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Domain – Cardiovascular health (guiding topics)
Cardiac Arrhythmias
Identification and Management
- Atrial Fibrillation (AF)
- History and Symptoms: Palpitations, shortness of breath, fatigue, dizziness.
- Examination: Irregularly irregular pulse.
- ECG: Absence of P waves, irregularly irregular R-R intervals.
- Management:
- Rate control: Beta-blockers, calcium channel blockers, digoxin.
- Rhythm control: Antiarrhythmics (e.g., amiodarone), electrical cardioversion.
- Anticoagulation: Use CHADS-VASc2 and HAS-BLED to assess the need for anticoagulation.
- Atrial Flutter
- History and Symptoms: Similar to AF.
- Examination: Rapid regular pulse.
- ECG: Sawtooth pattern of flutter waves, typically 2:1 or 3:1 block.
- Management:
- Rate control: Similar to AF.
- Rhythm control: Antiarrhythmics, electrical cardioversion.
- Anticoagulation: As per AF guidelines.
- Supraventricular Tachycardia (SVT)
- History and Symptoms: Sudden onset palpitations, dizziness, chest pain.
- Examination: Rapid regular pulse.
- ECG: Narrow complex tachycardia.
- Management:
- Vagal maneuvers: Carotid sinus massage, Valsalva maneuver.
- Pharmacological: Adenosine, beta-blockers, calcium channel blockers.
- Electrical cardioversion if unstable.
- Ventricular Fibrillation (VF)
- History and Symptoms: Sudden cardiac arrest.
- Examination: Unresponsive, no pulse.
- ECG: Chaotic, irregular electrical activity.
- Management: Immediate defibrillation, advanced cardiac life support (ACLS).
- Atrial and Ventricular Ectopics
- History and Symptoms: Palpitations, skipped beats.
- Examination: Irregular pulse.
- ECG: Premature beats (PACs, PVCs).
- Management: Reassurance if asymptomatic; beta-blockers if symptomatic.
- Heart Blocks/Conduction Disease
- First-Degree AV Block: Prolonged PR interval; typically benign, monitor.
- Second-Degree AV Block (Mobitz I and II):
- Mobitz I (Wenckebach): Progressive PR interval prolongation until a beat is dropped; usually benign.
- Mobitz II: Sudden dropped beats without PR prolongation; higher risk, may require pacemaker.
- Third-Degree AV Block (Complete Heart Block): No association between P waves and QRS complexes; requires pacemaker.
Valvular Heart Disease
- Mitral Stenosis
- Primary Aetiology: Rheumatic fever is the most common cause, often with a latent period of 20-40 years between the initial infection and symptom onset.
- Age Group: Typically presents in adults aged 30-50 years.
- Symptoms:
- Exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, palpitations, hemoptysis.
- Type of Murmur:
- Diastolic murmur best heard at the apex with the patient in the left lateral decubitus position.
- Classical Clinical Signs:
- Opening snap followed by a low-pitched, rumbling diastolic murmur.
- Signs of pulmonary hypertension: elevated jugular venous pressure (JVP), peripheral edema, hepatomegaly.
- Atrial fibrillation is common due to left atrial enlargement.
- Mitral Regurgitation
- Primary Aetiologies: Mitral valve prolapse (MVP), rheumatic heart disease, infective endocarditis, ischemic heart disease, degenerative changes.
- Age Group: MVP is common in younger adults; degenerative causes more common in the elderly.
- Symptoms:
- Dyspnea, fatigue, palpitations, orthopnea, and heart failure symptoms if severe.
- Type of Murmur:
- Holosystolic (pansystolic) murmur best heard at the apex, radiating to the axilla.
- Classical Clinical Signs:
- Displaced and hyperdynamic apical impulse.
- S3 heart sound if heart failure develops.
- Possible signs of left atrial enlargement and pulmonary congestion.
- Aortic Stenosis
- Primary Aetiologies: Age-related degenerative calcification, bicuspid aortic valve, rheumatic heart disease.
- Age Group:
- Degenerative calcification typically presents in the elderly (>65 years).
- Bicuspid aortic valve can present earlier, often between ages 40-60.
- Symptoms:
- Exertional dyspnea, angina, syncope, heart failure symptoms.
- Type of Murmur:
- Systolic ejection murmur best heard at the right upper sternal border, radiating to the carotids.
- Classical Clinical Signs:
- Slow-rising and diminished carotid pulse (pulsus parvus et tardus).
- Narrow pulse pressure.
- S4 heart sound due to left ventricular hypertrophy.
- Delayed peak of the systolic murmur (“late-peaking” murmur) indicating severe stenosis.
- Rheumatic Fever and Rheumatic Heart Disease
- Aetiology: Caused by an immune response to group A Streptococcus infection (e.g., strep throat or scarlet fever).
- Age Group: Typically affects children and adolescents (ages 5-15) but can have long-term effects leading to rheumatic heart disease in adults.
- Symptoms of Rheumatic Fever:
- Migratory arthritis, carditis, Sydenham chorea, erythema marginatum, subcutaneous nodules.
- Carditis in Rheumatic Fever: Pancarditis affecting the endocardium, myocardium, and pericardium.
- Valvular Involvement: Most commonly affects the mitral valve (leading to mitral stenosis or regurgitation), followed by the aortic valve.
- Type of Murmur: Depending on the affected valve: diastolic murmur for mitral stenosis, holosystolic murmur for mitral regurgitation, systolic ejection murmur for aortic stenosis.
- Classical Clinical Signs:
- Jones criteria for diagnosis: major (carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules) and minor criteria (fever, arthralgia, elevated acute phase reactants, prolonged PR interval).
- Chronic rheumatic heart disease may present with signs of heart failure, arrhythmias, and the respective murmurs of affected valves.
- Management of Valvular Heart Diseases
- Mitral Stenosis:
- Medical: Diuretics for symptom relief, anticoagulation if AF present, beta-blockers or calcium channel blockers for rate control.
- Procedural: Percutaneous mitral balloon valvotomy, surgical mitral valve replacement if severe.
- Mitral Regurgitation:
- Medical: ACE inhibitors, beta-blockers, diuretics for heart failure symptoms.
- Surgical: Mitral valve repair or replacement if severe and symptomatic.
- Aortic Stenosis:
- Medical: Limited role; focus on managing comorbid conditions like hypertension.
- Surgical: Aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI) if severe and symptomatic.
- Rheumatic Heart Disease:
- Primary prevention: Antibiotic treatment of streptococcal infections.
- Secondary prevention: Long-term antibiotic prophylaxis to prevent recurrence.
- Medical: Management of heart failure symptoms, anticoagulation if AF present.
- Surgical: Valve repair or replacement if severe valvular damage occurs.
Ischaemic Heart Disease (IHD)
Prevention and Treatment
- Risk Factor Management:
- Lifestyle Changes: Smoking cessation, diet, exercise.
- Medical Management: Statins, antihypertensives, antidiabetic medications.
- Risk Estimation Tools:
- Absolute Cardiovascular Risk Calculator: To estimate the 5-year risk of cardiovascular events.
- CHADS-VASc2: To assess stroke risk in AF patients.
- HAS-BLED: To assess bleeding risk in AF patients on anticoagulation.
- Management of Chest Pain:
- Acute Coronary Syndrome: Immediate ECG, troponins, and urgent referral to hospital.
- Pericarditis: Chest pain relieved by sitting forward, ECG changes (diffuse ST elevation), NSAIDs or colchicine.
- Myocarditis: Similar presentation to ACS, often requires cardiac MRI for diagnosis.
- Endocarditis: Fever, new murmur, positive blood cultures, antibiotics, and possible surgical intervention.
Shortness of Breath
Cardiac Causes
- Heart Failure:
- History and Symptoms: Dyspnea, orthopnea, PND, edema.
- Examination: Elevated JVP, crackles, peripheral edema.
- Management: Diuretics, ACE inhibitors, beta-blockers, lifestyle modifications.
- Cardiomyopathies:
- History and Symptoms: Dyspnea, fatigue, palpitations.
- Examination: Variable findings depending on type.
- Management: Tailored to the specific type (dilated, hypertrophic, restrictive).
- Arrhythmias:
- History and Symptoms: Palpitations, syncope, shortness of breath.
- Examination and ECG: Identify specific arrhythmia for targeted treatment.
Vascular Pathologies
Diagnosis and Management
- Aneurysms:
- Thoracic and Abdominal: Pulsatile mass, back pain, imaging (ultrasound, CT).
- Management: Monitoring vs. surgical repair based on size and symptoms.
- Peripheral Vascular Disease:
- Arterial Insufficiency: Claudication, diminished pulses, ABI testing.
- Varicose Veins: Visible veins, aching, compression stockings, surgery if severe.
- Chronic Skin Ulcers: Assessment and tailored management (compression for venous ulcers, revascularization for arterial ulcers).
- Phlebitis/Thrombophlebitis: Pain, redness, anticoagulation if necessary.
- Vasculitis: Systemic symptoms, biopsy, and immunosuppressive treatment.
Hypertension and Hypotension
Management
- Hypertension:
- Primary: Lifestyle modification, antihypertensive medications (ACE inhibitors, ARBs, beta-blockers, diuretics).
- Secondary: Identify and treat underlying cause (e.g., renal artery stenosis, endocrine disorders).
- Hypotension:
- Assessment: Orthostatic BP measurements, underlying cause identification.
- Management: Fluid resuscitation, addressing underlying cause.
Lipid Disorders
Screening and Management
- Screening: Lipid profile, particularly in high-risk groups (e.g., diabetes, family history of hypercholesterolemia).
- Management: Lifestyle changes, statins, and other lipid-lowering agents.
Paediatric Cardiac Issues
Recognition and Referral
- Minor Congenital Cardiac Disease:
- ASD, VSD, PDA: Murmurs, echocardiography, possible surgical repair.
- Major Congenital Cardiac Disease:
- Tetralogy of Fallot, TGA, Coarctation: Cyanosis, heart failure signs, surgical intervention.
- Rheumatic Fever/Rheumatic Heart Disease:
- History and Symptoms: Jones criteria, long-term penicillin prophylaxis.
- Kawasaki Disease:
- History and Symptoms: Fever, rash, conjunctivitis, coronary artery involvement.
- Heart Failure:
- Management: Based on underlying cause, medications, possible surgical intervention.
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