Cardiology notes summarising all cardiac disorders required for clinical studies in medical school. Investigations and managements based on UK guidance.
Look at specialty section and content list for the summary contents of this file.
Interpreting ECGs
General Observations PR-Interval
- Details: Name; DOB; Time; Date - Normal: 120-200 ms (3-5 small squares)
- Calibration: 25 mm/s is usual configuration Prolonged PR Interval
- Extras: Previous ECG for comparison - 1o AV Block: PR >200 ms
Heart Rate - 2o AV Block Type 1: Elongates until dropped QRS
- Calculation: Calculation dependent on rhythm - 2o AV Block Type 2: Stable PR + Random QRS drop
- Regular: Squares between R-R and divide into 300 - Complete AV Block: No AV communication
- Irregular: Count complexes on strip and times by 6 Shortened PR Interval
Heart Rhythm - WPWS: PR <120 ms + ∆ waves
- Regular: Squares between R-R are always same QRS Interval
- Regular Irregular: Pattern of R-R width - Normal: 120 ms (3 small squares)
- Irregularly Irregular: No pattern in R-R width Shortened QRS Interval
Cardiac Axis - NCT: QRS <120 ms + HR >100
- Leads: Assess with lead I and Lead II - Cx: AF; Atrial Flutter
- Normal: Lead I +ve and Lead II +ve and aVF +ve Prolonged QRS Interval
- Left Dev: Lead I +ve and Lead II -ve and aVF -ve - BCT: QRS >120 ms + HR >100
- Right Dev: Lead I -ve and Lead II +ve and aVF +ve - Cx: WPWS; VT; RBBB; LBBB
- Extreme Right: Lead I -ve and Lead II ve and aVF -ve Myocardial Infarction
- NB: Up-Up Up-Down Down-Up Down-Down - STEMI: ST-elevation
P-Waves - NSTEMI: ST Depression; T-Wave inversion
- Saw-Tooth: Atrial Flutter
- Chaotic: Atrial Fibrillation
- AF Types: Paroxysmal; Persistent; Permanent
- Flat: No Atrial Activity
, Cardiac Axis
Right Ventricular Hypertrophy Left Ventricular Hypertrophy
Emphysema Previous Inferior MI
Hyperkalaemia Emphysema
Ventricular Arrythmia Hyperkalaemia
ASD (Ostium Primum)
WPWS (right accessory pathway)
Normal in children
COPD
Pulmonary embolism
Dextrocardia
WPWS (left accessory pathway)
,Acute Coronary Syndromes
Description
Formerly known as ischaemic heart disease, ACS encompasses a range of conditions associates with sudden, reduced
blood flow to the heart. This blockage can be sudden and occur in one instant or it may come and go over a period of
time. Most commonly conditions arise from the build-up of fatty deposits within the coronary arteries of the heart
leading to angina pectoris and MI. Male sex, increased age and family history are all unmodifiable risk factors.
Acute Chest Pain
Presenting with Acute Chest Pain
- Acute Management - Chest Pain referral criteria
o Meds: GTN + 300 mg crushed Aspirin o Current Pain: Emergency
o Oxygen: If SPO2 ≥94 % o Pain <12 hrs ago + ECG changes: Emergency
o Targets: SPO2 94-98 % 88-92 % if retainer o Pain 12-72 hrs: Same-day hospital assessment
o ECG: Perform ASAP; Normal ECG does not exclude o Pain >72 hrs ago: ECG and troponin to assess
Presenting with Stable Chest Pain
- NICE Criteria for diagnosis of Anginal Chest Pain - Criteria for diagnosis
o Location: Pain in Chest; Neck; Shoulder; Jaw; Arms o 3 Features: Typical Angina Chest Pain
o Activity: Pain triggered by exertion o 2 Features: Atypical Angina Chest Pain
o Relief: Pain Relieved by rest or GTN in 5 mins o 0-1 Features: Non-Anginal Chest Pain
Angina Pectoris
Presentation Investigations
- Key: Dyspnoea; Sweating; Chest tightness - General
- Women: N&V; Abdominal pain; Stabbing chest pain o ECG: Slight ST elevation; Flat or Inverted T waves
- Pain: Central-left sided; May radiate to jaw or arm o Location: Use ECG to determine artery affected
Classifications o Troponin: May be elevated but usually ↔
- Stable: Exertional and relieved by 2-5 mins of rest - If stable angina cannot be excluded clinically
- Unstable: Occurs at rest and lasts >10 mins o 1L: CT Coronary Angiogram
- Prinzmetal: Usually overnight ST elevation clusters o 2L: Non-invasive functional imaging
- Decubitus: Precipitated by lying flat o 3L: Invasive Coronary Angiography
Causes Management
- Common: Atheroma - Stable Angina
- Rare: Anaemia; Tachyarrhythmias; Vasculitis o Risk mx: Aspirin and Statin for all patients
- Prinzmetal: Vasospasms; Cocaine; Triptans o 1L: β-B OR CCB + PRN GTN
- Precipitants: Cold air; Emotional distress; Smoking o 2L: β-B + Dihydropyridine CCB + PRN GTN
- NB: Angina more likely in DM; NSAIDs ↑ MI risk o 3L: Ivabradine OR Nicorandil OR Ranolazine
Risks o 4L: β-B + CCB + NO3- OR Ivabradine OR Nicorandil
- Non-Modifiable: Male sex; ↑ Age; FHx o NB: Only offer 3rd drug if patient awaiting for an
- Modifiable: Smoking; DM; HTN; HCL; Obesity assessment for a PCI or CABG
,Myocardial Infarction
Presentation Risk Factors
- Key: Anxiety; Profuse sweating; Dyspnoea; ↑ HR - Risks: HDL; HCL; HTN; Smoking; Obesity; FHx; DM
- Pain: Central crushing pain that radiates down left - Vasospasms: Rare; Cocaine; Emotion (Takotsubo)
- General: Feeling of heart-burn; Low grade fever Management
- Women: Epigastric sx; Palpitations; Jaw pain - Type: Elucidate type (see below for STEMI vs NSTEMI)
- NB: Silent MI more likely in elderly and DM - Post-MI: DABS ± MRA (Aldosterone Antagonist)
Investigations - DABS: DAPT + ACEi + Beta Blocker + Statin
- ECG Findings - MRA: 3-14 d post-MI if HF sx or LVF
o STEMI: ST Elevation - Diet: Mediterranean; ↓ Fats;
o NSTEMI: ST Depression; T-Wave inversion - NB: Do not recommend oily fish / Omega 3 diet
- Cardiac Enzymes - Driving: Driving ban for 6 wks post-MI
o Troponin: ↑ 3-12 hrs; ↑↑ 24-48 hrs; ↓ 5-14 d - Sex: Avoid for 4 wks post-MI
o CK-MB: ↑ 3-12 hrs; ↑↑ 24 hrs; ↓ 48-72 hr Complications
o Myoglobin: ↑ 1-4 hrs; Sensitive but not specific - Cc DREAD: Death; Rupture; oEdema; Arrythmia;
- General Aneurysm; Dressler’s syndrome
o CXR: Flash oedema; Batwing sign; Kerley B lines - Other: LV free wall rupture; Thrombus Stroke
o Bloods: FBC; U+E; Glucose; Lipid screen - PCI: Aneurysm Cardiac Tamponade
ST-Elevation Myocardial Infarction (STEMI)
Management
- General Management - 2L: Fibrinolysis within 12 hrs on risk assessment
o Oxygen: Avoid if SPO2 >93 % o Fondaparinux: Given before fibrinolysis
o Analgesia: Morphine preferred; Fentanyl if CI o NB: Prevents clot from increasing in size
o Anti-emetic: Metoclopramide; Prochlorperazine o Alteplase: Given via infusion
o GTN: If >180/110 GTN before tPA o Tenecteplase: Single bolus dose
o NB: GTN CI if SBP <90 (GTN mainly effects SBP) o Reteplase: Two bolus doses 30 mins apart
o Aspirin: PO 300 mg; 100-150 mg / d after - Check ECG 60-90 mins after fibrinolysis
- 1L: PCI within 120 minutes of admission o PCI: Up to 12 hours after fibrinolysis if failed
o DAPT: Clopidogrel if on anti-coag; Prasugrel if o Coronary Angiogram: If ECG still shows STEMI
not on an anti-coag; Either given with aspirin o NB: Do not repeat fibrinolysis
o Clopidogrel: Given with aspirin if on anticoag. - Diabetic Patients
o Unstable: If ↓ BP post-PCI offer CABG o DIGAMI: Switch to insulin IVI; Target BG <11 .0
o NB: Preferably wait >10 d post-MI (↑ survival) o NB: Do not routinely offer
Non-ST-Elevation Myocardial Infarction (NSTEMI)
Management
- General Management - Assess using GRACE Score
o Oxygen: Avoid if SPO2 >93 % o Low risk: Predicted 6-month mortality ≤3 %
o BATMAN: BBs; Aspirin; Ticagrelor; Morphine; o High risk: Predicted 6-month mortality >3 %
Anticoagulant; Nitrates - Low Risk GRACE Score AND Stable
o Analgesia: Morphine preferred; Fentanyl if CI o Conservative: DAPT + Fondaparinux
o Anti-emetic: Metoclopramide; Prochlorperazine o PCI: Consider if ischaemic after fibrinolysis
o GTN: If >180/110 GTN - High Risk GRACE Score OR Unstable
o NB: GTN CI if SBP <90 (GTN mainly effects SBP) o Angiography: Assess for PCI indication
o Aspirin: PO 300 mg; 100-150 mg / d after o Prasugrel: Offer if indicated for PCI
o Fondaparinux: Given with aspirin; CI if bleed risk - Assessments
o Fibrinolysis: Not performed as NSTEMI is usually o LV Function: Assess function before discharge
due to stenosis as opposed to clot so no benefit o Unstable Angina: Assess for unstable angina
I aVR V1 V4
Left Circumflex Artery
Lateral Septal Anterior
II aVL V2 V5
Right Coronary Artery
Inferior Lateral Septal Lateral
III aVF V3 V6
Left Anterior Descending Artery
Inferior Inferior Anterior Lateral
, Arrythmias
Supraventricular Tachycardia (SVT)
Description Investigations
- Umbrella term: Refers to non-ventricular tachycardia - ECG: Narrow Complex Tachy. (QRS <120; HR >100)
Presentation Management
- Features: Palpitations; Dyspnoea; Chest pain; LOC - Acute Management of AVNRT
Causes o 1L: Valsalva manoeuvre; Carotid massage
- Drugs: Digoxin OD; Theophylline; Caffeine o 2LA: IV Adenosine 61218 mg
- Inherited: Wolf-Parkinson White (WPW) Syndrome o 2LB: IV Verapamil is alternative in asthma
Classifications o NB: Meds only useful if heart structurally ↔
- Regular Atrial: Sinus Tachy.; Atrial Tachy.; SNRT o 3L: Electrical Cardioversion (see shocks below)
- Irregular Atrial: AF; Atrial Flutter; MAT - Prevention of Episodes
- Regular AV: AVRT; AVNRT; Automatic Junctional Tachy. o β-Blockers: Metoprolol; Atenolol; Propranolol
- NB: AVNRT commonest SVT in structurally ↔ hearts o Radio-Frequency Ablation: Catheter ablation
Atrial Fibrillation
Presentation Management
- Features: Palpitations; Dyspnoea; Chest Pain - Rate Control
- Exam: Irregularly irregular Pulse o β-Blockers: Bisoprolol; Atenolol
Types o Nondihydropyridine CCB: Diltiazem; Verapamil
- First detected: First occurrence of AF o Digoxin: No longer 1L; Preferred in HF
- Paroxysmal: Spontaneously starts and stops - Rhythm Control
- NB: 50 % become permanent AF in 10 yrs o Anticoagulation: ≥3 wks before induction
- Persistent: Continuous AF longer than 7 d o No Cardiac disease: Flecainide; Amiodarone
- Permanent: Persists despite cardioversion o Cardiac disease: Amiodarone
Causes - Cardioversion
- Common: HTN; Coronary Heart Disease; HF; Sepsis o 1L: DC Shock (emergency if unstable)
- Uncommon: Valvular heart disease (mitral valve) o 2L: Pharmacological conversion
Investigations o Maintenance: Sotalol; Amiodarone; Flecainide
- ECG: Absent P-waves - Catheter Ablation
o Procedure: Radiofrequency + Cryotherapy
o Anticoag.: >4 wks prior + during procedure
o Cc: Tamponade; Stroke; Pulm. valve stenosis
- Anticoagulation for stroke risk
o Assessment: CHA2DS2-VASc Score (see below)
o Anticoagulation: DOACs first line
o Echo: Perform if CHA2DS2-VASc is not high
o Risk assessment: HASBLED; ORBIT (preferred)
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