CARDIOLOGY

Crash revision

Omar K.
MRCP Ireland
ECG stress test
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Cardiac pharmacology

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Cardiac enz
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CX
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AF
• Acute AF (48h)
• If very ill or haemodynamically unstable: Emerg ency
cardioversion;
• if unavailable try

• 1_IV amiodarone.
• 2_Treat associated illnesses (eg MI, pneumonia).
• 3_Control ventricular rate:
• 1st-line verapamil (40–120mg/8h PO) or bisoprolol (2.5–
5.0mg/d PO). 2nd-line: digoxin
• or amiodarone.
• 4_Start full anticoagulation with LMWH
CHRONIC AF
• 55 YEARS IS THE CUTLINE

Young (rhythm control) Old (rate control)

SAF RaBCD

sotolol betablocker
Amiodarone Digoxine
Flecainide Rate control C.B

Add amiodarone (PRN)

AF & anticoag
• The CHA2DS2-VASc58 score quantifies risk of stroke and
may help in decision making.
Pacer maker (PACER)
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CRT

• Cardiac resynchronization therapy (CRT)

• improves the synchronization of cardiac contraction and
reduces mortality61 in people with symptomatic heart
failure who have an ejection fraction <35% and a QRS
duration >120ms.
• It involves biventricular pacing (both septal and lateral
walls of the LV) and if required also an atrial lead. It
• may be combined with a defibrillator.
HT (REO)
• Essential hypertension (primary, cause unknown). ~95% of
cases.
• Secondary hypertension ~5% of cases. Causes include:
• • Renal disease: The most common secondary cause. 75% are
from intrinsic renal disease: glomerulonephritis, polyarteritis
nodosa (PAN), systemic sclerosis, chronic pyelonephritis, or
polycystic kidneys. 25% are due to renovascular disease, most
• frequently atheromatous (elderly ,cigarette smokers, eg with
peripheral vascular disease) or rarely fi bromuscular
dysplasia (young ).
• • Endocrine disease: Cushing’s and Conn’s syndromes,
phaeochromocytoma, acromegaly, hyperparathyroidism. •
• Others: Coarctation , pregnancy , steroids, MAOI, ‘the Pill’.
Rheumatic fever (JR)
• Major criteria:

• Carditis: Tachycardia, murmurs (mitral or aortic regurgitation, Carey Coombs’

• murmur, p44), pericardial rub, CCF, cardiomegaly, conduction defects (45–70%).
• • Arthritis: A migratory, ‘flitting’ polyarthritis; usually aff ects larger joints (75%).
• • Subcutaneous nodules: Small, mobile, painless nodules on extensor surfaces of
• joints and spine (2–20%).
• • Erythema marginatum: (fi g 1) Geographical-type rash with red, raised edges and
• clear centre; occurs mainly on trunk, thighs and arms in 2–10% (p564).
• • Sydenham’s chorea (St Vitus’ dance): Occurs late in 10%. Unilateral or bilateral
• involuntary semi-purposeful movements. May be preceded by emotional lability
• and uncharacteristic behaviour.

• CASES
RF
• Minor criteria:
• • Fever
• • Raised ESR or CRP
• • Arthralgia (but not if arthritis is one of the major
criteria)
• • Prolonged PR interval (but not if carditis is major
criterion)
• • Previous rheumatic fever

• FEAR 0_o
mx
• 1_Bed rest until CRP normal for 2wks (may be 3 months).
• 2_Benzylpenicillin 0.6–1.2g IV stat, then penicillin V 250-500mg 4
times daily PO for 10 days (if allergic to penicillin, give
erythromycin or azithromycin for 10 days).
• 3_ Analgesia for carditis/arthritis: aspirin 100mg/kg/d PO in
divided doses (max 4–8g/d) for 2d, then 70mg/kg/d for 6wks.
Monitor salicylate level. Toxicity causes tinnitus, hyperventilation,
and metabolic acidosis. Alternative: NSAIDS (p548).
• If moderate-to-severe carditis is present (cardiomegaly, CCF, or 3rd-
degree heart block), add oral prednisolone to salicylate therapy.
• In case of heart failure, treatappropriately (p130)
• 4_• Immobilize joints in severe arthritis.
• 5_• Haloperidol (0.5mg/8h PO) or diazepam for the chorea
Prophy
• Secondary prophylaxis Penicillin V 250mg/12h PO.
Alternatives: sulfadiazine 1g daily (0.5g if <30kg) or
erythromycin 250mg twice daily (if penicillin allergic).
• Duration:
• If carditis+persistent valvular disease, continue at least
until age of 40 (sometimes lifelong).
• If carditis but no valvular disease, continue for 10 yrs. If
there is no carditis, 5 yrs prophylaxis (until age of 21) is
sufficient
Infective endocarditis (IE) Di
• Causes
• Strep viridans is common cause (>35%).
• Others: enterococci; Staph aureus/epidermidis; diphtheroids;
microaerophilic
• streps. Rarely: HACEK Gram –ve bacteria (Haemoph ilus–
Actinobacillus–Cardiobacterium–
• Eikenella–Kingella); Coxiella burnetii; Chlamydia. Fungi:
Candida; Aspergillus;
• Histoplasma. Other causes: SLE (Libman–Sacks
endocarditis); malignancy
Dx criteria
Immune phenomena

• Immune complex deposition: Vasculitis

• may affect any vessel. Microscopic haematuria is
common; glomerulonephritis and acute renal failure may
occur.

• Roth spots (boat-shaped retinal haemorrhage

• with pale centre; splinter haemorrhages (fig 2); Osler’s
nodes (painful pulp infarcts in f ngers or toes).
IEC tx
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CMP
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Acute pericarditis
• This is inflammation of the pericardium. It may be idiopathic
• or secondary to:
• • Viruses (Coxsackie, fl u, Epstein–Barr, mumps, varicella, HIV)
• • Bacteria (pneumonia, rheumatic fever, TB, staphs, streps, MAI
in HIV, p410)
• • Fungi
• • Myocardial infarction, Dressler’s (p712)
• • Drugs: procainamide, hydralazine, penicillin, cromolyn
sodium, isoniazid
• • Others: uraemia, rheumatoid arthritis, SLE, myxoedema,
trauma, surgery, malignancy
• (and antineoplastic agents), radiotherapy, sarcoidosis.
IHD MX
• Look for the interval between the event & reaching the H.

• if MI
• < 12 hrs >>>> PCI or thrombolysis
• > 12 hr >>>>> medical tx , then offer PCI later on .
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