Domain – Cardiovascular health (guiding topics)

Cardiac Arrhythmias

Identification and Management

1. 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.
2. 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.
3. 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.
4. 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).
5. 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.
6. 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

1. 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.
2. 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.
3. 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.
4. 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.
5. 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

1. Risk Factor Management:
   • Lifestyle Changes: Smoking cessation, diet, exercise.
   • Medical Management: Statins, antihypertensives, antidiabetic medications.
2. 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.
3. 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

1. Heart Failure:
   • History and Symptoms: Dyspnea, orthopnea, PND, edema.
   • Examination: Elevated JVP, crackles, peripheral edema.
   • Management: Diuretics, ACE inhibitors, beta-blockers, lifestyle modifications.
2. Cardiomyopathies:
   • History and Symptoms: Dyspnea, fatigue, palpitations.
   • Examination: Variable findings depending on type.
   • Management: Tailored to the specific type (dilated, hypertrophic, restrictive).
3. Arrhythmias:
   • History and Symptoms: Palpitations, syncope, shortness of breath.
   • Examination and ECG: Identify specific arrhythmia for targeted treatment.

Vascular Pathologies

Diagnosis and Management

1. Aneurysms:
   • Thoracic and Abdominal: Pulsatile mass, back pain, imaging (ultrasound, CT).
   • Management: Monitoring vs. surgical repair based on size and symptoms.
2. 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

1. 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).
2. 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

1. Minor Congenital Cardiac Disease:
   • ASD, VSD, PDA: Murmurs, echocardiography, possible surgical repair.
2. Major Congenital Cardiac Disease:
   • Tetralogy of Fallot, TGA, Coarctation: Cyanosis, heart failure signs, surgical intervention.
3. Rheumatic Fever/Rheumatic Heart Disease:
   • History and Symptoms: Jones criteria, long-term penicillin prophylaxis.
4. Kawasaki Disease:
   • History and Symptoms: Fever, rash, conjunctivitis, coronary artery involvement.
5. Heart Failure:
   • Management: Based on underlying cause, medications, possible surgical intervention.