Cardio - Collated from sources such as Passmed, Zero to Finals, AMBOSS, BMJ best practice PDF

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Collated from sources such as Passmed, Zero to Finals, AMBOSS, BMJ best practice...

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CARDIOVASCULAR DISEASE Normal ECG variants In an athlete:  Sinus brady  1st degree HB  Wenckebach phenomenon  T wave inversion in V1, aVR and III In children:  Partial RBB

Reference ranges:  PR = 120-200 ms – 3-5 small squares  QRS = 160/100 Severe = >180/110 If clinic reading is >140/90 take another reading and record whichever’s lowest  If BP is >140/90  Ambulatory blood pressure monitoring to confirm dx. Assess for end organ damage. Assess CV risk  If >180/120  same day specialist assessment if there’s papilloedema, confusion, chest pain, HF signs, AKI. If not assess for end organ damage - start anti-HTN if present, if not repeat reading in 7 days Ix for target end organ damage:  Urine dipstick for haematuria  Urinary ACR  HbA1c  U+E’s, creatinine, eGFR (CKD)  Fundoscopy  ECG (any LV hypertrophy?) Ix for CV risk:  Total Cholesterol and HDL cholesterol  QRISK tool - >10% Mx  If men)  Commonest cause of palpitations in pt’s with structurally normal hearts  Causes: o Unknown (#1) o Toxins e.g. caffeine, alcohol, recreational drugs o Drugs e.g. Theophylline, Salbutamol, amphetamines o Stress o Thyroid disorders Px  Palpitations  SOB  Anginal chest pain if there’s underlying CAD  Syncope or presyncope  Polyuria (due to release of ANP causing diuresis) ECG signs -

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Sinus tachy ~140-280 bpm Narrow QRS 150 bpm)

AF  Most common sustained arrhythmia - occurs in 1-2% of the population, usually in >75 yrs Paroxysmal AF = stops spontaneously within 7 days, usually within 48hrs. But can recur Persistent AF = continuous for >7 days (so unlikely to self-terminate) Long standing AF = >1 year Permanent AF = fails to terminate with cardioversion, or does terminate but relapses 100bpm (usually 160-180) Rate = 96 bpm Rhythm = irregularly irregular Down sloping ST depression and flattened/inverted T waves seen in V6, II, III and aVF suggests Digoxin effect

Complications  STROKE  VTE  Heart failure Mx of AF Was the onset within the last 48 hrs?  YES  Urgent admission for electrical cardioversion  NO… 

Conservative: o Pt education on AF - written information, discuss causes o Stroke awareness o Support groups o Advise on how it will impact life:

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DRIVING: can drive once cause has been identified and controlled for 4 weeks for normal drivers or 3 months for lorry/bus drivers Need to stop driving if the arrhythmia causes incapacity (disqualified if type 2 driver) Don’t need to tell DVLA

  Medical: o Rate control with Bisoprolol or Non-dihydropyridine CCB (usually diltiazem)  Digoxin if sedentary with non-paroxysmal AF  Rhythm control with Amiodarone is only really used for AF + HF pt’s o Assess stroke Vs bleeding risk

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Anticoagulate men with a score >1, women with a score >2 DOAC e.g. Apixaban, Dabigatran  “aban” = Xa inhibitor  Dabigatran = Direct thrombin inhibiter  **UNLESS THERE’S VALVULAR HEART DISEASE** Warfarin o Refer for cardioversion if tx doesn’t work Surgical: o Left atrial ablation o Pace and ablate

Follow-up  Within 1 week after starting tx  Annually

Atrial Flutter *Narrow complex tachy at 150bpm  Atrial Flutter until proven otherwise ECG signs - Narrow complex tachy (150 bpm) - Saw tooth pattern best seen in II, III, aVF - Loss of isoelectric baseline

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Mx Conservative: o Pt education o Talk about reducing risk factors Medical: o Acute - DC cardioversion (70-120J) o Long term - Ablation of the accessory pathway o Assess stroke risk using CHADSVASC and Anticoagulate

Broad complex Tachycardia *Broad QRS is VT until proven otherwise Main DDx for BCT = VT, SVT with aberrancy, VF, Torsade de pointes Sounds like VT  No prior hx of tachy  Structural cardiac disease, pacemaker or ICD  Unstable pt  Very broad QRS - >140ms (normal is 140) - QRS are similar morphology - Concordance (all chest leads are +’ve, or all -‘ve)

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VF Needs a precipitating stimulus e.g. ischaemia, electrolyte abnormalities Ventricles suddenly start contracting at rates up to 500 bpm This is too fast for them to contract in a synchronised way, so there’s loss of CO which will become fatal - (asystole) ECG changes in VF Chaotic, irregular deflections of varying amplitude No P waves, QRS complexes or T waves

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Amplitude decreases with duration (as myocardial stores are depleted, and it gets closer to asystole)

Causes of VT or VF  Ischaemia  Cardiomyopathies  Structural heart disease  Post-infarction  Iatrogenic o Digoxin o TCA’s  Electrolyte disturbance o Hypokalaemia o Hypocalcaemia o Hypomagnesaemia  Infection e.g. myocarditis Mx - SYSTEM 1. ABCDE  CHECK FOR ADVERSE SIGNS o YES  ALS - GET HELP (2222)  1) Chest compressions & DC cardiovert if shockable (VT or VF) (non-shockable - PEA, asystole)  Up to 3 shocks  120-150J 1st  Then 150-360J  2) IV Adrenaline 1mg (1 in 10,000) repeated every 3-5 mins as needed  2) IV Amiodarone 300mg over 20-60 mins  3) IV Amiodarone 900mg over 24 hrs o Non-shockable = chest compressions + adrenaline only o NO  1) IV Amiodarone 300mg over 20-60 mins  2) IV Amiodarone 900mg over 24 hrs  Once corrected, look for cause  Consider maintenance anti-arrhythmic’s  If there’s recurrent episodes of VT consider surgical input - ICD **For VF you can use NON-SYNCHRONISED DC cardioversion - because there’s no R wave to trigger defibrillation

Torsades de Pointes (TdP) 

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Aka Polymorphic VT o Need VT + QT prolongation (>11 small squares)  (start of Q wave to end of T wave) “Twisting peaks” - QRS complexes have varying amplitudes and durations Can be self-terminating, but often px with haemodynamic instability and collapse Can degenerate into VF (esp if HR is >220 bpm)

Causes  #1 = myocardial ischaemia  ALL THE HYPO’s  o Hypokalaemia o Hypomagnesaemia o Hypocalcaemia o Hypothermia  ^ICP  Congenital long QT

Drugs causing Long QT  Anti-psychotics  Type IA and IC antiarrhythmic’s  Sotalol  Amiodarone  TCA’s  Antihistamines  Macrolides  Antidepressants e.g. Citalopram, Venlafaxine

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Drugs Myocardial disease e.g. cardiomyopathy Complete HB TdP 2o to Hypokalaemia Initially: Rate = ~100 bpm Sinus rhythm U wave + T wave inversion indicating Hypokalaemia Developing into TdP

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Mx of TdP Rule out congenital long QT o Congenital long QT Mx: High-dose B-blockers for LQT1, Na channel blockers for LQT3 Consider other causes o Check U+E’s for electrolyte abnormalities o Look at drug chart for iatrogenic causes Otherwise: IV Mg

CHEST PAIN DDx: Cardiac disorder Dissecting Thoracic aneurysm Definition: >1.5x normal diameter - >5cm for ascending aorta - >4cm for descending Ix: CT with contrast Mx: Conservative e.g. reduce risk factors, monitoring - if small. Surveillance: - Annually if 4.5cm Surgical - if rapidly expanding, symptomatic at all, any aortic valve pathology of CT disorder hx, or ‘large’: >5.5cm - Growing >0.5cm/yr Surgical options: - Open repair for ascending or arch - Endovascular repair (TEVAR) for descending Pericarditis Causes: - Infection (coxsackie #1, usually

Signs Pt profile: 65 y/o male smoker with HTN & atherosclerosis  HTN  BP discrepancy between arms  Unequal pulses  New diastolic murmur (AR)  Neurological deficits

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Pericardial friction rub Evidence of pericardial effusion e.g. faint heart sounds

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Sudden tearing pain if ruptured --> back, inter-scapular Chest ‘pressure’ if not Back pain Signs of compression e.g. dysphagia, SVC syndrome, hoarseness (recurrent laryngeal nerve compression), horners (sympathetic trunk compression) BUT can be asymptomatic & incidental finding

Sharp, pleuritic, retrosternal pain --> L shoulder or arm, into abdomen

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viral, can be bacterial e.g. TB or fungal) Trauma Post-MI (Dressler’s syndrome) Post-cardiac surgery Post-radiotherapy SLE Rheumatic fever Iatrogenic (cyclosporin, penicillin)

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If it’s constrictive - fluid overload signs, kussmaul sign Saddle ST elevation & PR depression with reciprocal changes Sinus tachy

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Better when sitting forward Worse when lying down, on inspiration, when coughing or swallowing Fever Cough Arthralgia

Mx: Often self-limiting - NSAID’s + PPI - Colchicine 500mcg for 3 months for prevention

Cardiac tamponade Definition: pericardial effusion which ends up compressing heart Causes:  Bloody = trauma, aortic dissection, cardiac surgery, ventricular free wall rupture post-MI  Serous = idiopathic, acute pericarditis, malignancy, autoimmune disorders, HF, renal failure

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Pulsus paradoxus Beck’s triad: Hypotension JVP distension Muffled heart sounds Low voltage QRS Sinus tachy Possibly electrical alternans (QRS voltages vary)

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Sharp, sternal pain SOB Compressive sx e.g. Dysphagia, cough, hoarseness

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^JVP S3 Gallop Inspiratory crackles Wheeze

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Tachycardia

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Ankle swelling Orthopnoea Fatigue Severe breathlessness Cough Palpitations Breathlessness Syncope or pre-syncope

Ix: Echo Mx: ABCDE  Pericardiocentesis or surgery to drain fluid  Fluid resus +/- inotropes e.g. dobutamine  Identify underlying cause Heart failure

Arrhythmia

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Non-cardiac DDx o MSK Rib fracture Costochondritis o GI Pancreatitis PUD

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GORD Oesophageal rupture Cholecystitis o Psychosomatic o Respiratory problems e.g. PE Pneumothorax Asthma Lung collapse CAP

Investigations  Hx - assess if they need admitting  Examination  Bloods - FBC, U+E, TFT’s, LFT’s, CRP, lipids, BM, troponin  ECG  CXR

CVD = any condition that affects the heart or blood vessels  Caused by thrombosis, or atherosclerosis  NHS Health check is used to identify people at high risk of CVD o 40-74 y/o are invited every 5 yrs for a health check involving (basically health MOT): - CVD risk assessment with QRISK3 tool (variables are shown) -

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Assessing alcohol consumption and physical activity Cholesterol BMI Dementia check for 65-74 y/o DM screening CKD screening Mx of QRISK3 results 10% - (Conservative +) Medical: o Atorvastatin 20mg OD (evening) *If CVD develops - increase to 80mg OD (2o prevention dose)

Not for use if >85 y.o Not for people who already have CVD, CKD or T1DM Calculates a 10-year estimated risk

Starting Statins:  CI in pregnancy  LFT’s before starting, at 3 months and 12 months  Initial review after 4 weeks - check compliance, SE’s etc *Then review every 6-12 months  Side effects: o GI - nausea, vomiting, diarrhoea, abdo pain o Headache o Itching o **Muscle pain - Statins can cause RHABDOMYOLYSIS - tell pt they have to see Dr if they develop sudden muscle pain (esp with simvastatin + clarithromycin) o Can interact with grape-fruit juice

Angina = pain in the chest, neck, shoulders, jaw or arms caused by insufficient blood supply to the myocardium

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Causes #1 = CAD Valvular disease HCOM HTN

To classify as ‘stable’ angina, the pain needs to be:  On exertion or emotional stress  Last 10 minutes  Relieved by rest and GTN spray 

Atypical angina has extra sx e.g. o GI pain o Breathlessness o Nausea

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Prinzmetal’s angina is pain at rest caused by coronary artery spasm o Women > men o ST elevation during pain

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Investigations 12-lead ECG o May be normal o Evidence of ischaemia e.g. Pathological Q waves LBBB T wave flattening, elevation or inversion Mx Conservative: o Pt education o Discuss possible triggers e.g. exertion, stress, big meals, cold o Lifestyle advice to manage cardiovascular RF o DRIVING: For normal drivers - don’t need to tell DVLA, can drive if there’s sx control (STOP if sx are at rest or with emotion) For T2 drivers - must tell DVLA, licence may be taken away but might be permitted later if sx free for 6 wks

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Should always check with insurer that they’re still covered Medical: o GTN for rapid sx relief during activities *Can take 2nd dose after 5 mins if pain hasn’t subsided  If it’s still not gone after a further 5 mins  Call 999 o B-blocker or dihydropyridine CCB (nifedipine, amlodipine) 2nd line:  Long-acting nitrate (isosorbide mononitrate)  Nicorandil (vasodilator) 10mg BD o CI if using with Sildenafil  Ivabradine (funny current (If) inhibitor) 5mg BD or 2.5 mg BD if >75 o NOT if resting HR is 20 mins o “silent ACS” = no chest pain - seen in DM or elderly pt’s Nausea Sweating Dizziness Palpitations Investigations Bloods: FBC, U+E, LFT’s, CRP, Glucose, lipids, Mg o Keep checking electrolytes regularly Troponin at baseline, repeat at 6hrs and again at 12 hrs o T & I are the most sensitive ECG (8% = high risk  coronary angiography...