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Healthy diet in adults
from Uptodate, Healthy diet in adults by Graham A Colditz, MD, DrPh, Jan 4, 2013 and https://www.eatforhealth.gov.au/ Caloric Balance 2. Macronutrients Macronutrients are the primary sources of energy, and the proportion of these nutrients in the diet is key to health. Carbohydrates: 45-65% of Total Caloric Intake Proteins: 10-35% of Total…
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Lipoproteins and Atherosclerosis
Overview: Key Lipoproteins (Non-HDL cholesterol) Involved in Atherosclerosis: Oxidized LDL and its Role in Atherosclerosis: High-Density Lipoprotein (HDL) and its Protective Role: Role of Inflammatory Markers and Immune Response in Atherosclerosis: Impact of Antioxidants and Treatment: Triglyceride-Rich Lipoproteins and Apolipoprotein C-III (Apo C-III): Triglycerides Triglycerides are primarily synthesized in the…
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Dietary Fat
from UptoDate – Dietary fat Matthew W Gillman, MD, SM Total Fat Intake Effects of Total Fat on Health Challenges with Low-Fat Diets Type of Fat Trans Fats Trans fats are artificially created through a process called hydrogenation, which solidifies liquid oils. They are commonly found in processed foods like…
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Bradycardia
Presentation: Etiologies of Sinus Bradycardia Sinus bradycardia can result from a wide range of intrinsic (inherent) and extrinsic factors. Understanding these causes is essential for targeted management. Intrinsic (Inherent) Etiologies Extrinsic Etiologies Evaluation of Sinus Bradycardia Treatment and Management Differential Diagnosis of Bradyarrhythmias Prognosis Sick Sinus Syndrome (SSS) Prevalence: Approximately…
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premature ventricular complexes
Origin of Ectopic Beats Premature contractions (“ectopics”) are classified by their origin Definition and Classification ECG Diagnostic Criteria: Compensatory Pause: Clinical significance Differential Diagnosis: Etiology and Risk Factors Clinical Presentation Evaluation Management Prognosis and Complications
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Anti-Lipids
STATINS Most Potent Oral Lipid-Modifying Agents First-Line Therapy for elevated LDL-C (low-density lipoprotein cholesterol). Lipid Reduction: Lowers LDL-C and triglycerides. Non-lipid Benefits: Antiplatelet properties. Potency of Statins: Effectiveness: Administration Timing: Factors to Consider When Choosing a Statin: Baseline Tests Before Statin Therapy: Avoiding Drug Interactions: Statin Metabolised by Statin concentration…
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Infective Endocarditis
Disease Characteristic: Inflammation of the endocardium, typically affecting heart valves Causes and Organisms Risk Factors Pathophysiology Diagnosis History Signs Clinical Features Embolic Manifestations Cutaneous Findings Investigations Diagnosis Management Complications Prevention High-Risk Patients High-Risk Procedures Antibiotic Prophylaxis Regimens Special Considerations Patient Education Monitoring and Follow-Up Feature Rheumatic Fever (RF) Infective Endocarditis…
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Heart Failure – Chronic Management
FROM: National Heart Foundation of Australia and Cardiac Society of Australia andNew Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018 https://www.heartlungcirc.org/article/S1443-9506(18)31777-3/fulltext Pharmacological Management of Chronic Heart Failure Heart Failure With Reduced Left Ventricular Ejection Fraction (HFrEF) Medications Recommended in All Patients: Medications Recommended in…
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Approach to palpitations
Aetiology Palpitations: Associated Symptoms and Causes Cardiac:Arrhythmias Cardiac: Nonarrhythmic cardiac causes Serious Indicators: Symptom Characteristics: Orthostatic Intolerance: Psychiatric causes Drugs and medications Extracardiac causes History Taking Key Clinical Findings with Palpitations and Suggested Diagnoses Finding Suggested diagnosis Single “Skipped” Beats Benign ectopy Feeling Of Being Unable To Catch One’s Breath…
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lifestyle risk factors modification
Smoking cessation Nutrition weight control smoking alcohol exercise
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murmurs (kids)
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Heart Block
Delayed conduction of electrical current as it passes through the conducting system May occur at any level in the conducting system (AV node, Bundle of His or bundle branch) Block in either AV node or the bundle → AV block ** Revision: PR interval → there is a problem with…
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Tachyarrhythmias and differentiating clinical features
Causes of tachyarrhythmias and differentiating clinical features Rate P-waves Variability Most common demographic Sinus Tachycardia <220 Present, normal morphology Variable Typically unwell children or systemic illness Supra Ventricular Tachycardia >220 (commonly 250-300 in infants) Absent or after QRS Fixed AVRT including WPW After QRS Neonates and…
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SVT – Paroxysmal Supraventricular Tachycardia (PSVT)
Case: Jane is a 42 yr old women who teachers at the local primary school. She attends your surgery at lunch time complaining of feeling light headed and dizzy. Jane reports she has suffered these symptoms for one hour and has never had them before. She is feeling palpitations and…
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Pre-excitation syndromes
Wolff-Parkinson-White (WPW) Syndrome ECG features of WPW in sinus rhythm Tachyarrhythmias associated with WPW syndrome Atrioventricular reentrant tachycardia (AVRT) WPW with AF – FBI = Fast Broad Irregular tachycardia Management of AVRT For orthodromic AVRT: For antidromic AVRT: ECGS: Main Abnormalities: Irregularly irregular broad complex tachycardia Extremely rapid ventricular rates…
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palpitations in children
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Sinus tachycardia
DIAGNOSIS ECG Inappropriate sinus tachycardia (IST) Postural orthostatic tachycardia syndrome (POTS)
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Narrow Complex Tachycardia
Two main categories: AV NODE INDEPENDENT AV NODE DEPENDENT MANAGEMENT Undifferentiated Narrow Complex Tachycardia Ventricular stand-still post Adenosine AV NODE INDEPENDENT AV NODE DEPENDENT
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Ventricular fibrillation (VF)
Features: always associated with absent pulse and loss of consciousness ECG Differential diagnosis Management: Electrical cardioversion Management: Drug therapy Special circumstances
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Torsades de pointes (TdP)
Risk factors Causes of prolonged QT Antipsychotics Antiarrhythmics Tricyclics Other antidepressants Antihistamines Others Chlorpromazine Quinidine Amitriptyline Citalopram Diphenhydramine Erythromycin Haloperidol Procainamide Doxepin Escitalopram Loratadine Clarithromycin Droperidol Disopyramide Imipramine Venlafaxine Terfenadine Quinine Quetiapine Flecainide Desipramine Bupropion Chloroquine Olanzapine Sotalol Hydroxychloroquine Thioridazine Amiodarone Management
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Ventricular tachycardia (VT)
Monomorphic Polymorphic complex of normal duration. (the first of the narrower complexes is a fusion beat (the next two are capture beats) Brugada Criteria:: RS Complex R to S interval >100 msec (2.5 small boxes) AV dissociation Morphology Criteria for VT in V1-2 and aVR AV dissociation = Ventricular rate…
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Arrythmias (simple summary)
TOO FAST TOO SLOW NARROW COMPLEX BROAD COMPLEX NARROW COMPLEX BROAD COMPLEX REGUALR IRREGULAR REGULAR IRREGULAR SVTFlutterSinus Tachy AFA-flutter with variable block VTConduction abN VFAF with LBBB Sinus (medications)AF (medications)SSS(sick sinus Syndrome)2nd degree heart block BBB3rd degree HBPoisoned Heart (hypoxia, acidosis, overdose, hypothermia) TOO FAST TOO SLOW Compromised Stable Compromised…
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ECG interpretation
4. AXIS Lead I Lead aVF differential Normal axis (0 to +90 degrees) Positive Positive Left axis deviation (-30 to -90) Positive Also check lead II. To be true left axis deviation, it should also be down in lead II Negative LVHleft anterior fasicular blockinferior wall MInote: Bifascicular block = RBBB…
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Novel Oral Anticoagulants (NOAC)
- Direct thrombin inhibitors: Dabigatran - Factor Xa inhibitors: Rivaroxaban, Apixaban Indications: NOAC dosing and PBS listings for prevention of stroke and SE in patients with NVAF Recommendation Apixaban Dabigatran Rivaroxaban Dosing 5 mg twice daily 150 mg twice daily 20 mg once daily Dose adjustments 2.5 mg twice…
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Warfarin
Contraindications to warfarin therapy Factors that influence the INR Advice on Managing Bleeding Risk Specific Situations
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Rhematic Fever
Pathophysiology: High-Risk Groups for Acute Rheumatic Fever (ARF) and Rheumatic Heart Disease (RHD): High-Risk Groups for Rheumatic Fever: Reasons for Increased Risk of Rheumatic Fever: History and Examination Preceding Illness: Vital Signs: Cardiovascular System (CVS): Rheumatological: Rash: Central Nervous System (CNS) – Sydenham Chorea: Dermatology: Differentials Diagnosis & Investigations Currently,…
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Atrial Fibrillation
Intro Risk factors, disease associations and potentially reversible precipitants for atrial fibrillation Risk factors and disease associations Potentially reversible precipitants ObesityHypertensionType 2 diabetes/impaired glucose toleranceSmokingObstructive sleep apnoeaCoronary artery diseaseValvular heart diseaseHeart failureChronic kidney disease HyperthyroidismAlcohol excessElectrolyte abnormalitiesSepsisAnaemiaMedications Classification Presentation Investigations ECG Management Treat any underlying cause – anaemia, thyrotoxicosis etc.…
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Metabolic syndrome
Waist circumference thresholds for abdominal obesity Recommended threshold in waist circumference for abdominal obesity (high risk) Population Men Women European/North American ≥102 cm ≥88 cm Asian ≥90 cm ≥80 cm Central and South American ≥90 cm ≥80 cm Middle Eastern/Mediterranean ≥94 cm ≥80 cm Sub-Saharan African ≥94 cm ≥80…
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Familial hypercholesterolaemia
Familial Hypercholesterolaemia (FH) is a relatively common inherited cause of premature coronary artery disease, transmitted in an autosomal dominant pattern. It is an inherited lipid disorder, where, if left untreated, men have a 50% risk of developing coronary heart disease (CHD) by age 50, while women have a 30% risk…
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Hypercholesterolemia
There are five major classes of lipoprotein Chylomicrons Triglyceride rich Atherogenic VLDL – Very low density lipoprotein IDL – Intermediate density lipoprotein LDL – Low density lipoprotein Cholesterol rich HDL – High density lipoprotein Anti-atherogenic Secondary dyslipidemia Causes Effects on lipid profile HypothyroidismHyperparathyroidismNephrotic syndromeCholestasisAnorexia nervosaCushings syndromes Increased LDL – C Type 2…
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Hypertension
Risk Factors Causes/History In history identify Category Systolic Diastolic Grade 1 140-159 90-99 Grade 2 160-179 100-109 Grade 3 >180 >110 Isolated systolic >140 <90 Isolated systolic with wide pulse pressure >160 <70 Examination Evidence of Arterial Disease: Palpation: Endocrine System Abnormalities: Obesity Assessment: Fundoscopy (Essential): Investigations: Urine dipstick BLOODS…
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Sudden Cardiac Arrest
most common: birth to 13 years aged 14 to 24 years causes:
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Cardiomyopathy
Hypertrophic Cardiomyopathy (HCM) Structural changes Processes responsible for clinical manifestations of HCM: Clinical features Apical HCM Narrow, “dagger-like” Q waves in inferior and lateral leads ECG finding in apical HCM is giant T-wave inversion in the precordial leads Dilated Cardiomyopathy (DCM) Common ECG associations with DCM Ischaemic dilated cardiomyopathy: Atrial…
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Heart Failure – MEDICATIONS
Medications indicated Drugs used in heart failure with reduced left ventricular ejection fraction Drug Indications Mechanism Adverse effects Precautions ACE inhibitors First-line therapy when LVEF <40% Reduces sodium reabsorption Reduces aldosterone Hypotension Worsening renal function HyperkalaemiaChronic cough Angioedema Previous angioedema Other drugs that increase potassium Angiotensin receptor antagonists (sartans) If intolerant of ACE inhibitors Reduces vasoconstriction Reduces…
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Heart Failure GP Action Plan
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Heart Failure – acute (APO)
Causes of acute decompensation of chronic heart failure Acute myocardial ischaemia or infarctionHypoxia (e.g., pneumonia, pulmonary embolism)Arrhythmia (e.g., atrial fibrillation, ventricular tachycardia/ectopy)Noncompliance with medications, fluid or salt restrictionInfection (e.g., respiratory, endocarditis, urinary, skin)Pericardial tamponadeAnaemiaReceiving drugs that may worsen chronic heart failureHyperthyroidism or hypothyroidismAdrenal insufficiency or corticosteroid excessIncreased sympathetic drive (e.g.,…
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Heart Failure
Symptoms and signs of heart failure More typical symptoms More specific signs Dyspnoea (usually with exertion)OrthopnoeaParoxysmal nocturnal dyspnoeaFatigue Elevated jugular venous pressureHepatojugular refluxThird heart soundLaterally displaced apex beat Less typical symptoms Less specific signs Nocturnal coughWheezeAbdominal bloatingAnorexiaConfusion (elderly)DepressionPalpitationsDizzinessSyncopeBendopnoea (shortness of breath when leaning forward) Weight gain (>2 kg/wk)Weight loss (in advanced…
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Oedema
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Atrial myxoma
Evaluation Differential Diagnosis Prognosis
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Myocarditis/Pericarditis after mRNA COVID-19 Vaccines
mRNA vaccines Symptoms and outcomes Myocarditis Pericarditis Symptoms Chest pain, pressure or discomfortPalpitationsShortness of breathNon-specific symptoms e.g. fatigue Chest pain which may be sharp, worse when lying down, and alleviated when sitting up and leaning forwardPain on deep inspiration Signs May have normal examinationTachycardiaSevere myocarditis: signs of cardiac dysfunction e.g.…
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Myocarditis
CAUSES (HIGAAP) ASSESSMENT HISTORY EXAMINATION INVESTIGATIONS MANAGEMENT
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Cardiac tamponade
Signs of Tamponade
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Pericardial effusion
Causes: Signs/Symptoms
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Pericarditis
Causes: Common Causes of pericarditis and pericardial effusions Cause Prevalence Investigation Idiopathic Most common Diagnosis of exclusion Viral Most common cause of infectious pericardial diseaseAdenovirusCoxsackievirus (Most common viral cause)Cytomegalovirus (CMV)Epstein-Barr Virus (Mononucleosis)InfluenzaHuman Immunodeficiency Virus (occurs in 20% of AIDS Cases)Mumps/Measles/ VaricellaViral Hepatitis Not routine to perform serological testing. Diagnosis is…
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Acute Coronary Syndrome – Stable Angina Management
Australian Prescriber VOLUME 38 : NUMBER 4 : AUGUST 2015 Diagnosis: Risk Stratification: Clinical Evaluation: Stress Testing: Imaging of Coronary Arteries: Lifestyle Modification: Prevention of Cardiovascular Events: Drug Indications Mechanism Adverse effects Precautions Nitrates (short- and long-acting) Relief of acute or anticipated pain (short-acting)Prevention of angina (long-acting) Systemic and coronary…
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Acute Coronary Syndrome – long term management
Goal: Recommendations Smoking Complete cessation No exposure to environmental/ passive tobacco smoke – ceasing ↓ %Y mortality by half– Patients should be asked about tobacco use status at every office visit– Consider pharmacotherapy for patients smoking >10 cigarettes per day: Nicotine replacement therapy (NRT) — is the first line choice of…
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Acute Coronary Syndrome – Complications
Complications Post-AMI First 2-3 Days: Later Complications: Other Late Complications: Pain Management Left Ventricular Failure Cardiogenic Shock Right Ventricular Infarction Pericarditis Arrhythmias Thromboembolic Disease Cardiac Rupture Ventricular Aneurysm Dressler’s Syndrome Valvular Heart Disease
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Acute Coronary Syndrome – STEMI
Definition: clinical sx consistent w ACS w ECG features including any of: Reperfusion Critera: Qwaves Area of Infarction Type of Infarct ECG Leads Reciprocal ECG Changes Heart Territory Coronary Vessel Inferior Infarct II, III, aVF I, aVL Inferior wall of the left ventricle Right Coronary Artery (RCA) or Left Circumflex…
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Acute Coronary Syndrome – NSTEMI
Most pt’s will present with prolonged or recurrent central chest discomfort but others (elderly, DM, women) may present with atypical sx. Risk = DM & stress Most pt’s with NSTEMI are normal on PE. An abnormal ECG, esp dynamic ST-segment deviation (≥0.5mm) or new T-wave inversion (≥2mm) will confirm the…
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Cardiac Investigations
Troponins High-sensitive Troponin (hs-Trop T and hs-Trop I) Purpose: Kinetics: Advantages: Disadvantages: Causes of Elevated Troponin in Absence of Acute Coronary Syndrome (ACS): Clinical Practice: Troponin Test Indications in General Practice: Important Considerations: Pitfalls in General Practice: Additional Considerations: Rapid and substantial increases in hs-trop T enhance the likelihood of…
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Acute Coronary Syndrome
Differential Diagnosis PAIN Onset: PAIN Characteristic Provocative Factors definitions NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION OF ANGINA Class 1 Patients with cardiac disease but without resulting limitation of physical activity.Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. Class II Patients with cardiac disease resulting in…
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Chest pain in GP land
Causes of chest pains presenting in general practice, compared with emergency departments Percentage in general practice (%) Percentage in emergency departments (%) Musculoskeletal conditions 29 7 Respiratory conditions,including pneumonia,pneumothorax and lung cancer 20 12 Psychosocial conditions 17 9 Serious cardiovascular conditions, including myocardial infarction, unstable angina, pulmonary embolism and heart…
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Aspirin for the Primary Prevention of Cardiovascular Disease
NOTE: Diabetes mellitus is associated with a substantially increased CVD risk, meaning patients are generally excluded from primary prevention trials. In Australia (https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-11-cardiovascular-disease-prevention) In USA New Zealand: considered to equate to high risk (>15%) and aspirin is recommended. Age Five-year CVD risk level Recommendation for primary prevention of CVD Recommendation…
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Cardiovascular Risk Classification
Conducting a comprehensive risk assessment Absolute cardiovascular disease (CVD) risk assessment Target population First Nations people aged 18-29 years : The following CVD risk factors should be screened, as part of an annual health check (or opportunistically) or at least every 2 years : Clinically determined high risk: The Variables…