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Cardiology 6th March 2025, Alexander Wallace, Milena NossenLearningOutcomes ❏ Chest pain: Differential diagnosis (ACS, PE, pericarditis, etc.) ❏ Hypertension: Diagnosis, management, complications ❏ Heart failure: Types, symptoms, treatment strategies ❏ Arrhythmias: ECG interpretation, management of common arrhythmias (AF, VT) ❏ Ischemic heart disease: Risk factors, management, and prevention ❏ Cardiac auscultation: Key murmurs and their significanceQuestion 1 A 55 year old caucasian man reports to the GP Answers: for his regular blood pressure monitoring appointment. In clinic his BP is 151/97. His A Add indapamide past medical history includes HTN, T2DM, and CKD. B Add spironolactone His current medications include atorvastatin 80mg OD, ramipril 10mg OD, amlodipine C Switch ramipril to telmisartan 10mg OD and dapagliflozin 10mg OD. D Add atenolol His most recent blood tests are: E Add doxazosin Bicarbonate 26 (22-29), Na 136 (135-145), K 3.8 (3.5-5.0), urea 6 (2.0-7.0), creatinine 135 (55-120). What is the most appropriate next step? Hypertension A 55 year old caucasian man reports to the GP for his regular blood pressure monitoring appointment. Answers: In clinic his BP is 151/97. His past medical history A Add indapamide includes HTN, T2DM, and CKD. B Add spironolactone His current medications include atorvastatin 80mg OD, ramipril 10mg OD, amlodipine 10mg OD and dapagliflozin 10mg OD. C Switch ramipril to telmisartan D Add atenolol His most recent blood tests are: E Add doxazosin Bicarbonate 26 (22-29), Na 136 (135-145), K 3.8 (3.5-5.0), urea 6 (2.0-7.0), Creatinine 135 (55-120). What is the most appropriate next step?>140/90 = offer ABPM >180/120 = urgent referral ABPM >135/85 = treatQuestion 2 62 year old female presents to the ED with a 7 hour history of chest pain and clamminess. She has been experiencing worsening crescendo chest pain over the past month. She has no medical or drug history. NKDA. She receives morphine, aspirin 300mg and GTN spray. Vitals: HR 114, BP 142/85, sats 97%, temp 37.5, RR 18. Her ECG demonstrates inferior ST elevation and troponin is raised (300), the decision is taken to undergo PPCI. What medication is most important to give immediately prior to PCI? A Prasugrel B Dalteparin C Ramipril D Bisoprolol E AlteplaseACS 62 year old female presents to the ED with a 7 hour history of chest pain and clamminess. She has been experiencing worsening crescendo chest pain over the past month. She has no medical or drug history. She receives morphine, aspirin 300mg and GTN spray. Vitals: HR 114, BP 142/85, sats 97%, temp 37.5, RR 18. Her ECG demonstrates inferior ST elevation and troponin is raised (300), the decision is taken to undergo PPCI. What medication is most important to give immediately prior to PCI? A Prasugrel B Dalteparin C Ramipril D Bisoprolol E AlteplaseSTEMI: dual-antiplatelet prior to PCI NSTEMI = GRACE score (6 month %mortality), if >3% then offer PPCI otherwise conservative managementSecondaryprevention-ACS Dual antiplatelet therapy: aspirin (lifelong) and a second antiplatelet, usually prasugrel or ticagrelor (12 months) ACEi - helps with cardiac remodelling Beta-blocker Statin Aldosterone antagonist Don’t forget cardiac rehabilitation and lifestyle adviceMI complications Cardiac arrest, cardiogenic shock, chronic heart failure Arrhythmias: VF, bradycardia AV block (inferior MI) Pericarditis: within 48 hours of event Dressler’s syndrome: 2-6 weeks post event, pericarditis pain, fever, pleuritic chest pain. NSAID Left ventricular aneurysm: left ventricular failure, thrombus can form (stroke) Ventricular rupture: 1-2 weeks post MI, presents with acute heart failure secondary to cardiac tamponade (raised JVP, hypotension and quiet heart sounds), urgent pericardiocentesis VSD: 1 week post event. Acute heart failure and pan-systolic murmur. TTE. surgery Mitral regurg: due to papillary muscle rupture (pan-systolic murmur)Question 3 A 43 year old female presents to ED with a sharp chest pain worse on breathing in. This suddenly came on 3 hours ago. Her Well’s score is 4.5. She has no past medical history apart from a laparoscopic cholecystectomy 3 weeks ago. She undergoes a CTPA and a diagnosis of a pulmonary embolism (PE) is made. Vitals Vitals: HR 114, BP 142/85, sats 97%, temp 37.5, RR 22. Which is the most appropriate treatment for her PE? A dalteparin for 3 months B warfarin for 3 months C apixaban for 3 months D inferior vena cava filter E apixaban for 6 months Pulmonaryembolism A 43 year old female presents to ED with a sharp chest pain worse on breathing in. This suddenly came on 3 hours ago. Her Well’s criteria for PE is 4.5. She has no past medical history apart from a laparoscopic cholecystectomy 3 weeks ago. She undergoes a CTPA and a diagnosis of a pulmonary embolism (PE) is made. Vitals Vitals: HR 114, BP 142/85, sats 97%, temp 37.5, RR 22. Which is the most appropriate treatment for her PE? A dalteparin for 6 months B warfarin for 3 months C apixaban for 3 months D inferior vena cava filter E apixaban for 6 monthsPulmonaryEmbolism (PE) 2-level Well’s score for PE: - >4 = likely - 4 or less = unlikelyPE treatment Anticoagulation: DOAC (apixaban, rivaroxaban) Provoked (3 months of anticoagulation) Unprovoked (6 months of anticoagulation) Cancer (3-6 months of anticoagulation) Circulatory failure e.g. hemodynamically: thrombolysis (alteplase) Recurrent: inferior vena cava filterDVT Treatment same as PE: Anticoagulant (DOAC) for 3 or 6 months depending on if it was provoked or not.Question 4 A 65-year-old man with a history of hypertension and dyslipidaemia presents to his GP with chest pain occurring during exertion and relieved by rest. He has been diagnosed with stable angina pectoris. His current medications include atenolol 50 mg once daily, aspirin 75 mg once daily, and simvastatin 40 mg at night. Despite adherence to his medications, he continues to experience episodes of chest pain when walking uphill. On examination, his blood pressure is 130/80 mmHg, and his heart rate is 68 bpm. He has already been optimised on his beta-blocker therapy. What is the most appropriate next step in his management? A. Increase the dose of atenolol to 100 mg once daily B. Add a calcium channel blocker to his current therapy C. Refer for elective percutaneous coronary intervention (PCI) D. Add a long-acting nitrate to his current therapy E. Refer for coronary artery bypass grafting (CABG)Question 4 A 65-year-old man with a history of hypertension and dyslipidaemia presents to his GP with chest pain occurring during exertion and relieved by rest. He has been diagnosed with stable angina pectoris. His current medications include atenolol 50 mg once daily, aspirin 75 mg once daily, and simvastatin 40 mg at night. Despite adherence to his medications, he continues to experience episodes of chest pain when walking uphill. On examination, his blood pressure is 130/80 mmHg, and his heart rate is 68 bpm. He has already been optimised on his beta-blocker therapy. What is the most appropriate next step in his management? A. Increase the dose of atenolol to 100 mg once daily B. Add a calcium channel blocker to his current therapy C. Refer for elective percutaneous coronary intervention (PCI) D. Add a long-acting nitrate to his current therapy E. Refer for coronary artery bypass grafting (CABG)StableAnginaManagement of stable angina Lifestyle modifications Drug treatment 1. All patients: aspirin + statin + SL GTN spray 2. Beta-blocker OR calcium channel blocker (amlodipine/diltiazem) 3. Increase to maximum tolerated dose 4. Both BB and CCB 5. Alternatively: long-acting nitrate, ivabradine, nicorandil, ranolazine Surgery - if drug treatment optimised - CABG or PCIQuestion 5 A 74 year old male is seen in the heart failuret is the most appropriate clinic with worsening symptoms of cough, orthopnoea and paroxysmal nocturnal dyspnoea.edication to next be started to reduce the risk of mortality? Meds: bisoprolol, candesartan, simvastatin NKDA A furosemide B ramipril Examination: bibasal crackles, ejection systC eplerenone murmur, bilateral pitting oedema to mid shins D dapagliflozin Vitals: HR 91, BP 142/85, sats 97%, temp 37.E ivabradine 15. Echo EF 35%, NT-proBNP 500Heart failure A 74 year old male is seen in the heart failure clinic with worsening symptoms of cough,What is the most appropriate medication orthopnoea and paroxysmal nocturnal dyspto next be started to reduce the risk of Meds: bisoprolol, candesartan, simvastatinrtality? NKDA A furosemide Examination: bibasal crackles, ejection B ramipril murmur, bilateral pitting oedema to mid C eplerenone Vitals: HR 91, BP 142/85, sats 97%, tempD dapagliflozin 15. E ivabradine Echo EF 35%, NT-proBNP 500Question 6 A 68 year old female has a diagnosis of What is this patient’s stage on the New heart failure is experiencing marked York Heart Failure Classification? limitation in physical activity; she is comfortable at rest but less than ordinary A I activity causes fatigue and dyspnea. Her symptoms are causing a significant B II C III limitation in activity. D IV E VHeart failure A 68 year old female has a diagnosis of What is this patient’s stage on the New heart failure is experiencing marked York Heart Failure Classification limitation in physical activity; she is comfortable at rest but less than ordinary activity causes fatigue and A I dyspnea. Her symptoms are causing a B II significant limitation in activity. C III D IV E VHeart failure New York Heart Failure Classification 1-4 Diagnosis: Don’t forget basics: ECG, CXR, respiratory function, bloods NT-proBNP - not specific - 400-2000 = 6 week TTE - >2000 = 2 week TTE TTE - Preserved EF: >50% - Diastolic dysfunction - Non-preserved EF: <50% - Systolic dysfunctionHeart failure management Loop diuretics for congestive symptoms Reduced EF: - ACEi & beta blocker - Aldosterone antagonist (spironolactone, elepeneone) - SGLT2i (dapagliflozin) - Ivabradine, sacubitril-valsartan, hydralazine with a nitrate, digoxin - Cardiac resecronisation therapy (triple chamber, biventricular), ICD, valvular surgery Preserved EF: - manage co-morbidities e.g. HTN, AF Others: annual flu jab and one off pneumococcal vaccine Acute leftventricular failure Causes: over fluid load in CKD, sepsis, MI CXR: pleural effusion, Kerley B lines, cardiomegaly, dilated upper vessels, alveolar oedema Management: - sit up, IV furosemide, oxygen (CPAP) - fluid monitor (in & out), stop IV fluids - specialists: ○ Inotropic agent (^cardiac output): dobutamine, milrinone ○ Vasopressor (vasoconstriction = ^BP): norepinephrine, epinephrine, vasopressin (ADH) Keep ACEi/BB, only stop BB if <50bpm, heart block or shockQuestion 7 What does this ECG show? A. Left bundle branch block B. Right bundle branch block C. Left anterior fascicular block D. Bifascicular block E. Trifascicular blockQuestion 7 What does this ECG show? A. Left bundle branch block B. Right bundle branch block M C. Left anterior fascicular block D. Bifascicular block E. Trifascicular block NECG interpretationECG interpretation-step-by-step 1. Rate a. 300 divided by number of large squares between b. Number of QRS complexes on rhythm strip times 6 2. Axis a. I and aVF positive - normal b. I negative, aVF positive - RAD - ‘’reaching’’ c. I positive, aVF negative - LAD - ‘’leaving’’ 3. Rhythm a. Regular or irregular? b. Regular irregular or irregular irregular? 4. P-waves a. Each followed by QRS complex? b. Morphology 5. PR interval a. Normal 0.12-0.2s (3-5 small squares) b. Prolonged - first degree heart block c. Shortened - Wolff Parkinson White d. PR depression in pericarditisECG interpretation-step-by-step 1. Rate a. 300 divided by number of large squares between b. Number of QRS complexes on rhythm strip times 6 2. Axis a. I and aVF positive - normal b. I negative, aVF positive - RAD - ‘’reaching’’ c. I positive, aVF negative - LAD - ‘’leaving’’ 3. Rhythm a. Regular or irregular? LAD b. Regular irregular or irregular irregular? A. Can be normal! A. Normal in children/ 4. P-waves thin adults B. LVH. Each followed B. QRSRVHmplex? C. Left anteriorlogy C. Left posterior 5. PR interval hea.bloNormal 0.12-0.2s (3-5 small squares) D. Inferior MI D. Anterolateral MI E. Hyperkalaemiaged - firE. degSeptal defectck F. VTc. Shortened - WoF. ParResp distress, PE d. PR depression in pericarditisECG interpretation-step-by-step 1. Rate a. 300 divided by number of large squares between b. Number of QRS complexes on rhythm strip times 6 2. Axis a. I and aVF positive - normal b. I negative, aVF positive - RAD - ‘’reaching’’ c. I positive, aVF negative - LAD - ‘’leaving’’ 3. Rhythm a. Regular or irregular? b. Regular irregular or irregular irregular? 4. P-waves a. Each followed by QRS complex? b. Morphology 5. PR interval a. Normal 0.12-0.2s (3-5 small squares) b. Prolonged - first degree heart block c. Shortened - Wolff Parkinson White d. PR depression in pericarditisECG interpretation-step-by-step 1. Rate a. 300 divided by number of large squares between b. Number of QRS complexes on rhythm strip times 6 2. Axis a. I and aVF positive - normal b. I negative, aVF positive - RAD - ‘’reaching’’ c. I positive, aVF negative - LAD - ‘’leaving’’ 3. Rhythm a. Regular or irregular? b. Regular irregular or irregular irregular? 4. P-waves a. Each followed by QRS complex? b. Morphology 5. PR interval a. Normal 0.12-0.2s (3-5 small squares) b. Prolonged - first degree heart block c. Shortened - Wolff Parkinson White d. PR depression in pericarditisECG interpretation-step-by-step 1. Rate a. 300 divided by number of large squares between b. Number of QRS complexes on rhythm strip times 6 2. Axis a. I and aVF positive - normal b. I negative, aVF positive - RAD - ‘’reaching’’ c. I positive, aVF negative - LAD - ‘’leaving’’ 3. Rhythm a. Regular or irregular? b. Regular irregular or irregular irregular? 4. P-waves a. Each followed by QRS complex? b. Morphology 5. PR interval a. Normal 0.12-0.2s (3-5 small squares) b. Prolonged - first degree heart block c. Shortened - Wolff Parkinson White d. PR depression in pericarditisECG interpretation-step-by-step 6. QRS morphology a. narrow(normal) <0.12s b. Broad >0.12s - BBB! c. Tall complexes suggest hypertrophy 7. QT interval d. QTc >0.45s is prolonged 8. ST segment e. Elevation -> infarction f. Depression -> ischaemia 9. T waves g. flattened/inverted ->ischaemia, hypokalaemia, often normal h. Peaked -> hyperkalaemia 10. U waves i. Should not be present! j. Best seen in V2/3 k. -> hypokalaemiaECG interpretation-step-by-step 6. QRS morphology a. narrow(normal) <0.12s b. Broad >0.12s - BBB! c. Tall complexes suggest hypertrophy 7. QT interval d. QTc >0.45s is prolonged 8. ST segment Causes. Elevation -> infarction f. Depression -> ischaemia 9. T wavesgs B. g.poflattened/inverted ->ischaemia, C. Hypohypokalaemia, often normal D. h.ypoPeaked -> hyperkalaemia 10. U waveslial (long QT syndrome, i.ugShould ot be present! F. IHD, myocarditis j. Best seen in V2/3 k. -> hypokalaemiaECG interpretation-step-by-step 6. QRS morphology a. narrow(normal) <0.12s b. Broad >0.12s - BBB! c. Tall complexes suggest hypertrophy 7. QT interval d. QTc >0.45s is prolonged 8. ST segment e. Elevation -> infarction f. Depression -> ischaemia 9. T waves g. flattened/inverted ->ischaemia, hypokalaemia, often normal h. Peaked -> hyperkalaemia 10. U waves i. Should not be present! j. Best seen in V2/3 k. -> hypokalaemiaECG interpretation-step-by-step 6. QRS morphology a. narrow(normal) <0.12s b. Broad >0.12s - BBB! c. Tall complexes suggest hypertrophy 7. QT interval d. QTc >0.45s is prolonged 8. ST segment e. Elevation -> infarction f. Depression -> ischaemia 9. T waves g. flattened/inverted ->ischaemia, hypokalaemia, often normal h. Peaked -> hyperkalaemia 10. U waves i. Should not be present! j. Best seen in V2/3 k. -> hypokalaemiaECG interpretation-step-by-step 6. QRS morphology a. narrow(normal) <0.12s b. Broad >0.12s - BBB! c. Tall complexes suggest hypertrophy 7. QT interval d. QTc >0.45s is prolonged 8. ST segment e. Elevation -> infarction f. Depression -> ischaemia 9. T waves g. flattened/inverted ->ischaemia, hypokalaemia, often normal h. Peaked -> hyperkalaemia 10. U waves i. Should not be present! j. Best seen in V2/3 k. -> hypokalaemiaBundle Branch Blocks Left Bundle Branch Block Right Bundle Branch Block WiLLiaM MaRRoW (MaRRoN) Causes: Causes: A. RVH A. Aortic stenosis B. cor pulmonale C. Pulmonary embolus B. Ischaemic heart disease D. Ischaemic heart disease C. Hypertension E. Rheumatic heart disease D. Dilated cardiomyopathy F. Congenital heart disease (e.g. atrial septal E. Anterior MI defect) G. Myocarditis F. Hyperkalaemia G. Digoxin toxicity H. CardiomyopathyMore blocks… Bifascicular Block Trifascicular Block RBBB + either left anterior fascicular Bifascicular Block + 3rd degree heart block (LAD) OR left posterior block fascicular block (RAD) However often also used with 1st/ 2nd degree heart blockQuestion 8 A 65-year-old man presents to the emergency department complaining of palpitations and dizziness that began two hours ago. He has a history of hypertension and chronic obstructive pulmonary disease. On examination, his pulse is irregular at ~135 beats per minute, and his blood pressure is 130/80 mmHg. Laboratory investigations, including electrolytes, are within normal limits (sodium 140 mmol/L, potassium 4.2 mmol/L, creatinine 80 µmol/L). His ECG is shown on the right: What is the most likely underlying arrhythmia causing his presentation? A. Ventricular Tachycardia B. Atrial Fibrillation C. Torsades de Pointes D. Atrial Flutter E. Supraventricular TachycardiaQuestion 8 A 65-year-old man presents to the emergency department complaining of palpitations and dizziness that began two hours ago. He has a history of hypertension and chronic obstructive pulmonary disease. On examination, his pulse is irregular at ~135 beats per minute, and his blood pressure is 130/80 mmHg. Laboratory investigations, including electrolytes, are within normal limits (sodium 140 mmol/L, potassium 4.2 mmol/L, creatinine 80 µmol/L). His ECG is shown on the right: What is the most likely underlying arrhythmia causing his presentation? A. Ventricular tachycardia B. Atrial Fibrillation C. Torsades de pointes D. Atrial flutter E. Supraventricular TachycardiaAtrial FibrillationAtrial Fibrillation Causes: ‘’Disorganised atrial electrical activity and contraction’’ ★ Ischaemic heart disease ★ Hypertension ★ Valvular heart disease (esp. mitral stenosis / regurgitation) ★ Acute infections ★ Electrolyte disturbance (hypokalaemia, hypomagnesaemia) ★ Thyrotoxicosis ★ Drugs (e.g. sympathomimetics) ★ Alcohol ★ Pulmonary embolism ★ Pericardial disease ★ Acid-base disturbance ★ Pre-excitation syndromes ★ Cardiomyopathies: dilated, hypertrophic. ★ PhaeochromocytomaFeatures ECG Symptoms irregular irregular rhythm , no P waves Palpitations, dyspnoea, chest pain Irregular pulse Fibrillatory waves – can mimic P waves. Fine Embolic event <0.5mm or coarse >0.5mm Ventricular rate variable - commonly 110-160 but can be ‘slow AF’ QRS complex - <120ms but can be narrow if e.g pre-existing BBBManagement Classification Management Rate control – for majority of cases recommended by NICE 1st line BB or CB (rate limiting) First episode – initial detection of AF regardless of 2nd line combination therapy of 2 of BB, CB (diltiazem) or symptoms or duration digoxin Rhythm control – indicated if co-existent HF, new onset AF or Recurrent AF – More than 2 episodes of AF reversible cause -> drug therapy (flecainide) - contraindicated in ischaemic/ Paroxysmal AF – Self terminating episode < 7 days structural heart disease Other drugs could include BB, dronedarone, amiodarone Persistent AF – Not self-terminating, duration > 7 days ->cardioversion - offer if >48 hours or if haemodynamically unstable greatly increase risk of emboli causing the stroke – hence <48 Long-standing persistent AF – > 1 year of symptoms or 3 weeks anticoagulation Permanent (Accepted) AF – Duration > 1 yr in which Risk of stroke rhythm control interventions are not pursued or are CHA2DS2 –VASc score – offer anticoagulation if 2 or more unsuccessful –consider for men if 1 - 1st line DOAC , 2nd warfarin Also consider bleeding risk – ORBIT scoreManagement Classification Management Rate control – for majority of cases recommended by NICE 1st line BB or CB (rate limiting) First episode – initial detection of AF regardless of 2nd line combination therapy of 2 of BB, CB (diltiazem) or symptoms or duration digoxin Rhythm control – indicated if co-existent HF, new onset AF or Recurrent AF – More than 2 episodes of AF reversible cause -> drug therapy (flecainide) - contraindicated in ischaemic/ Paroxysmal AF – Self terminating episode < 7 days structural heart disease Other drugs could include BB, dronedarone, amiodarone Persistent AF – Not self-terminating, duration > 7 days ->cardioversion - offer if >48 hours or if haemodynamically unstable greatly increase risk of emboli causing the stroke – hence <48 Long-standing persistent AF – > 1 year of symptoms or 3 weeks anticoagulation Permanent (Accepted) AF – Duration > 1 yr in which Risk of stroke rhythm control interventions are not pursued or are CHA2DS2 –VASc score – offer anticoagulation if 2 or more unsuccessful –consider for men if 1 - 1st line DOAC , 2nd warfarin Also consider bleeding risk – ORBIT scoreManagement Classification Management Rate control – for majority of cases recommended by NICE 1st line BB or CB (rate limiting) First episode – initial detection of AF regardless of 2nd line combination therapy of 2 of BB, CB (diltiazem) or symptoms or duration digoxin Rhythm control – indicated if co-existent HF, new onset AF or Recurrent AF – More than 2 episodes of AF reversible cause -> drug therapy (flecainide) - contraindicated in ischaemic/ Paroxysmal AF – Self terminating episode < 7 days structural heart disease Other drugs could include BB, dronedarone, amiodarone Persistent AF – Not self-terminating, duration > 7 days ->cardioversion - offer if >48 hours or if haemodynamically unstable greatly increase risk of emboli causing the stroke – hence <48 Long-standing persistent AF – > 1 year of symptoms or 3 weeks anticoagulation Permanent (Accepted) AF – Duration > 1 yr in which Risk of stroke rhythm control interventions are not pursued or are CHA2DS2 –VASc score – offer anticoagulation if 2 or more unsuccessful –consider for men if 1 - 1st line DOAC , 2nd warfarin Also consider bleeding risk – ORBIT scoreQuestion 9 A 65-year-old man presents to the emergency department with palpitations and dizziness. He has a history of ischaemic heart disease and a previous myocardial infarction. On examination, his pulse is 150 beats per minute and irregular, and his blood pressure is 110/70 mmHg. He is haemodynamically stable with no signs of chest pain or heart failure. An electrocardiogram (ECG) is shown on the right side: What is the most appropriate initial management? A. Administer intravenous amiodarone B. Administer intravenous verapamil C. Perform immediate synchronised DC cardioversion D. Administer intravenous adenosine E. Start beta-blocker therapyQuestion 9 A 65-year-old man presents to the emergency department with palpitations and dizziness. He has a history of ischaemic heart disease and a previous myocardial infarction. On examination, his pulse is 150 beats per minute and irregular, and his blood pressure is 110/70 mmHg. He is haemodynamically stable with no signs of chest pain or heart failure. An electrocardiogram (ECG) is shown on the right side: What is the most appropriate initial management? A. Administer intravenous amiodarone B. Administer intravenous verapamil C. Perform immediate synchronised DC cardioversion D. Administer intravenous adenosine E. Start beta-blocker therapyVentricularTachycardiaVentricularTachycardia Broad-complex tachycardia, originating from Causes the ventricles Ischaemic Heart Disease monomorphic VT - single focus origin point Dilated Cardiomyopathy Hypertrophic Cardiomyopathy Chaga’s DiseaseMore ECGs…Clinical Significance Impairs cardiac output -> hypotension, collapse, acute cardiac failure -> decreased myocardial perfusion -> degeneration to VFClassifications 1. Clinical Presentation a. Haemodynamically stable b. Haemodynamically unstable 2. Duration a. Sustained: >30s b. Non-sustained: 3 or more episodes, self-terminating <30s 3. Morphology a. Monomorphic VT b. Polymorphic VT c. Torsades De Pointes (Polymorphic with QT prolongation) d. Right Ventricular Outflow Tract Tachycardia e. Fascicular Tachycardia f. Bidirectional VT g. Ventricular Flutter h. Ventricular Fibrillation (VF)Management Unstable - systolic <90, chest pain, heart Stable failure Drug therapy with antiarrhythmics -> immediate DC cardioversion -> amiodarone -> lidocaine, procainamide -> DO NOT use verapamilAlgorithmQuestion 10 A 42-year-old woman presents to her GP with progressive shortness of breath and fatigue over the past few months. She also reports episodes of palpitations and mild haemoptysis. Her past medical history is significant for rheumatic fever during childhood. On examination, she has a low-pitched, mid-diastolic rumbling murmur heard best at the apex with the bell of the stethoscope when she is lying in the left lateral position. Which of the following is the most likely diagnosis? A. Mitral regurgitation B. Aortic stenosis C. Tricuspid stenosis D. Mitral stenosis E. Atrial septal defectQuestion 10 A 42-year-old woman presents to her GP with progressive shortness of breath and fatigue over the past few months. She also reports episodes of palpitations and mild haemoptysis. Her past medical history is significant for rheumatic fever during childhood. On examination, she has a low-pitched, mid-diastolic rumbling murmur heard best at the apex with the bell of the stethoscope when she is lying in the left lateral position. Which of the following is the most likely diagnosis? A. Mitral regurgitation B. Aortic stenosis C. Tricuspid stenosis D. Mitral stenosis E. Atrial septal defectMurmursCardiacauscultationAorticmurmurs Aortic Stenosis Aortic Regurgitation Features: chest pain, dyspnoea, syncope Features: Murmur: early diastolic murmur, high-pitched and Murmur: ejection systolic, radiation to carotids. 'blowing' in character) louder on expiration increased by handgrip manoeouvre If severe: narrow pulse pressure, slow rising pulse, Collapsing pulse, wide pulse pressure, Quincke’ sign soft/absent S2, S4, thrill, left ventricular hypertrophy (nailbed pulsation), De Musset’s sign (head bobbing) Causes: degenerative calcification, bicuspid valve, post-rheumatic, HOCM Causes: Valve disease - rheumatic fever, calcification, Management: connective tissue diseases Asymptomatic - observe -> if asymptomatic but valvular gradient >40mmHg Aortic root disease - spondyloarthropathies, HTN, syphilis, Marfan’s, Ehler-Danlos syndrome and left ventricular dysfunction - consider replacement Management: replace if severe AR and either Symptomatic - valve replacement -> SAVI if young, symptomatic or LV systolic dysfunction TAVI if high riskAorticmurmurs Aortic Stenosis Aortic Regurgitation Features: dyspnoea, orthopnoea, palpitations, chest Features: chest pain, dyspnoea, syncope pain Murmur: ejection systolic, radiation to carotids. louder on expiration Murmur: early diastolic murmur, high-pitched and If severe: narrow pulse pressure, slow rising pulse, 'blowing' in character). Loud S2 soft/absent S2, S4, thrill, left ventricular hypertrophy increased by handgrip manoeouvre Collapsing pulse, wide pulse pressure, Quincke’ sign Causes: degenerative calcification, bicuspid valve, (nailbed pulsation), De Musset’s sign (head bobbing) post-rheumatic, HOCM Causes: Management: Valve disease - rheumatic fever, calcification, Asymptomatic - observe connective tissue diseases -> if asymptomatic but valvular gradient >40mmHg Aortic root disease - spondyloarthropathies, HTN, syphilis, Marfan’s, Ehler-Danlos syndrome and left ventricular dysfunction - consider replacement Management: replace if severe AR and either Symptomatic - valve replacement -> SAVI if young, TAVI if high risk symptomatic or LV systolic dysfunctionMitral murmurs Mitral Stenosis Mitral Regurgitation ->increased pressure in left atrium, pulmonary -> less efficient cardiac output vasculature, right heart -> myocardial thickening, leading to heart failure Features: dyspnoea, haemoptysis Murmur: mid-late diastolic murmur, loud S1, Features: asymptomatic, fatigue, SOB, oedema opening snap. ‘Rumbling, low-pitch’ Murmur: ‘blowing’, pansystolic, radiating to axilla. Low volume pulse, malar flush Quiet S1, split S2 Atrial fibrillation (due to left atrial enlargement) Causes: rheumatic fever!! Causes: post-MI, mitral valve prolapse, infective endocarditis, rheumatic fever, congenital Management: If AF - warfarin for moderate/severe MS DOAC might be suitable for mild MS Management: increase cardiac output e.g. Asymptomatic - regular echo nitrates, diuretics, inotropes, balloon pump Symptomatic - mitral balloon valvotomy or valve If HF - ACEi, BB, spironolactone replacement Severe - surgical repair > replacementMitral murmurs Mitral Stenosis Mitral Regurgitation ->increased pressure in left atrium, pulmonary -> less efficient cardiac output vasculature, right heart -> myocardial thickening, leading to heart failure Features: dyspnoea, haemoptysis Murmur: mid-late diastolic murmur, loud S1, Features: asymptomatic, fatigue, SOB, oedema opening snap. ‘Rumbling, low-pitch’ Murmur: ‘blowing’, pansystolic, radiating to axilla. Low volume pulse, malar flush Quiet S1, split S2 Atrial fibrillation (due to left atrial enlargement) Causes: rheumatic fever!! Causes: post-MI, mitral valve prolapse, infective endocarditis, rheumatic fever, congenital Management: If AF - warfarin for moderate/severe MS DOAC might be suitable for mild MS Management: increase cardiac output e.g. Asymptomatic - regular echo nitrates, diuretics, inotropes, balloon pump Symptomatic - mitral balloon valvotomy or valve If HF - ACEi, BB, spironolactone replacement Severe - surgical repair > replacement SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteachingReferences Heart failure, ACS, PE, DVT, hypertension - Passmedicine Stable angina Nice Guidelines - stable angina —----- ECG interpretation https://oxfordmedicaleducation.com/ecgs/ecg-interpretati on/ Life in the fast lane —------ AF: Atrial Fibrillation • LITFL • ECG Library Diagnosis Passmedicine - Atrial Fibrillation Nice Guidelines - Atrial Fibrillation —--- VT https://litfl.com/ventricular-tachycardia-monomorphic-ecg- library/ Passmedicine - Ventricular tachycardia Resus guidelines adult tachycardia —----------- Murmurs Passmedicine - AS,AR, MS,MR, murmurs