al © Copyright www.p s.com (Constantly updated for online subscribers) Habikevecom ay Cardiology Strict Copyrights! KEYS No Sharing or Copying Allowed by any means Compensations and Version 3.0 Penalties Worldwide System is Active (Corrected|, (Updated, Lighter] ith the Most Recent Recalls and the UK Guideline: ATTENTION: This file will be updated online on our website frequently! (example: ec cu) , and so on) Key Acute Coronary Syndrome (ACS) Patients with Ischemic Chest Pain Perform ECG Y No ST elevation sT elevation 40-60% ; Non ST elevation myocardial Unstable angina (UA) infarction (NSTEMI) Copyrights @ Plab1Keys.com2|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Acute Coronary Syndrome \ Lv | To ceo see a [Acute Coronary Syndrome includes; V ST elevation myocardial infarction (STEMI). V Non-ST elevation myocardial infarction (NSTEMI). Vv Unstable angina. The classic and most common feature of ACS is chest pain. Copyrights @ Plab1Keys.com3|Page [Cardiology] ©Copyright www.plab1keys.com (Constantly updated for online subscribers) V Typically, central/left-sided/ substernal/ epigastric. V May radiate to the jaw, the left arm, the shoulder. V Often described as ‘heavy’ or constricting, ‘like an elephant on my chest’ - Itshould be noted however in real clinical practice that patients present with a wide variety of types of chest pain and patients/doctors may confuse ischaemic pain for other causes such as dyspepsia. - Certain patients e.g. diabetics/elderly may not experience any chest pain > Silent MI & Other possible symptoms in ACS include: [ may appear pa « Risk Factors of Ischemic Heart Disease: Unmodifiable risk factors Modifiable risk factors Increasing age Smoking Male gender Diabetes mellitus Family history Hypertension Hypercholesterolaemia Obesity Copyrights @ Plab1Keys.com4|Paze [Cardiology] ©Copyright www.plab1keys.com (Constantly updated for online subscribers) ulinves igat Ns} v|ECG| V {cardiac markers e.g. [troponin] ECG in ST-elevation MI of the STEMI as follows: Baud SS era) Inferior Mt U1 Ill aVF Lateral Mi |, aVL, V5, V6 Anterior or (Anteroseptal) == V1— V4 Anterolateral MI. |, aVL, V4, V5, V6 “ © tacctookcom/plabiteys @) @plab.keys > elevated ST segment in certain leads gives a clue about the site and type Meer ent it Coronary Left Circumflex LAD (Left Anterior Descending) LAD or Left Circumflex * © Plabiteyscom "1" Copyrights @ Plabikeys.com5|Page [Cardiology] ©Copyright www.plab1keys.com (Constantly updated for online subscribers) xample|: OO oy Inferior MI: Note the ST elevation in leads If, I and aVF wa (Likely: Right coronary artery occlusion) ey ECG features of Left main coronary artery occlusion [LMCA]: V Wide spread ST depression. V ST elevation in aVR. Do > [Emergency coronary angi graphy. Copyrights @ Plab1Keys.com6 [Page [Cardiology] ©Copyright www.plab1keys.com (Constantly updated for online subscribers) Occluding thrombus Complete thrombus Non occlusive aoe Sea eee occlusion as tissue damage & mil myocardial necrosis Savclevationsion Non specific ECG or new LBBB eG ST depression +/- T wave inversion on ieicyarcdlcandiac Normal cardiac Ee enzymes enzymes 5 Elevated cardiac More severe enzymes symptoms Management of ST elevation MI (STEM ) a > (IV Morphine, 02, Nitrates, Aspirin 300 mg) + Heparin (either unfractionated or LMW such as enoxaparin or fondaparinux) Copyrights @ Plab1Keys.com7[Page [Cardiology] ©Copyright www.plab1keys.com (Constantly updated for online subscribers) + If the patient presents within 12 hours of the onset of the symptoms > Primary PCI (Percutaneous Coronary Intervention) “The gold standard” In this procedure (PCI), the blocked arteries are opened up using a balloon (angioplasty) following which a stent may be deployed to prevent the artery occluding again in the future. This is done via a catheter inserted into either the radial or femoral artery + If Not, or PCI is unavailable > Thrombolysis (Alteplase is preferred over Streptokinase). + (Chronic) Long-term Management of MI 1) Aspirin for life. 2) Ticagrelor or Prasugrel for 12 months “or: Clopidogrel”. 3) Beta Blockers (for 12 months) “e.g. atenolol, bisoprolol ® concor, zebeta’. 4) ACE inhibitors (for life) “e.g. captopril, enalapril, ramipril” [If intolerant to ACEi such as dry cough, use ARBs instead e.g. losartan, valsartan, irbesartan] 5) Statins (for life) “e.g. Atorvastatin 80 mg PO OD”. Se, Long-term MI Rx = 5 Drugs: Aspirin, Clopidogrel, BB, ACEI, Statins, (aaBcrs| > Aspirin, ACE inhibitors, Beta-blockers, Clopidogrel + Statins Copyrights @ Plab1Keys.comB| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Management of NSTEMI & Unstable Angina: (based on the recent UK guidelines) Important: For all patients where the diagnosis of NSTEMI or Unstable Angina is made — [Aspirin 300 mg|(+) [LMWH e.g. Enoxaparin, Dalteparin] “or |Fondaparinux) need to be given as soon as possible. v Aspirin 300 mg. V Nitrates or morphine to relieve chest pain if required Vv Antithrombin: |LMWH e.g. Enoxaparin, Dalteparin “or Fondaparinux”| should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a patient’s creatinine is > 265 umol/I, unfractionated heparin should be given. Fondaparinux and LMWH are given Si ly, whereas Unfractionated Heparin is given Intravenously]. v Second antiplatelet: e.g. Clopidogrel, Prasugrel. Copyrights @ Plab1Keys.comgIp Cardiology] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Vv Intravenous glycoprotein lib/Illa receptor antagonists (eptifibatide or tirofiban) should be given to patients who have an intermediate or higher risk ), and who are scheduled to undergo angiography within 96 hours of hospital admission. v Coronary angiography should be considered within 96 hours of first admission to hospital to patients who have a predicted 6-month mortality /%. It should also be performed as soon as possible in patients who are clinically unstable. Examples of recent exams’ question [Example 1) A patient presents with (acute chest pain radiating to jaw and shoulder + other features suggesting ischemic heart disease...) However, ST elevation on ECG. What to Do Next? > Measure Cardiac Enzymes, especially ({Troponin|| V If Troponin is high > |NON-STEMI = Non-ST elevation MI v Immediate management Copyrights @ PlabiKeys.com10 P ardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) > Give Subcutaneous LMWH OR Fondaparinux| + |Aspirin 300 mg Notes: Low Molecular Weight Heparin Examples > Dalteparin, Enoxaparin, x (trade name Arixtra) is an anticoagulant medication chemically related to low molecular weight heparin. [Example 2) A 60 YO man with Hx of smoking, HTN and DM presents to his GP complaining of 25 minutes of left side dull aching chest pain radiating to his jaw. He was given Aspirin 300 mg by his GP and then sent to medical services in a local hospital. He is no longer in pain. The ECG is normal. The troponin is elevated 202 ng/L (Normal: <5 ng/L). What is the next step in management? A) Alteplase. B) Subcutaneous fondaparinux. C) IV Glyceryl trinitrate (GTN). D) IV Morphine. Since the ECG is normal, alteplase is wrong. Copyrights @ Plab1Keys.comaay © Copyright plab1keys.com (Constantly updated for online subscribers) Since ECG is normal and Troponin is high > Non-STEMI > Anti-coagulation (LMWH e.g. Dalteparin, Enoxaparin or Fondaparinux). [Example 3] A 62 YO man with Hx of smoking and HTN presents complaining of 25 minutes of left side constricting chest pain radiating to his left shoulder. He was given Aspirin 300 mg and trinitrates for the pain. ECG was then done and showed ST elevation in leads V1-V4. What is the most appropriate next step in management? > PCI “Percutaneous Coronary Intervention’). If not among the choices, pick > |Alteplase “Thrombolysis”! [Example 4) A.59 YO hypertensive patient presents to the A&E complaining of dull central chest pain for around 4 hours. His vitals are as follows: HR: 99, BP: 155/95, RR: 21, O2 sat on room air: 97% Chest X-ray is normal. Troponin level is pending. He was given IV morphine for his chest pain. The ECG is as follows: Copyrights @ Plab1Keys.com12] Page [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) aN SH TSE " APH avL What is the most appropriate next step in management? Chest pain + T wave inversion suggests > myocardial ischemia}. In this case, 2 drugs should be given immediately: V [Aspirin 300 mg}. Vv [LMWH or Fondaparinux. Pick the one that is given in the choices. “low-risk patients can be treated conservatively. However, if subsequent ischemia develops > coronary angiography with PCI”. Copyrights @ Plab1Keys.com13|P ardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) What if the ECG shows features of left main coronary artery occlusion (Wide spread ST depression + ST elevation in aVR)? > Emergency coronary angiography. [Example 5] A 61 YO patient presents to the A&E complaining of dull central chest pain for around 4 hours. His vitals are as follows: HR: 75, BP: 135/85, RR: 21, O2 sat. on room air: 97% He was given IV morphine for his chest pain. The ECG is as follows: a i SN See fy ar we v6 What is the most appropriate next step in management? Copyrights @ Plab1Keys.com14|P ogy] ©Copyright plab1keys.com (Constantly updated for online subscribers) This ECG shows the typical features of |Left main coronary artery occlusion|: * Widespread ST depression, and ¢ ST elevation in aVR. Do > [Emergency coronary angiography. Key [cardiac Tamponade| Hypotension [| Muffled Heart Sounds [J High JVP (Distended neck veins). ® Others: Dyspnea, Pulsus Paradoxus, Tachycardia After MI > Acute pericarditis > Pericardial effusion > Cardiac Tamponade © Traumais the most important cause of cardiac tamponade. Copyrights @ Plab1Keys.com15|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) N.B. Chest X-ray that shows Sree > Think of either [EUR Msateen (OR) EERIEPeIone ners. © Dx: Echocardiogram] is diagnostic [Urgent pericardiocentesis. e Rx aCe eee OMe CLA Teta rere g) “ae CeCe POPC s ert? bing bet UTE Tals Deal Copyrights @ Plab1Keys.com16| Page [Cardiology] ©Copyright v plab1keys.com (Constantly updated for online subscribers) Cardiac Tamponade Important! If the patient is in hypovolemic shock (severely low BP) and the question asks about the [INITIAL] treatment line and Iv fluids| is within the option, pick it! Copyrights @ Plab1Keys.com17|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Cardiac Tamponade: Oxygenation and ventilation > 1 to 2 LIV fluid NS > bedside Pericardiocentesis. Key lat Myxoma o Benign tumours. Copyrights @ Plabikeys.com18|Page [Card © Copyright plab1keys.com (Constantly updated for online subscribers) © 75% in the left atrium. o Tend to grow on the wall (inter-atrial septum). o 10% are inherited > Familial myxoma o Features: B OC iececay — Mid-diastolic murmur, Dyspnea, Syncope, Congestive HF. [§Small pieces may break off and travel to arteriesfe-Wony-atulsui) kell different parts of the body such as: @ Lung > Can cause PE (Pulmonary Embolism) ¢ Brain >Can cause Stroke @ Peripheries > Clubbing and Blue fingers. a IX brillation’ o Dx >|Echo| > Pedunculated heterogenous mass typically attached to the region of fossa ovalis (inter-atrial septum). o Important note: Copyrights @ Plab1Keys.com19] ardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) If acute limb ischemia develops “sudden painful swollen limb with a loss of pulse” -> we could save the limb by performing an urgent catheter Embolectomy. Key A patient was hit by a car into his chest and is brought to the emergency department. His neck veins are distended, Heart sounds are faint, hypotensive and tachycardic. The likely Diagnosis > Cardiac Tamponade. The most appropriate management > Pericardiocentesis * Beck's Triad Hypotension, Muffled Heart Sounds, High JVP (Distended neck veins). Key lax is Deviation © If QRS in lead | is up (+ve) and in lead II is down (negative) > Left axis deviation © If QRS in lead | is down (-ve) and in lead II is up (t+ve) > Right axis deviation Copyrights @ Plab1Keys.com20| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) ae ee ea Lead Il ae av ed ae isoelectric Normal Left axis Right axis Right superior Indeterminate axis deviation deviation axis deviation axis —30° to +90° -30° to-90° +90°to +150° +150° to +270° limb leads Copyrights @ Plab1Keys.com21| Page [Cardiology] ©Copyright www.piab tkeys.com (Constantly updated for online subscribers) -90° aVF Copyrights @ Plabikeys.com2|Pege Cardiology © Copyright www.piab1keys.com (Constantly updated for online subscribers) Lead | te Lead Il Aka Normal axis These causes are important! Causes of Left Axis Deviation {nferior MI Left Ventricular Hypertrophy Left Anterior Fascicular block (or hemiblock) Obese Wolff Parkinson White Syndrome (delta wave) TL 1, Left axis deviation Right axis deviation Causes of Right Axis Deviation Lateral MI Right Ventricular Hypertrophy Left Posterior Fascicular Block (or hemiblock) Thin, Tall, Children Chronic Lung Disease Pulmonary Embolism Copyrights @ Plab1Keys.com23)? age [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) © Causes of EXTREMER Right Axis Deviation (No man’s land) = (North west axis): o Congenital Heart Disease. o Left Ventricular Aneurysm. For PLAB 1, you need to know either it is left axis deviation (Lead | is up and Lead II is down) or right axis deviation (Lead | is down and Lead Il is up) and the causes of each (in the table above). Key Types of heart block First degree heart block © PR interval > 0.2 seconds (Only prolonged PR intervals). (i.e. PR interval occupies more than 1 large square (or 5 small squares). Second degree heart block type 1 (Mobitz | = Wenckebach)| > Progressive prolongation of the PR interval [type 2 (Mobitz u) > PR interval is constant but the P wave is often not followed by a QRS complex. Copyrights @ Plab1Keys.com24|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) [thi ‘d degree (complete) heart block) * There is no association between First degree AV block ‘Second degree AV block (Mobitz! or Wenckebach) SSS Third degree AV block with junctional escape 4 CA ‘Copyrights @ Plabikeys.com25|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Management; @ 1% Degree Heart Block and Mobitz type 1 usually > do not require treatment (as long as the patient is Asymptomatic). & Mobitz type 2 and Complete heart block (3 degree heart block) > require permanent pacemaker For your knowledge: | square = p.o4 seq. © 1 large square contains 5 small squares = p2 seq Copyrights @ Plab1Keys.com26|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Key Atrial Fibrillation - fibrillatory waves Atrial Flutter - sawtooth pattern ¢ Agents used to control rate (Rate Control) in patients with ° Beta-blockers (e.g. atenolol, bisoprolol, metoprolol) > First line but Contraindicated in Asthma ° Calcium channel blockers [non-dihydropyridine CCB] (e.g. diltiazem, verapamil) > used in Asthmatic patient. ° Digoxin > (not considered first-line anymore as they are less effective at controlling the heart rate during exercise. However, they are the preferred choice if the patient has coexistent heart failure) Copyrights @ Plab1Keys.com27|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) v If haemodynamically unstable (e.g. SBP < 90) > [ardioversion| (Shock) ° Atrial Flutter management ~ |Cardioversion (Shock) Key entricui lar tachycardia| V Ventricular tachycardia (VT) is broad-complex tachycardia originating from a ventricular ectopic focus. v It can develop into ventricular fibrillation and therefore requires urgent treatment. v P wave might be present or absent. N.! © ECG showing broad complex tachycardia in a (still) conscious patient even if semiconscious + atrial activity and “haemodynamically ” > Ventricular tachycardia] > Give famiodarone|He stable! © ECG showing ventricular tachycardia in a haemodynamically u le (e.g. SBP S 90) patient -> [DC cardioversion = shock. He is unstable but has a pulse. © If the patient is > Mentricular Fibrillation] > Defibrillation = Asynchronized shock Copyrights @ Plab1Keys.com28|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) [As the patient is still conscious and with a felt pulse, it is likely ventricular tachycardia; not ventricular fibrillation. However, remember that ventricular tachycardia is managed by amiodarone if the patient is stable and by cardioversion if unstable]. If No pulse > Immediate Defibrillation. tachycardia (VT) clinically. Ventricular Tachycardia ° Ventricular fibrillation is the most important shockable arrhythmia}. © Hypokalemia (J K’*) is the most important cause of ventricular Ventricular Fibrillation Atrial Flutter avlwwlwhann Copyrights @ Plab1Keys.com29| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Atrial Fibrillation Palpitation, Tachycardia, Dyspnea, Fibrillatory waves on the ECG, Irregularly irregular rhythm > Give Beta-Blocker, If Asthmatic > Give Calcium Channel Blocker}. Atrial Flutter “Fluttering Feeling in the chest”, Sawtooth waves on the ECG > [cardioversion] Ventricular Regular and Fast rhythm. Tachycardia Ongoing lightheadness, Palpitations, Chest pain > Give [Amiodarone| If unstable (SBP <90, ) consciousness) > |immediate Cardioversion| Ventricular Older adult, Sudden collapse, Not breathing, Fibrillation Unconscious, No pulse > [’Immediate Defibrillation” Sinus Lightheadness, hypotension, vertigo, syncope, Bradycardia dizziness. N.B. Sinus bradycardia is normal in young athletes. Copyrights @ Plab1Keys.com30]? age [Cardiology] ©Copyright www.piab1keys.com (Constantly updated for online subscribers) & The first drug of choice for Symptomatic Bradycardia (Dizziness, feeling unwell) > Atropine Sinus Physiological situation (exercise, stress, anger). Tachycardia Hx of infection. WPWS Delta wave on the ECG Key Management of Congestive Heart Failure, While loop diuretics (furosemide, bumetanide) and nitrates are important in the management of acute or decompensated cardiac failure, they have no. effect on long-term survival. & The following medications have all been shown to ! in patients with le! + ACE-inhibitors + Beta-blockers + Angiotensin receptor blockers (ARBs) « Aldosterone antagonists (e.g. Eplerenone, Spironolactone) + Hydralazine with nitrates Copyrights @ Plab1Keys.com31] e [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) How to manage CHF? (Important) © For all patient, for symptomatic relief and to reduce the volume overload > Diuretics (e.g. Furosemide I Lasix ™) © Start with either an ACE inhibitor or Beta blocker (one drug at atime). © |f the symptoms persist > Add the other one (ACEi or BB). © If the symptoms still persist > Add Spironolactone Side Note Spironolactone is a p agi VA Ai: if the patient has Diabetes, we start with ACE inhibitors (e.g. Ramipril) instead of Beta-Blockers. Copyrights @ Plab1Keys.com32|P ogy] ©Copyright plab1keys.com (Constantly updated for online subscribers) ACE inhibitors are reno-protective and thus beneficial for diabetic patients. “Try to link AC! h DM in your © If HF + AF > Digoxin N.B. One might ask “Won't Furosemide + ACE inhibitors lead to hyperkalemia? The answer is > No! © Thiazide and Loop Diuretics (e.g. Furosemide) > HypOkalemia. © ACEI (e.g. Ramipril) and Spironolactone > HypeRkalemia Key [The Summary of STEMI (ST-Elevation MI) Management 10 gin Acute Settings) > MONA (Morphine, O2, Nitrates, Aspirin 300 mg) + Heparin (either unfractionated or LMW such as enoxaparin/ fondaparinux) Copyrights @ Plab1Keys.comage [Cardiology] ©Copyright www.piab1keys.com (Constantly updated for online subscribers) + If the patient presents within 12 hours of the onset of the symptoms > PC (Percutaneous Coronary Intervention)) “The gold standard” + If Not, or PCI is unavailable > Thrombolysis (Alteplase). a (Chronic) Long-term Management of MI Aspirin for life, Ticagrelor or Prasugrel for 12 months “Clopidogrel previously”, Beta Blockers (for 12 months), ACE inhibitors, Statins So, Long-term MI Rx =5 Drugs: Aspirin, Clopidogrel, BB, ACEI, Statins, |AABC+S| > Aspirin, ACE inhibitors, Beta-blockers, Clopidogrel + Statins Key Patent Foramen Ova' il V The foramen allows blood to pass from the right atrium to the left atrium. V The opening is supposed to close soon after birth, but sometimes it does not. In about 1 out of 4 people, the opening never closes. If it does not close, it is called a PFO. v In most of these individuals, the PFO causes no problems and remains undetected throughout life. Copyrights @ Plab1Keys.com34| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) v PFO has long been studied because of its role in paradoxical embolism (an embolism that travels from the venous side to the arterial side). This may lead to a stroke or transient ischemic attack. v [Transesophageal echocardiography, is considered the most accurate investigation to demonstrate a patent foramen ovale. vA patent foramen ovale may also be an incidental finding. The important point to remember is: Trans-oesophageal Echocardiography (TOE) with bubble contrast is the gold standard in diagnosing Patent Foramen Ovale (PFO). Copyrights @ Plab1Keys.com35|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) PFO: blood passes from Rt atrium > to Lt atrium Key | [Important Complications of Ml * This most commonly occurs due to patients developing ventricular 1 and is the most common cause of death following a MI. * Patients are managed as per the ALS protocol with defibrillation. Copyrights @ Plabikeys.com36|Page [Card © Copyright plab1keys.com (Constantly updated for online subscribers) If the patient survives the acute phase, their ventricular myocardium may become dysfunctional resulting in chronic heart failure. Management: @ For all patient for symptomatic relief and to reduce the volume overload > Loop Diuretics (e.g. Furosemide) @ Start with either ACEi or BB. (One drug at a time) @ If the symptoms persist > Add the other one (ACEi or BB). @ If the symptoms still persist > Add Spironolactone (Aldosterone Antagonist). © Ventricular fibrillation, as mentioned above, is the most common cause of death following a MI. Other arrhythmias can also occur e.g. ventricular tachycardia. @ Management: 1) Check the patient’s pulse, if no pulse, commence the arrest protocol immediately (and deliver immediate defibrillation) Copyrights @ Plab1Keys.com37| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) 2) Administer 02. PaRICaRaHIS “important v" © Occurs within 48 hi e. 2 days) after MI. & Features > Pleuritic chest pain that is worse on lying flat and during inspiration + Fever + Pericardial rub. © Pericardial effusion may develop leading to enlarged globular heart on chest X-ray and is confirmed by echocardiogram. @ ECG > Widespread Saddle Shaped ST Elevation with upward concavity + PR Depression. BA full-dose ) should be used (aspirin, 2-4 g/d; ibuprofen 1200-1800 mg/d; indomethacin 75-150 mg/d); treatment should last at least 7-14 days. DRESSIERSISRAROME “irrportant v" @ Similar to pericarditis in features but it tends to occur 2-6 weeks following a myocardial infarction. @ The underlying pathophysiology is thought to be an against antigenic proteins formed as the myocardium recovers. @ It is characterised by a combination of fever, pleuritic chest pain that worsens on inspiration and lying flat, pericardial effusion and a raised ESR. @ It is treated with NSAIDs. Copyrights @ PlabiKeys.com38| Page [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) @ ECG: Widespread Saddle Shaped ST Elevation + PR Depression. @ The ischaemic damage sustained during a MI episode may weaken the myocardium resulting in a thin muscular layer; thus, aneurysm formation. @ This usually occurs 4-6 weeks post MI. @ This is typically associated with persistent ST elevation| and left ventricular failure. & A thrombus may form within the aneurysm increasing the risk of stroke. Patients are therefore anticoagulated. ECG > Persistent ST Elevation + Left Ventricular Failure. CXR -> Enlarged heart with a bulge at the left heart border. Echo > Paradoxical movement of the ventricular wall. & Rupture of the interventricular septum usually occurs in the first week after a Ml attack and is seen in around 1-2% of patients. @ Features: acute heart failure associated with a pan-systolic murmur. @ An echocardiogram is diagnostic and will exclude acute mitral regurgitation which presents in a similar fashion. @ Urgent surgical correction is needed. Copyrights @ Plab1Keys.com39|P ardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) (eRHPETnTPaINPegUPTTOHEMICAR): “important v” pansystolie murmur @ Occurs 2-15 days after the MI (Mostly inferior Ml). @ Due to > Ischemia or rupture of the papillary muscles of the mitral valve. @An early-to-mid systolic or Pansystolic murmur is typically heard. & May present with |Hypotension|, [Tachycardia] and Pulmonary edemal. @Dx—> Echocardiogram. @ Treatment — vasodilator therapy but often requires emergency surgical repair. important Note: ® Pericarditis (Can occur as a Complication of Ml, may develop shortly after MI within 2 days) and Dressler’s syndrome (presents 2-6 weeks after MI) both have the same features: — Pleuritic chest pain that worsens on lying flat and during inspiration, and improves on upright sitting forward. + Pericardial rub, Copyrights @ Plab1Keys.com40|P2ge [Cardiology] ©Copyright www.piabtkeys.com (Constantly updated for online subscribers) + Widespread Saddle shaped ST elevation on the ECG. They can also lead to Pericardial effusion] (Enlarged globular heart on chest X-ray) and if severe enough, [cardiac Tamponade| can also develop (also enlarged globular heart of the X-ray + Beck’s Triad: Hypotension, Muffled Heart Sounds, High JVP). Key 13 Types of MI / Sites of Myocardial Infarction (ARREHISEIM (Left Anterior Descending LAD) seen [ieee ST elevated leads onECG | The likely Occluded Artery Inferior ML 11M, aVF Right Coronary Lateral MI 1, aVL, VS, V6 Left Circumflex Anterioror (Anteroseptal) V1 V4 LAD (Left Anterior Descending) AnteroLateral Ml |, aVL, V4, V5, V6 LAD or Left Circumflex *H © taccrckeomblstites @)@rkb1tes © Plabtieyscom —* Copyrights @ Plabikeys.comai} © Copyright plab1keys.com (Constantly updated for online subscribers) Wide spread ST depression (+) ST elevation in aVR > [Left main coronary artery [LMCA] occlusion] > Emergency coronary angiography| Key 14 For Theoretical Exams} 5 Any patient presents with S > Give MONA (Morphine, O2, Nitroglycerin, and then: > Send immediately for |PCI) (Percutaneous Coronary Intervention). * If PCl is not obtainable = [Alteplase.. [i.e. thrombolysis] + If PCI and Alteplase are not given, pick >|Streptokinase.. [i.e. thrombolysis]. 5 Any patient presents with N: > After giving morphine, 2 medications should be given immediately: v [Oral Aspirin 300 mg (+) Vv SC |Low molecular weight heparin| “or” SC |Fondaparinux. i.e. (widespread ST depression + ST elevation in aVR): Copyrights @ Plab1Keys.com42|P ardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) after giving morphine > [Emergency coronary angiography, Key 15 @ The first drug of choice for BymptomaticBradycardil = tttS*«s@ (Dizziness, feeling unwell) is > Atropine (Given 0.5 mg IV push and may be repeated up to a total dose of 3 mg). What if he was given atropine but no response? Next step would be > [Temporary transcutaneous pacemaker}. © 2" Line > Dopamine. © 3" Line > Epinephrine. 4 N.B. If the question was “the next best step” (or) “the initial line’, the Answer will be > Key 16 v Hypotension, Vv Muffled “faint = weak” Heart Sounds, V High Jugular Venous Pressure [JVP] (= Distended neck veins). > Cardiac Tamponade. Copyrights @ Plab1Keys.com43|P © Copyright ww om (Constantly updated for online subscribers) > Echo for Dx and Pericardiocentesis for Rx Key 17 Infective Endocarditis (IE) New Murmur + Fever > think of [infective Endocarditis (IE) + Malaise, Rigors. The initial step > Bieealeuiture v then > Echo] VE ail SA previous episode of endocarditis > the strongest risk factor. & Rheumatic valve disease. @ Prosthetic valves. @ Congenital heart defects. @ Intravenous drug users (IVDUs: typically causing tricuspid lesion). CR RO Le ech cued - Staph. Aureus is the commonest cause of IE in general. - Staph. Epidermidis is the commonest cause after prosthetic valve surgery. Copyrights @ Plab1Keys.com4a|Page [Card © Copyright plab1keys.com (Constantly updated for online subscribers) - Strept. Viridans (especially sterpt. Mitis and strept. Sanguinis) are the commonest cause in people with poor dental hygiene or following a dental procedure. CM Py ued Infective endocarditis is diagnosed in any of the following situations: * 2 major criteria, or © 1 major and 3 minor criteria, or © 5 minor criteria 1) Positive blood cultures & Two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group, (Or) @ Persistent bacteraemia from two blood cultures taken > 12 hours apart or three or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis. Not to be confused, it is true that staph. Aureus is the commonest pathogen in IE; however, it is not specific for IE as it causes many other inflammations. 2) Evidence of endocardial involvement (i.e. +ve Echo for IE) Copyrights @ Plab1Keys.com45 |P2 Cardiology] ©Copyright www.plabikeys.com (Constantly updated for online subscribers) @ Positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves). (Or) & New valvular regurgitation 1. Predisposing heart condition or intravenous drug use. 2. Microbiological evidence that does not meet the major criteria. 3. Fever > 38°C. 4. Vascular phenomena > Major emboli, Splenomegaly, Clubbing, Splinter haemorrhages, Janeway lesions, Petechiae or purpura. 5. Immunological phenomena - Glomerulonephritis, Osler’s nodes, Roth spots. N.B. - Osler’s Nodes: painful, red nodules on the hands or feet that can persist for hours to days. - Janeway lesions: Non-tender, small, erythematous or hemorrhagic macular or nodular lesions on the soles or palms. (they occur due to septic micro- emboli that deposit the bacteria under the skin). Copyrights @ Plab1Keys.com46|P2ge [Cardiology] ©Copyright www.plab1keys.com (Constantly updated for online subscribers) Splinter sae Osler node Roth's spot Janeway lesion itial “Empirical” “Blind” therapy * Native valve endocarditis > - Amoxicillin + low-dose Gentamicin. (Or), - Vancomycin + low-dose Gentamicin (If Penicillin allergic or MRSA “Methicillin-Resistant Staph. Aureus” is suspected or Severe Sepsis). ° If Hx of prosthetic valve endocarditis> Vancomycin + low-dose Gentamicin + Rifampicin The most important note to remember is that in any patient presenting with +a new heart > suspect and order until proven otherwise. Copyrights @ Plab1Keys.com47|Pege [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) Example 1|: Aman who had dental extraction a few days ago presents with petechia. His vitals are stable except his body temperature which is 38.9. On examination (O/E): He has petechiae, painful nodules on his palms, and a cardiac murmur. The likely Dx > |Infective Endocarditis. (Fever + New Murmur). The underlying cause of this condition > infection]. The next investigating step > blood culture} (followed by Echo). Example 2 A man presents with Fever, confusion, petechiae. This is a picture of his soles Copyrights @ Plab1Keys.com48|Pege [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) What is the most appropriate investigation? > Blood Culture) These lesions are likely faneway lesions|(minor criteria of infective endocarditis). ¢ Likely > Infective endocarditis} > Do Blood culture then Echocardiogram 18 Copyrights @ Plab1Keys.com49|Pege [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) “To determine the need to anticoagulants”. Cc Congestive heart failure 1 (or LV dysfunction) H Hypertension BP>140/90 1 or treated hypertension on medication Ao Age =75 years 2 D Diabetes Mellitus | So Prior Stroke or TIA or 2 Thromboembolism Vv Vascular disease (e.g. MI, PVD, Aortic plaque) | A Age 65-74 years | Sc Sex category (female gender) I Give Warfarin or DoAC (Direct-Acting Oral AntiCoagulants, such as Apixaban, Rivaroxaban, Edoxaban, Dabigatran) To: \ Consider giving Warfarin or DOAC to Men who score 2 1. Advantages of DOAC: o No need for INR Monitoring, o Faster Onset of Action (2-4 hours), Copyrights @ Plab1Keys.coms0]Pege [C ardiology] ©Copyright www.plabikeys.com (Constantly updated for online subscribers) o Reduces the risk of intracranial Hemorrhage. Disadvantages of DOAC: o No Antidote o Require strict compliance by the patients. The in apa The patien The @ The patien |cHA2Ds2-vase score’ is used to determine the need to anticoagulants tient who has atrial fibrillation. V important |ABCD2 score} (Prognostic) is used to identify the risk of future stroke in its who have had a suspected TIA in the following 7 days. V Not advised to be used now according to the recent 2019 CKS guidelines. 'HAS-BLED score estimates the risk of major bleeding for patients on anticoagulation for atrial fibrillation. DRAGON score predicts the 3-month outcome in ischaemic stroke its receiving tissue plasminogen activator (tPA) e.g. alteplase. Copyrights @ Plab1Keys.comsa] v]_ ©Copyright plab1keys.com (Constantly updated for online subscribers) & The jarisK2 score] is used to determine the risk of a cardiovascular event in the next 10 years. Key 19 Pulmonary edema Often caused by congestive heart failure. When the heart is not able to pump efficiently > blood may return into the veins > then to the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs. Desaturation (Low O2 Sat.), Dyspnea (SOB), Orthopnea (SOB worsens when lying down), Auscultation > Crepitations “Crackles = rales”. Tachycardia. While aces usually shows features of pulmonary edema (The single most appropriate Investigation), the underlying cause requires Copyrights @ Plab1Keys.com52| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) to be identified (e.g. Congestive Heart Failure, Complication of MI > Acute Mitral Regurgitation due to papillary rupture, Ventricular aneurysm, ...etc.) @ The Most Appropriate Investigation > (Chest X-Ray}. “imp v” & The Investigation Needed to Identify the Underlying Cause > [Echo “impv” [Mona] (But the last A -Aspirin- is replaced by F -Furosemide-): > Morphine, O02, Nitrates, i > (Lasix). 1) Sit the patient up (Popup position) and give O2 (aim for O2 saturation of 2 95%, or 2 90% in COPD patients). 2) Spray 2 puffs of sublingual GTN (Glyceryl TriNitrates). 3) Give Furosemide (Lasix) 40 mg IV (Slowly). 4) Give Diamorphine (2.5-5 mg IV slowly) or Morphine (5-10 mg IV slowly) to relieve pain, anxiety and distress. N.B. A good difference between |Pulmonary Edema and Pulmonary Embolism| is that Pulmonary Oedema can be diagnosed by Chest X-ray while Pulmonary Embolism needs CTPA (CT Pulmonary Angiogram). Copyrights @ Plab1Keys.com53| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) This might be given as a hint in a question. Congestive Heart Failure — Heart unable to maintain circulation Pulmonary Edema — Fluid build up in lungs Pulmonary Edema Copyrights @ Plabikeys.com54)P2ge [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Pulmonary Oedema > Kerley Lines (Expansion of the interstitial space by fluid) Copyrights @ Plabikeys.com55|Page [Cardiology] ©Copyright www.piab tkeys.com (Constantly updated for online subscribers) ~~ Pulmonary Oedema > Kerley Lines + Bat’s wing hilar shadow Key | Scenario 20 20 days after MI, a patient developed sudden Dyspnea. O/E > Tachycardia, Desaturation (88% on Room Air), Hypotension and Bilateral Chest Crackles. @ The likely Dx > Pulmonary Oedema. & The appropriate Initial investigation > Chest X-Ray. & The best investigation to identify the cause > Echocardiography. Copyrights @ Plabikeys.com56| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) '@ Treatment > MONF| Important: If pulmonary edema is cuased by existent hi (Morphine, O2, Glyceryl Trinitrates, Pulmonary Oedema -> Kerley Lines (Expansion of the interstitial space by fluid) 2, the patient needs to be discharged on either [ACE inhibitor or a beta blocker, (one drug at a time). If asthmatic + ACE inhibitor is preferred over BB as BB may worsen asthma. Copyrights @ Plabikeys.com57] © Copyright plab1keys.com (Constantly updated for online subscribers) Key ra [The Typical Presentation of Acute MI (75% of cases)|: @ Central Chest Pain or Epigastric pain or Substernal pain that is severe, sudden, crushing, pressuring, squeezing, constricting or burning. @ Radiates to arms, shoulders, neck or jaw. @ + Sweating (Diaphoresis), Nausea, Vomiting, Fatigue and/or Palpitations. © SOB “Shortness of breath”. Important DD: [Dissecting Aneurysm] Aortic dissection Although Dissecting aortic Aneurysm may have more or less a similar presentation to MI, to be chosen as an answer, there should be other clinchers pointing towards dissecting aneurysm such as: Mf unequal pulses in upper ims NAHx of Marfan Syndrome (tall, long slender limbs and fingers). SAHx of Ehlers-Danlos syndrome/ turner syndrome Se ee ee WAHTN is the most important risk factorf WaThe patient presents with Hypotension, SOB, tachycardia, sweatingh Copyrights @ Plab1Keys.com58|Page [Cardio © Copyright plab1keys.com (Constantly updated for online subscribers) Points on Aortic Dissection * Aortic dissection is a rare but serious cause of chest pain. Pathophysiology > tear in the tunica intima of the wall of the aorta. * Injury of the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. * In most cases, this is associated with a sudden onset of severe chest or back pain, often described as “tearing” in character. Also, vomiting, sweating, and lightheadedness may occur. © Other symptoms may result from decreased blood supply to other organs, such as stroke or mesenteric ischemia. * Aortic dissection can quickly lead to death from not enough blood flow to the heart or complete rupture of the aorta. * The transoesophageal echocardiogram (TEE) is a good test in the diagnosis of aortic dissection, with a sensitivity up to 98% and a specificity up to 97%. It has become the preferred imaging modality for suspected aortic dissection. * Other good investigations > CT scan with contras/ MRI. eln settings > | © Stanford classification of Aortic Dissection: type type B: descending aorta, distal to left subclavian origin, 1/3 of cases ing aorta, 2/3 of cases Copyrights @ Plab1Keys.com59]? e [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) @ Management od Aortic Dissection * Type A > surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention. * Type B > conservative management, bed rest, reduce blood pressure: IV labetalol to prevent progression Copyrights @ Plab1Keys.com60)? age [Cardiology] ©Copyright www.piab1keys.com (Constantly updated for online subscribers) Key 22 Left Bundle Branch Block (LBBB) In the context of chest pain, new LBBB is significant as it is an indication for thrombolysis / percutaneous coronary intervention (PCI). LBBB features on ECG: SESTERES Shape) RPSREEORENORS sally n Lead), av. and ve but not always. (ibeepinvertedl(Negative)IGRS: usually in lead (v1). @ Left Axis Deviation (Not always) MU SSeS LUMO v tm “M” shaped QRS in Leads: 1, aVL, V6. @ Deep (Negative) “Inverted” QRS in V1. Copyrights @ Plab1Keys.com61|P ardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) Key ||[Ruptured Abdominal Aortic Aneurysm (AAA) @ |The classical picture} a triad of: Pain|, Hypotension), pulsatile tender abdominal mass. - Sudden onset severe abdominal + Lower back + Flank pain. - Shock (Hypotension, Sweating, Fainting) - Absent Lower Limb Pulse, mottled skin. Git is a Ug es eutay: therefore, immediate jUltrasound[a the most appropriate initial investigation. @ If no U/Sin the options, go for Gen abdomen. 5 Screening for Abdominal Aortic Aneurysm (AAA) in the UK: Vv Men only. v Once only. V In 65" year. Vv by Ultrasound. Copyrights @ PlabiKeys.com62| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Key | [Management of Chronic Heart Failure} 24 In a patient with Heart Failure LL Edema, Dyspnea, Orthopnea, Ejection fraction less than 40%], The management would be: © For symptomatic relief and to reduce the volume overload, all patients should receive -> Diuretics (e.g. loop diuretics e.g. Furosemide) © Start with either ACEi or BB. (one drug at atime) © If the symptoms persist > Add the other one (ACEi or BB). e If still symptomatic > Add spironolactone “potassium sparing diuretics”. . ana: the patient with Heart Failure has Diabetes, we start with (e.g. Ramipril) instead of Beta-Blockers. Even in hypertension “as you will see in the coming keys”, any patient despite the age and ethnicity who has diabetes and HTN, start with ACE inhibitors as step 1. Copyrights @ Plab1Keys.com63]? age [Cardiology] ©Copyright \ plab1keys.com (Constantly updated for online subscribers) Key 25 [Coronary Artery Dominance} » The artery that supplies the Posterior Descending Artery (PDA) determines the coronary dominance. » In 5%| of the population, the Right coronary artery (RCA) gives off the PDA (Right Dominant). + In |159%| of the population, the left circumflex! gives off the PDA (Left Dominant). @ Hence, the artery that has artery dominance is the (RA), as it gives off the PDA in 85% of people. Key 26 Dressler’s syndro me| @ It tends to occur around 2-6 weeks following a MI. & The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. @ It is characterised by a combination of fever, pleuritic pain worsens on inspiration and on lying flat, pericardial effusion and a raised ESR. Copyrights @ Plab1Keys.com64| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) BECG > \ 1 + PR Depression @ It is treated by NSAIDs. Its features are more or less similar to acute pericarditis. However, pericarditis usually occurs only a few days after MI. Key Hypokalemia| [Muscle weakness and cramps +|U wave on the ECG & One important reason for hypokalemia is Thiazide like Diuretics (e.g. Bendroflumethiazide) and Loop diuretics (e.g. Furosemide) But not Potassium-sparing diuretics (e.g. Spironolactone) which causes HypeRkalemia. @ Spironolactone, ACE inhibitors, ARBs > |HypeRkalemial. @ Loop diuretics, Thiazide like diuretics > HypOkalemial. @ The ECG changes in HypUkalemia > U Wave Copyrights @ Plab1Keys.com65| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Management of hypokalemia U wave (hypokalemia) > an additional wave after (T-wave) 1) Oral or IV Potassium chloride} (based on severity), e.g. if K+ <2.5} > [IV 2) Stop/ Treat the cause (e.g. stop furosemide, thiazide like diuretics). Loop Diuretics (e.g. Furosemide) ° Thiazide-like diuretics (e.g. bendroflumethiazide, indapamide) © Vomiting and Diarrhea Villous Adenoma ¢ Renal tubular failure * Cushing Syndrome © Conn’s disease (1ry hyperaldosteronism) © ACE inhibitors (e.g. enalapril). * ARBs (e.g. losartan). © Potassium-sparing diuretics (e.g. Spironolactone/ Eplerenone) * CKD/ Acute renal failure © Addison’s (1ry Adrenal Insufficiency). © Congenital Adrenal Hyperplasia (CAH). Key | [Paroxysmal Supraventricular Tachycardia 28 E (Narrow-Complex SVT) Copyrights @ Plab1Keys.com66| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) = Usually in young patients = Presents with Palpitations, Light-headedness, Recurrent, Young. Management: imp V * initia tine) > (Carotid massage|. + Not improved? > Intravenous jadenosine (6mg Rapid IV Bolus), still not improved? — give additional 12mg adenosine, still not improved? — give another 12mg adenosine. N.B. Adenosine is contraindicated in asthmatics > Verapamil (CCB) is the preferred option in SVT in a patient with Asthma. * Still not improved? > Electrical DC “Cardioversion” + Prevention of future episodes > R-Blockers or Radio-frequency ablation. In summary: Copyrights @ Plab1Keys.com67| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) B Carotid Massage and Valsalva Manoeuvre B IV Adenosine 6 mg 8 IV Adenosine 12 mg 8 IV Adenosine 12 mg 8 Cardioversion (Shock) errant eye (Narrow/Complex\ViI), 1+ line > Carotid Massage & Valsalva Manoeuvre. 2nd fine > 1V Adenosine. ~~ 3r¢ ine -> Cardioversion. Polymorphic (Broad-Complex) Ventricular Tachycardia E Torsades De Pointes (TDP) & Beat-to-beat variations with no uniform pattern of ventricular contractions. Copyrights @ Plab1Keys.com68| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) @ Broad QRS (except in resting status), Prolonged QT, Fainting episodes, Patient might be a young athlete, Recurrent. & Treatment - |v Magnesium Sulphatd > |V Magnesium Sulphate. N.B. Verapamil should NOT be used in VT. & =a Ventricular sl achycardia Ss Say eek eens lly ECG Indicating Torsades de Pointes Key 29 For patients who present with STEMI, give MONA (Morphine, 02, Nitroglycerin, Aspirin) and send immediately for Pa (Percutaneous Coronary Intervention). Copyrights @ Plab1Keys.com69|P ogy] ©Copyright plab1keys.com (Constantly updated for online subscribers) en in the options? Pick > Alteplase “preferred” or Streptokinase| (Tissue Plasminogen Activator) ® Key | MI (Acute chest pain radiating to jaw, shoulder...) BUT |without ST elevation 30 | on ECG. What to Do Next? > Request Cardiac Enzymes, especially (Troponin) If Troponin is high > NON-STEMI Elevation MI + (Give LIMWH OR Fondaparinux{ + [Aspirin 300 mg] Copyrights @ Plab1Keys.com701? age [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) Patients with Ischemic Chest Pain Perform ECG y NoST elevation ST elevation ED Non ST elevation myocardial ST elevation myocardial infarction (NSTEMI) infarction (STEMI) ¥ Unstable angina (UA) Key 31 6 weeks after MI, a patient returns with SOB when walking long distance and his ECG shows ST elevation in V1-V5 leads. (Persistent ST elevation post-MI > Think of: @ The ischaemic damage sustained during a MI episode may weaken the myocardium resulting in a thin muscular layer; thus, aneurysm formation. @ This usually occurs 4-6 weeks post MI. @ This is typically associated with persistent ST elevation| and left ventricular failure. Copyrights @ Plab1Keys.com7p Pe e [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) & A thrombus may form within the aneurysm increasing the risk of stroke. Patients are therefore anticoagulated. ECG > Persistent ST Elevation + Left Ventricular Failure. CXR > Enlarged heart with a bulge at the left heart border. Echo > Paradoxical movement of the ventricular wall. Key 32 Hypertension Management Hypertension classification Stage Criteria Stage 1 Clinic BP > 140/90 mmg and subsequent ABPM daytime hypertension average or HBPM average BP > 135/85 mmHg Stage 2 Clinic BP > 160/100 mmHg and subsequent ABPM daytime or hypertension HBPM average BP > 150/95 mmHg Stage 3 “Severe Clinic systolic BP > 180 mmHg, hypertension” clinic diastolic BP 2 110 mmHg Keys: ABPM ~ Ambulatory Blood Pressure Monitoring. Copyrights @ Plab1Keys.com72|Page [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) HBPM ~ Home Blood Pressure Monitoring. N.B. Clinic BP is usually higher than ABPM and HBPM because some people get stressed or feared while at a clinic > a slight increase in BP. Management of hypertension| should not be forgotten: © Low salt diet. * Caffeine intake should be reduced. © Stop smoking. * Drink less alcohol. Eat a balanced diet rich in fruits and vegetables. * Exercise more. © Lose weight. When to Treat Stage 1 Hypertension? * Treat if the patient’s age is < 80 years AND + any of the following: diabetes ora. 10-vear. cardiovascular risk equivalent to > 20%. & Note: Ifa patient is completely free and has a stage 1 Hypertension > Lifestyle and Diet Modification + review (Follow up). Copyrights @ Plab1Keys.com73|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) & Note: In a patient with stage 2 hypertension at a clinic (Clinic BP > 160/100) > Before commencing antihypertensive drugs, record either ABPM or HBPM|. © Note: For patients < 40 years and with stage 2 hypertension or higher > {Consider a specialist referral to exclude secondary causes of the HTN. If ABPM or HBPM 2 150/95 mmhg (i.e. confirmed stage 2 or higher hypertension) — [We¥eset The Steps of The Management of Hypertension * Patients < 55-years-old — start with ACE inhibitor (A) or ARBs. * Patients > 55-years-old lor] of Afro-Caribbean origin “of any age” = start with Calcium channel blocker. In other words: Copyrights @ Plab1Keys.com74|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) White + < 55 YO) > start with lacei/arBs| as a step 1 management of HTN. White + > 55 YO|— start with (CCB| as a step 1 management of HTN. |Afro-Caribbean + any age} — start with ece} as a step 1 management of HTN. Step 2 (still hypertensive after step 1) © Both: ACE inhibitor + Calcium channel blocker (A + C) Step 3 (still hypertensive after step 2) * Add a Thiazide Diuretic (D) So, 3 medications are taken > |ACEil + kcal + [Thiazide like Diuretid (A+C+D). - Example of ACEi > Enalapril. - Example of CCB > Amlodipine. Examples of thiazide diuretics — chlorthalidone (12.5-25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) Bendroflumethiazide is a thiazide like diuretic; however, it is no longer recommended by NICE as an antihypertensive. Copyrights @ Plab1Keys.com75|Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) * consider further diuretic treatment. & If potassium < 4.5 mmol/l > add spironolactone (Potassium Sparing) 25mg OD. @ If potassium > 4.5 mmol/l > add a higher-dose thiazide-like diuretic. ¢ If further diuretic therapy is not tolerated or is contraindicated or ineffective, consider an alpha- or beta-blocker. ll Patients who fail to respond to step 4 measures should be referred to a specialist. NICE recommend: If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs > seek expert advice. Blood pressure targets & For Diabetic patients with Hypertension: If end-organ damage (e.g. renal disease, retinopathy) k 130/80 mmHg otherwise 140/80, mmHg. @ For Hypertensive patients without DM: Clinic BP ABPM / HBPM Age < 80 years 140/90 mmHg 135/85 mmHg Age > 80 years 150/90 mmHg 145/85 mmHg Copyrights @ Plab1Keys.com761° © Copyright plab1keys.com (Constantly updated for online subscribers) lypertension + Diabetes (V. Imp. @ Always treat hypertension in a DIABETIC patient with regardless of the age as it is reno-protective “Unless if the eGFR is <30”. @ However, if this diabetic patient is Afro-Caribbean, > start with both |ACE inhibitor + Calcium Channel Blocker as a first step. ™ Before commencing ACE inhibitor for any patient > If eGFR (Glomerular Filtration Rate) is low; <30 as in advanced Chronic Kidney Disease — ACEi and ARBS should be avoided in this case Why ACE inhibitor is used for Diabetic Hypertensive patients? - It is reno-protective (unless eGFR is low; <30; in advanced CKD). - It has protection against diabetic retinopathy. - It has +ve effect on glucose metabolism. Key 33 Postural Hypotension (Orthostatic Hypotension) - Adrop in systolic blood pressure of at least 20 mm Hg within three minutes of standing. Copyrights @ Plab1Keys.com77| Page [Cardiol © Copyright ww.plab1keys.com (Constantly updated for online subscribers) - ora drop in diastolic blood pressure of at least 10 mm Hg within three minutes of standing. - BP is measured on lying position, then on standing position. - Dx: |Monitor BP). @ Postural hypotension is common in elderly people especially those who take multiple drugs (/Polypharmacy) and those with hypertension. ® Anti-hypertensive medications can cause postural hypotension as well. & The (Vascular resistance) decl hypertension. 5 that control HR (Heart Rate) and VR ith age, particularly in patients with Q] An elderly man complains of difficult mobilisation. He often feels dizzy upon trying to stand + He has a Hx of Recurrent Falls. Management? > [Blood pressure monitoring] & |Assess and review the patient’s Medications. Copyrights @ Plab1Keys.com78) P © Copyright plab1keys.com (Constantly updated for online subscribers) Q] An elderly man takes several medications for hypertension and heart failure. He often feels dizzy upon trying to stand + He has a Hx of Recurrent Falls? The likely cause of his postural hypotension > |polypharmacy} Blood pressure moni a Management > Key 34 Again, any patient of any age and any ethnic group presents with Hypertension and he is a Diabetic patient Start with > [Ace inhibitor] (e.g. Enalapril). (Note, if the eGFR is 30 or below, ACEi and ARBS should be avoided). Key 35 (Absent “P” wave on ECG + [irregularly Irregular Rhythm| + Palpitation| Diagnosis? > [atrial Fibrillation). Management? V First line > v If asthmatic > Avoid beta-blockers and give v If the patient has associated HF > give |digoxin. + beta-blockers, calcium channel blockers}. > Calculate ‘CHAZDS2-VASCc Score (Key number 18) and accordingly: Copyrights @ Plab1Keys.com791° age [Cardiology] ©Copyright www.piab1keys.com (Constantly updated for online subscribers) > Give (Warfarin) or (DOAC) or nothing according to the Cha2ds2vasc score. & Examples of DOAC “Direct-Acting Oral AntiCoagulants” -important v- (Apixaban]| Rivaroxaban, Edoxabanl, [Dabigatran)’. Key Fever + New Murmur] > |Infective Endocarditis “until proven otherwise”. 36 Be careful, the reason of IE is > Infection] “infective” endocarditis. - Staph. Aureus is the commonest cause of IE in general. - Staph. Epidermidis is the commonest cause after prosthetic valve surgery. - Strept. Viridans (especially sterpt. Mitis and strept. Sanguinis) are the commonest cause in people with poor dental hygiene or following a dental procedure. Key |Ment r Ectopics| 37 = Three-beat patterns = Ventricular Trigeminy. @ Asense of a missed/skipped beat, unsustained palpitation + Dyspnea and Dizziness due to immature discharge of a ventricular ectopic focus which produces > an early and broad QRS complex. Copyrights @ Plab1Keys.com80]? age [Cardiology] ©Copyright www.piab1keys.com (Constantly updated for online subscribers) @ Causes > Ischemic heart disease (MI), Cardiomyopathy, Stress, Alcohol, Caffeine, Cocaine, Medications OR Naturally. @ Over half the population have silent, or asymptomatic ventricular ectopics which are discovered incidentally on a routine ECG. @ If there is No underlying Heart disease (e.g. IHD, Cardiomyopathy) > Benign; no clinical significance. @ If these ventricular ectopics are due to IHD or Cardiomyopathy > May precipitate to more life-threatening arrhythmias like Ventricular Fibrillation. Key 38 {The Typical Presentation of Acute MI (75% of cases)| & Central Chest Pain or Epigastric or Substernal pain that is severe, sudden, crushing, pressuring, squeezing or burning and radiates to arms, shoulders, neck or jaw. @ + Sweating (Diaphoresis), Nausea, Vomiting, Fatigue and/or Palpitations. SOB “Shortness of breath”. # Keep in mind that some patients may present with additional Atypical feature such as Abdominal Pain, Jaw pain or Altered mental status. Copyrights @ Plab1Keys.comBi] P 2 e [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) Key 39 Long term medications post-Myocardial Infarction = 5 Drugs Aspirin, Clopidogrel, 8- Blockers, ACEi, Statins AABCS > Aspirin, ACEi, BB, Clopidogrel, Statin (e.g. Atorvastatin) Key 40 A patient with chronic heart failure developed gout. A medication for his gout is prescribed. A few days later, the patient came back to the hospital complaining of worsening of his Heart Failure symptoms (SOB, Orthopnea). - The likely cause of this patient’s gout > Thiazide like diuretics (e.g. bendroflumethiazide) or Loop Diuretics (Both can cause hyperuricemia (Gout) and both can be used to treat volume overload caused by Heart Failure) - The likely cause of this patient’s worsening of SOB and Orthopnea > NSAIDs (e.g. Ibuprofen) that was prescribed to treat his gout. Important Notes & Never give NSAIDs (e.g. Ibuprofen) nor selective COX-2 inhibitors (e.g. Celecoxib) to the following patients: (Chronic Kidney Disease, Chronic Heart Failure, Ischemic Heart Disease). Copyrights @ Plab1Keys.com82) P 2 e [Cardiology] ©Copyright www.plabikeys.com (Constantly updated for online subscribers) @ These drugs can worsen the HF (worsening the SOB and Orthopnea) and also the renal function. @ Remember that NSAIDs inhibit the synthesis of prostaglandins > thus, decrease the eGFR, retain more salt and water (risk factor for HF). @ N.B. Thiazide like diuretics and Loop diuretics decrease the clearance of Uric Acid > leading to Gout (Hyperuricemia) © N.B. NSAIDs such as Ibuprofen are used for the treatment of Gout. If given to a patient with chronic heart failure, they would worsen the HF symptoms (Orthopnea and Dyspnea). Key 41 in-Hospital Cardiac Arrest algo hy] If. No Signs of Life (i.e. No breathing, No detectable Pulse): 1) Ring the emergency bell and call resuscitation team| (Code Blue) first. Then > 2) Start CPR30:2). Then > 3) (Get defibrillator. Then > 4) ALS when the resuscitation team arrives) Copyrights @ Plab1Keys.com83 Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Collapsed/Sick patient Shout for help and i Ce Ce Tue Are there signs of life? (Breathing, Pulse, Movement) ABCDE — recueciation _fardovertote, team Key 42 In STEMI patient, what if PCI is not given in the options? Pick > Alteplase| “oreferred” or Streptokinase| (Tissue Plasminogen Activator) = ie. [Thrombolysig, Key Diabetic patients may develop “Silent MI” i.e. painless MI. Thus, they may die suddenly and silently without feeling any chest pain (They won’t feel chest pain > They won't seek medical help). This is because they may not feel chest pain due to autonomic neuropathy. Copyrights @ Plab1Keys.com84|Pege [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Key |A scenario to test your knowledge on a previous topid 44 An elderly male presents with Palpitations and Shortness of breath on exertion. The ECG is as follows. What is the likely diagnosis and management? Eee errr Sp I (EEE ESE IESE IE Eee Bee Answer: Copyrights @ Plab1Keys.coma5|Pege [C ardiology] ©Copyright www.plabikeys.com (Constantly updated for online subscribers) Cia fathetke < @ Irregularly Irregular Rhythm. Absent “P” wave. 1 Fine Fibrillatory waves. Palpitation, Tachycardia, Dyspnea (SOB), Fibrillatory waves on e ECG, Irregul im = Absent “P” wave. Key Remember; 45 @ In Supraventricular tachycardia] (Narrow QRS Complex) If thi gin > We firstly perform {Carotid Massage] and WValsalva Manoeuvre}. is fails > We give |lV Adenosine. polymorphic ventricular tachycardia| (i.e. torsade’s de pointes) ~> IV magnesium sulfated. Copyrights @ Plabikeys.com861 P ogy] ©Copyright www.plabikeys.com (Constantly updated for online subscribers) P wave bued iT wave Wr @ First line > Carotid massage and Valsalva Manoeuvre Then > IV Adenosine Key Beck’s Triad in Cardiac Tamponade| 46 Hypotension, Muffled Heart Sounds, High JVP (Distended neck veins). © Trauma (e.g. stab in the chest) is the most important cause for cardiac tamponade. Copyrights @ Plab1Keys.com87| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) © Dx: Echocardiography is diagnostic. e Tx: x Urgent pericardiocentesis|. Key ||Remember that: 47 @ In Atrial Myxoma| > Mitral valve obstruction > Mitral Stenosis > Early or Mid-diastolic murmur, Pyspneal, byncope| @ In [Atrial Myxoma| > Breakdown of small emboli from the mass that can travel down the blood and cause ischemia in multiple sites, leading to > (e.g. Pulmonary Embolism] Stroke} (Clubbing, Blue fingers) Therefore, in a patient with Hx of syncope, SOB, Pulmonary Embolism and early-mid diastolic murmur — Think of [Atrial Myxomal. Key ||Points on Alcohol 48 UK guidelines recommend that a person should drink - No more than 14 units a week, Copyrights @ Plab1Keys.com88]? e [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) - No more than 3 units a day, - with at least 2 alcohol-free days a week. Example: If someone drinks 7 units of alcohol a week and smoke 20 cigarette a day, we should refer him to > Smoking Cessation Clinic. This is because his alcohol intake is insignificant as per NICE whereas his smoking is significant. Key 49 JA scenario to test your knowledge on a previous topid 4 days after MI, an elderly patient presents with Fatigue and Dyspnea. On Auscultation > Pansystolic murmur at the apex and radiates to the axilla was heard. > The likely Dx > [Mitral Regurgitation). > The likely Cause > |Rupture of Papillary Muscles). (CRPETRTPaINPegUPaTTGHOMICAR): “important v" pansystolie murmur @ Occurs 2-15 days after the MI (Mostly inferior Ml). Copyrights @ Plab1Keys.com89]? e [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) @ Due to — Ischemia or ri of the mitral valve. @An early-to-mid systolic or Pansystolic murmur is typically heard. @ May present with |Hypotension|, [Tachycardia] and Pulmonary edema. gDx—> Echocardiogram. @ Treatment — vasodilator therapy but often requires emergency surgical repair Key 50 [A scenario to test your knowledge on a previous topid 2 days after MI, an elderly patient presents with fever and chest pain. ECG shows ST elevation with upward concavity. > cute Pericardi PREREMEIPERCGREY “imcortant v" @ Occurs within 2- is after MI. @ Features > Pleuritic chest pain that is worse on lying flat and during inspiration + Fever + pericardial rub © Pericardial effusion may develop leading to enlarged globular heart on chest X-ray and is confirmed by echocardiogram. ECG - Widespread Saddle Shaped ST Elevation with upward concavity + PR Depression. Copyrights @ Plab1Keys.com90| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) BA full-dose N ) should be used (aspirin, 2-4 g/d; ibuprofen 1200-1800 mg/d; indomethacin 75-150 mg/d); treatment should last at least 7-14 days. Key | For Acute Myocardial Infarction patients, the analgesic that can be 51 | used while in the ambulance is still > IV Morphine. & Remember the initial management for acute MI > (MONA) : Morphine, Oxygen, Nitrates, Aspirin. IMI Analgesia while in an ambulance (Pre-Hospital) 1) Glyceryl Trinitrate (GTN) sublingual or spray. 2) + Opioids ( .5-5 mg Diamorphine or 5-10 mg Morphine. - N.B. Around 1/3 of the patients with MI have nitrate-resistant chest pain; therefore, morphine is given additionally to relieve chest pain. oaWhy IV and not IMy v IM absorption is unreliable + Copyrights @ Plab1Keys.com91|P2ge [Cardiology] ©Copyright www.piabtkeys.com (Constantly updated for online subscribers) v If the patient receives thrombolysis later on, the site of IM injection might bleed. Key Ventricular Old adult, Sudden collapse, Not breathing, 52 Fibrillation Unconscious > Shock “defibrillation” Broad Complex Tachycardia @ Tachyarrhythmia is one of the complications of MI. # An ECG showing broad complex tachycardia in a (still) conscious patient + atrial activity > Ventricular tachycardia > . If the patient is hemodynamically unstable; i.e. unconscious, collapsed, not breathing > Ventricular Fibrillation > 1) Check the patient’s pulse, if no pulse, commence the arrest protocol immediately. 2) Administer 02. 3) If the patient is hemodynamically unstable: Shock followed bylv Amiodarone followed by further Shocks if needed. @ N.B. HypOkalemia is the most important cause of ventricular tachycardia (VT) clinically. Copyrights @ Plab1Keys.com92|P2ge [Cardiology] ©Copyright www.piabtkeys.com (Constantly updated for online subscribers) Key | Treatment of Cardiac Tamponade > Pericardiocentesis. 53 Key | Tall Tented T-wave > HypeRkalemia. 54 & U-wave > HypOkalemia. Vi ve aye i as: | i a f\ LAT fe Sa ‘Vel Vented VeWare aRtedcanta Plabi eyscom| Important Causes of HypeRkalemia: ACE inhibitors, Spironolactone, NSAIDs, Renal Failure, Acidosis, Adrenal Insuffici , Addison's disease. Firstly > Protect the cardiac membrane by giving IWiealeium|eluconate (OR: Calcium Chloride). Then > Reduce the serum Potassium by giving Insulin with Dextrose OR sometimes salbutamol inhalation. ot ©) tactoctsomettton G@riabikoo © Plabtteyscom *H# Copyrights @ Plab1Keys.com93° ardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) Key 55 [A scenario to test your knowledge on a previous topid 45 Y/O African patient has BP 160/90 on three separate occasions. What is the initial line of treatment? > {Calcium Channel Blocker (CCB) (First Step Management of hypertension in African-Caribbean patients is (CCB) regardless of the age). White + < 55 YO|- start with [ACEi |ARBs| as a step 1 management of HTN. White + > 55 YO|— start with (CCB| as a step 1 management of HTN. |Afro-Caribbean + any age} -> start with kecB| as a step 1 management of HTN. (Any ethnicity + Any age + Diabetes| > start with ceil ARBs|as a step 1 management of HTN Key [Remember that} LBBB is associated with acute Ml. Copyrights @ Plab1Keys.com94|P2ge [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) hy a Af Lat =" ralebed QRS in Leads: |, aVL, V6. @ Deep (Negative) “Inverted” QRS in V1. | © (acca isc) N\A A ire Key 57 Heart Murmurs, Defect Where is it Symptoms heard? Aortic Ejection Systolic Right 2°¢ICS just Dyspnea on si . lateral to activity, Anginal persis sternum, radiates chest pain, to Carotid artery syncope Aortic Early Diastolic Right 2™71CS just Symptoms of Regurgitation lateral to Heart Failure sternum Pulmonary Ejection Systolic Left 2"¢ICSjust Systemic Stenosis lateral to Cyanosis sternum, radiates Copyrights @ Plabikeys.com95| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Pulmonary Early-Diastolic Regurgitation Mitral Stenosis Mid-Late Diastolic, with opening click Mitral Pan-Systolic Regurgitation Tricuspid Diastolic Rumble Stenosis Tricus Pan-Systolic Regurgitation ‘opyright plab1keys.com Example! > Mitral Regurgitation to left shoulder of infraclavicular area Left 2°4 ICS just lateral to sternum Apex (left 5 ICS midclavicular line) Apex (left St" ICS MCL), radiates to Axilla 4-5" ICS over the left sternal border. 4-5 ICS over the left sternal border. Symptoms of Right-Sided Heart Failure Symptoms of Heart Failure Symptoms of congestive Heart Failure; edema, Ascites Fluttering Discomfort in the neck Symptoms of Right-Sided Heart Failure A patient with Hx of MI presents with Orthopnea (Cannot lie down flat), Bibasilar crepitations, Pan-systolic murmur. Copyrights @ Plab1Keys.com96|P2ge [Cardiology] ©Copyright www.piabtkeys.com (Constantly updated for online subscribers) > do Echi Key ||A scenario to test your knowledge on a previous topid 58 A Young adult presents with f od prolonged QT. There are sinus rhythm and normal P-R interval. No FHx of arrhythmias or sudden death. The likely Dx> Polymorphic Ventricular Tachycardia (Torsades de pointes) @ Beat-to-beat variations with no uniform pattern of ventricular contractions. & Broad QRS (except in resting status), Prolonged QT, Fainting episodes, Patient might be a young athlete. Recurrent. 5 Treatment] — |v Magnesium Sulphate N.B. Verapamil should NOT be used in VT. Copyrights @ Plabikeys.com97|P2ge [Cardiology] ©Copyright www.piabtkeys.com (Constantly updated for online subscribers) [Polymorphic Cert ‘complex VentricularysTachycardia’ es Say Ee 1V Magnesium Sulphate clbry Key 59 An elderly patient with a Hx of stroke presents with exertional dyspnea. ECG shows Atrial Fibrillation. Chest X-ray shows Straight left heart border. > Mitral Stenosis). + The most common cause of mitral stenosis > rheumatic fever, rheumatic fever and rheumatic fever. Pathogenesis of Mitral Stenosis: Mitral stenosis impedes left ventricular filling > increased left atrial pressure (Which will lead to I ial h hy; therefore, CXR shows Straight left side heart border) > Blood returns Back to lungs > Pulmonary Congestion > Right Ventricular Failure (Hepatomegaly, Ascites, Oedema) Copyrights @ Plab1Keys.com98] Page [Card © Copyright plab1keys.com (Constantly updated for online subscribers) Features © Mid-late diastolic murmur (best heard on expiration) “low pitched” © Loud $1, opening snap * Low volume pulse * Malar flush ° Atrial fibrillation Note: @ Left heart murmurs (Mitral and Aortic) are best heard during expiration & Right heart murmurs (Tricuspid and Pulmonary) best heart in inspiration Careful! Left and right refer to the site of the valve, not the area of auscultation Features of severe MS © The length of murmur increases © The opening snap becomes closer to S2 Copyrights @ Plab1Keys.com99| Page [Cardiology] ©Copyright www.plabtkeys.com (Constantly updated for online subscribers) Chest x-ray in MS Left atrial enlargement (often) > Straightening the left border} of the heart. ECG (may show): - Signs of Right ventricular hypertrophy - P mitrale (bifid P wave) - AF Echocardiography -> (Thickening of Mitral valve leaflets) Key | First line treatment in AF (if no asthma) > B-Blockers (e.g. Metoprolol)| Key | \ Ejection Fraction (+) | Septal Wall Thickness > *" | Ditated Cardiomyopathy @ 7 Ejection Fraction (+) 7’ Septal Wall Thickness > Copyrights @ Plab1Keys.com100 | Cardiology] ©Copyright www.plab1keys.com (Constantly updated for online subscribers) * Dilated heart leads to systolic (+ diastolic) dysfunction * All 4 chambers are affected but the Left Ventricle is more affected than the Right Ventricle. * Features include arrhythmias, emboli, mitral regurgitation * Absence of congenital, valvular or ischaemic heart disease SS Causes often considered separate entities * alcohol: may improve with thiamine * postpartum * hypertension S Other causes * inherited * previous MI * infections e.g. Coxsackie B, HIV, diphtheria, parasitic * endocrine e.g. Hyperthyroidism ¢ infiltrative e.g. Haemochromatosis, sarcoidosis * neuromuscular e.g. Duchenne muscular dystrophy * nutritional e.g. Kwashiorkor, pellagra, thiamine/selenium deficiency drugs e.g. Doxorubicin Copyrights @ PlabiKeys.com] ©Copyright www.plab1keys.com (Constantly updated for online subscribers) Inherited dilated cardiomyopathy * around a third of patients with DCM are thought to have a genetic predisposition * alarge number of heterogeneous defects have been identified * the majority of defects are inherited in an a although other patterns of inheritance are seen ant fashion Key 62 PUTA ACS Latere Cat A In Supraventricular tachycardia (Narrow-Complex) (SVT) 4 If the patient is haemodynamically stable > start with Valsalva manoeuvre and Carotid massage to stimulate the vagal tone (Parasympathetic which decreases the heart rate). - If still ill? > Give [Adenos | 6 mg IV bolus. - If no response? > give another Adenosine double dose (12 mg). - If still no response? > give another Adenosine double dose (12 mg). - Unsuccessful yet? > Cardioversion. 4 If the patient is Jlaaemodynamically Unstable| > start with Cardioversion. Copyrights @ Plab1Keys.com102 | © Copyright www.plabtkeys.com (Constantly updated for online subscribers) In Polymorphic Ventricular Tachycardia (Broad-Complex)| = (Torsade De Pointe)| > Give IV MgSO4 (Magnesium Sulphate) Ue - Start with B-Blockers (e.g. Metoprolol). - If Asthmatic patient > Calcium Channel Blockers. - If Associated Heart Failure > Digoxin. TA eu Lae Coah ec Li Leiee Give Amiodarone. Haemodynamically Unstable| — e.g. \ Hypotension (SBP < 90), \ Loss of Consciousness, Others: V HR > 150. \ Severe dizziness or syncope. V Ongoing chest pain. Copyrights @ Plab1Keys.com103 | Page [Cardiology] ©Copyright plab1keys.com (Constantly updated for online subscribers) V increasing SOB. — Immediate DC Cardioversion\. [Any arrhythmia in an unstable patient + DC Cardioversion] Key An elderly patient suddenly fell unconscious, he recovered completely within a few minutes, he remembers the event very well, he did not trip, he felt hot and flushed after the episodes but he did not feel dizzy or sweaty before the fall. The best Investigation > A2lead ECG Analysis and Causes of Falls. 1) Cardiac cause (e.g. Arrhythmia). 2) Postural (Orthostatic) Hypotension. 3) Hypoglycemia. 4) Seizure. Copyrights @ Plab1Keys.com