Holter Monitor = 24 hour ECG tape
Cardiac stress test = ECG + blood pressure monitoring on treadmill. Can be combined with echocardiography or nuclear imaging (thalidomide) to assess blood flow to the heart.
CT coronary calcium – identifies extent of calcified plaque in coronary arteries. Use in patients with 10-29% risk of having Coronary Artery Disease
TIMI identifies % risk at 14 days of all-cause mortality, new/recurrent MI or severe recurrent ischaemia
GRACE scoring identifies probability of Death or Death/MI in hospital or at 6 months.
CHAD2S2Vasc is probability of a patient with AF having a stroke within a year.
Framingham Risk Score estimates the 10-year cardiovascular risk
Wells Clinical Score indicates likelihood of DVT or PE at that time
Classify hypertension into stages. Stage 1 = Clinic BP >= 140/90 and subsequent ABPM average 135/85. Stage 2 = +10 for clinic BP and +15 for ABPM. Severe = clinc systolic >=180 or diastolic >= 110.
FIRST STEP = offer ambulatory/home blood pressure monitoring.
LIFESTYLE INTERVENTIONS:- diet & exercise, alcohol, caffeine, salt intake, smoking, local initiatives, relaxation therapies
Diuretic – use chlorthalidone or indapamide.
STEP 4:- DIURETIC TREATMENT FIRST:- if K+ <4.5 use spironolactone 25mg OD. If K+>4.5 add higher dose thiazide. If not tolerated, contraindicated or ineffective add alpha or beta blocker.
FIRST – ABC approach and rule out acute coronary syndrome (troponin and ECG)
Risk of CAD – age, sex and type of angina.
Rule out other causes of chest pain
Verapamil CAN’T be given with a beta blocker. Risk of heart failure. Diltiazem used with caution (risk of AV block) Must give amlodipine/felodipine.
Low risk = initial conservative management
Low risk (>1.5-3.0%) = 300mg clopidorel and continue for 12 months) THEN if recurrent ischaemia coronary angiography
Intermediate and above = 300mg clopidogrel and continue for 12 months. Add a glycoprotein inhibitor (tirofiban or eptifabatide). Bvalirudin as an alternative to combination heparin therapy. Coronary angiography (with PCI if indicated) within 96 hours. Discuss with cardiologist then do either CABG or PCI or conservative if indicated.
Dressler’s syndrome:- occurs 2-6 weeks post MI. Autoimmune reaction against antigenic proteins. Fever, pleuritic pain, pericardial effusion and raised ESR. Treated with NSAIDs.
Aneurysm = persistent ST elevation and left ventricular failure
Free wall rupture:- seen 1-2 weeks afterwards present with acte heart failure and cardiac tamponade.
VSD = acute heart failure with pan systolic murmur.
Rate control = beta-blockers, calcium channel blockers, digoxin
Rhythm control = amiodarone if structural heart disease, fleicanide if no structural heart disease
Anticoagulation & cardioversion: if onset >48 hours anticoagulate 3 weeks prior to cardioversion and 4 weeks after.
No specific treatment for RBBB
LBBB may be caused my ischaemia or aortic stenosis. Treat underlying cause.
Due to accessory pathway – bundle of kent
Treatment = cardioversion. Electrical if haemodynamically unstable. Pharmacological if stable. Radiofrequency catheter ablation.
Smoking, alcohol, sexual activity, flying, driving
Yearly influenza vaccines & one-off pneumococcal vaccine
Ivabradine used ONLY in NYHA II-IV, HR >75, with LV ejection fraction <35%. MUST have been stable on aldosterone antagonist, ACEi & beta-blockers
DRUG Treatment = diuretics (frusemide), amlodipine, anticoagulants (for sinus rhythym with history of thromboembolism, left ventricular aneurysm, intracardiac thrombus), aspirin 75-150mg daily, POSITIVE inotropic agents (dobutamine/milrinone), amiodarone (ONLY AFTER SPECIALIST CONSULTATION)
Other interventions = implantable defibrillator, valve replacements
Monitoring = Medication reviews, cardiac function reviews, monitor U&Es, serum creatinine, & eGFR. Consider monitoring BNP in hospital or if drug treatment is difficult. Serum digoxin 8-12 hours post-last dose if toxicity suspected.
Haemodynamic changes = venous stasis, mitral stenosis/varicose veins
Endothelial injury/dysfunction = hypertension, chronic inflammation, bacteria
Hypercoagulability = hyperviscosity, antithrombin III deficiency, nephrotic syndrome, trauma, cancer, pregnancy, race, age, smoker, obesity
MSK = calf muscle tear/strain, haematoma, sprain or rupture of tendon, fracture
CVS = superficial thrombophlebitis, Post-thrombotic syndrome, Venous obstruction, Vasculitis, Heart Failure
Other = Ruptured Baker’s cyst, cellulitis, dependent oedema, lymphatic obstruction, septic arthritis, cirrhosis, nephrotic syndrome
Refer for same-day assessment if pregnant/in the puerperium/IV drug user/no d-dimer test availableIf LIKELY to have DVT (Wells Score of 2 or more) refer for same-day assessment/management
If UNLIKELY to have DVT take blood sample for D-dimer testing
Admission criteria = patient at enhanced risk of bleeding, IV drug abuser, dementia, PE, bilateral DVT, pregnant
Engage in regular walking exercise, elevate leg when sitting, extended travel should be delayed for 2 weeks after starting treatment
CTEPH occurs in 0.5-5% of people. Emboli replaced over months or years by fibrous tissue
Well Score = <2: low risk (3.4%). 2-6: moderate risk (27.8%). >6 points: high risk (78.4%)
*Unless d-dimer test result could be available immediately
D-dimer testing, CXR & ECG to exclude alternatives, ABG, CTPA, VQ scan, lower limb compression venous ultrasoundECHOCARDIOGRAPHY IF HYPOTENSIVE, absence of RHF excludes PE
Relatively common – 5% of all A&E admissions are pericarditis.
Diffuse st segment elevation “saddle changes”
Two types of recurring: incessant = once NSAIDs withdrawn symptoms return. Intermittent = long gaps between symptoms
Staph aureus – 30% of IE associated with prosthetic valves. Most common cause overall. HIGH MORTALITY.
Viridans = 50-60% of subacute IE cases
Group D strep = subacute and 3rd most common cause
Intermedius = 15% of all cases of IE
A,C & G strep = high mortality
Group B strep = acute disease, high mortality. Occurs in pregnancy and elderly.
Blood cultures = consistent with infective endocarditis e.g. STREP VIRIDANS and the HACEK group. Persistent staphu aureus/epidemidis bacteraemia. Positive serology for coxielle burnetti, bartonella or chlamydia psittaci. Positive molecular assays for gene targets
Evidence of endocardial involvement = positive echocardiogram or new valvular regurgitations.
MANAGEMENT = ADMIT. Empirical therapy = amoxicillin and gentamicin/vancomycin and gentamicin and rifampicin (if prostetic valve/penicillin allergic)
Staph = flucloxacillinStreptococci = benzylpenicillin
Prosthetic valve = benzylpenicillin + gentimicin
ALWAYS FOLLOW LOCAL GUIDELINES