclude ________

management is ____________

interventricular septum…first week

heart failure with pan systolic murmur (best heard at the lower left sternal border), bibasilar crackles, shock (hypotension and tachycardia)

echocardiogram…acute mitral regurgitation

urgent surgical correction

acute mitral regurgitation

occur ___________ post MI (mostly _______ MI)

cause : ischemia or _______________ of mitral valve

features ___________ (typically at _______)

may present with __________, ________, __________

if with ___________ → _______, _________, ______

diagnostic is _________

treatment is ______, often require _______

2-15 days… inferior

rupture of papillary muscle

pansystolic murmur…apex

hypotension, tachycardia, pulmonary edema

pulmonary edema… SOB (dyspnea)..bi basal crackle, tachycardia

echo

vasodilators…surgical repair

acute tricuspid regurgitation.

similar to mitral but _________ is heard over ______________

pan systolic murmur… lower left sternal border

medications that reduce mortality in patients with left ventricular failure

ACEi

BB

ARBs (angiotensin receptor blockers)

AA (aldosterone antagonists - spironolacton/eplerenone)

hydralazine with nitrates