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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