Cardiology

Aortic Stenosis

Asymptomatic and valvular gradient <40mmHg

Review regularly

Asymptomatic but gradient >40mmHg

Plus feature of left ventricular dysfunction - consider surgery

Symptomatic

Valve replacement

Ballon valvuloplasty limited to patients with critical AS not fit for replacement

Heart Failure

RHF = Pleural effusion

LHF = Pulmonary oedema

1st line: ACEi + beta-blockers + Diuretics

2nd line: Add Spironolactone or Hydralazine + isorbide dinitrate

3rd line: Digoxine or cardiac resin therapy

Acute heart failure: Loop diuretic (furosemide), morphine, GTN, O2, sit up - POD MAN

NSTEMI

MONA + fondaparinux 2.5mg SC

High risk - GPIIb/IIIa infusion refer for PCI in 72h (in 24h if score >140)

Low risk - Discharge if repeat trop -ve, start secondary prevention drugs, arrange stress test and angio

STEMI

Urgent PCI if available - fibrinolysis of PCI not available and transfer to PCI centre ASAP

CABG

Left main stem disease

Triple vessel disease

Unsucessful = angioplasty

Complications of MI

Cardiac arrest - VF

Heart block - if SAN involved

Right ventricular failure - low CO and raised JVP

Tamponade

Low CO, pulses paradoxes, raised JVP, muffled heart sounds

Papillary muscle rupture

New murmur after MI - consider valve replacement

Ventricular septal defect

Pansystolic murmur, raised JVP, heart failure

Dressler's syndrome

1-3 weeks post MI, recurrent pericarditis, pleural effusions, fever, anaemia and raised ESR - treat with NSAIDs

Left Ventricular Aneurysm

4-6 weeks post MI, persistent ST elevation, LVF, recurrent VT, systemic embolism - anticoagulant and remove

Mitral regurgitation

Asymptomatic - monitor

CHA2DS2 VASc

1 - Consider anticoagulant if male; 2 or more - Anticoag

If fast AF - beta blocker

Diuretic - improve symptoms

Abx if IE

Replace valve if a) Acute, b)Evidence of LV remodelling

Heart muscle disease

Myocarditis

  • idiopathic, infection or drugs
  • flu-like prodrome followed by chest pain, fever, palpitations, tachypnoea
  • ECG looks like MI with AV block
  • +ve trop
  • Supportive treatment
  • Pt recover or get crashing HF

HOCM

  • FH of sudden death young
  • Jerky pulse, double apex beat, ESM
  • Can present with death (VT) or syncope
  • Don't exercise test
  • Beta-blocker,calcium channel blocker, anticoagulant, Septal myomectopy or transplant

Pericarditis

  • Secondary to infection
  • Pericardial Rub
  • Chest pain relieved on sitting forward
  • NSAIDs + colchicine

Cardiomyopathies

Dilated

Restrictive

Stiff heart - diastolic days; amyloidosis, haemochromotosis, sarcoidosis, scleroderma, feature of RVF (raised JVP, hepatomegaly, oedema ascites, S4) - Treat cause

Most common (flabby dilated heart - get systolic dys); alcohol, postpartum, viral, autoimmune associated; heart failure signs, S3; bed rest, digoxin, anticoags, ACEi, pacing - transplant