CARDIOLOGY

ResponseSee ECG library - Be able to do this

ResponseDiagnosis of STEMI in LBBB using modified sgarbossa criteria. Any of the following is a STEMI
Any lead with >1mm concordant ST elevation (QRS and ST in same direction)
Any lead V1-V3 with >1mm concordant ST depression (QRS and ST in same direction)
Any lead with ST elevation more than 25% of a preceding S wave

New onset LBBB in a stable patient with chest pain is no longer an indication for reperfusion.
LBBB AND strong clinical suspicion is an indicator for reperfusion.

• PACSA

Response Be able to do this - See ECG library

ResponseECG changes suggestive of critical proximal LAD stenosis
No precordial Q waves
Normal precordial wave progression
Minimally elevated ST segments (<1mm)
Inverted or biphasic T waves V1-V6 (mainly V2-V3)

• Wellens A = Biphasic
• Wellens B = Deeply inverted

ResponsePE/RV strain
RBBB
HCM
Raised ICP
Normal paeds
Persistent juvenile T wave inversion
Vasospasm/cocaine
Brugada

ResponseManagement as per ACS – Aspirin, Plavix/Ticag, heparin
Admit CCU monitored bed (If rural should be transferred for PCI over an admission)

• Serial ECG’s to assess for development of LAD/Anterior STEMI

BP control (SBP ~120

• GTN
• Beta blocker (metoprolol vs IV)

Urgent angiogram within 24 hours – for management of presumed critical LAD stenosis
Immediate PCI if redevelops symptoms

ResponseSTE III>2 consistent with RV involvement – They love this. Means NO nitrates

ResponseFavouring RHYTHM control
Young patient
Sevre symptoms
Short duration of symptoms
Heart failure due to AF
Mild or moderat L atrial enlargement only

Favouring RATE control
Age >65
Asymptomatic
Longstanding/persistent AF
L atrial enlargement

ResponseBasically, pick the drug based on the side effect profile
RATE control

• Beta blockers - Metoprolol 25 mg PO or 2.5-5mg IV – Ind: normal BP, minimal/no CCF, No Contra (eg: asthma)
• Ca blocker – Verapamil 2.5mg IV to 15 m – ind: Avoid hypotension and current CCf, avoid if on beta blocker. No beta blockade so good if Beta blocker CI (eg asthma)
• Digoxin 500 mics PO/V – ind: Low BP, Presence of CCF. Has slow onset of action
• MgSO4 – 10-20 mmol slo IV – may aide in rate control, care with hypotension

Rhythm control (cardioversion)

• Flecainide 2mg/kg PO/IV – Structurally normal heart if AF <48 hours
• Amiodarone 5mg/kg slow IV – If flecainide contraindicated and AF <48h. CI iodine allergy, hypotension, thyroid dysfunction, long QT
• Sotalol 40-80 mg – CI Long QT, asthma, hypotension

ResponseCardiac

• Htn
• Valvular disease (inc Rheumatic valvular heart disease)
• IHD/CAD
• CHF
• Cardiomyopathy
• Genetic
• Post cardiac surgery
• Sick sinus syndrome, Pre-excitation syndromes
• Pericarditis

Non Cardiac

• Hyperthyroid
• Sepsis
• EtOH – “holiday Heart”
• OSA
• COPD
• Stimulants
• PE
• Electrolyte abnormalities (Hypokalaemia, Hypomagnesaemia)
• Hypothermia = slow AF

ResponseRisk of stroke = CHADS2VASc (Definitely Anticoagulate if M >=2, F>=3, consider if >0)
CHF
Htn
Age >65
Diabetes
Stroke (2)
Vascular disease
Age >75
Sex (female)

Risk of bleeding = HAS BLED (0-1 = anticoagulated, >=3 HIGH risk so use alternate therapy, 2 = consider. Score of 4 = 4% risk of major bleed in 100 patient years)
Htn
Abnormal liver/kidney function
Stroke
Bleeding
Labile INR
Elderly (age >65)
Drugs or alcohol

ResponseHaemodynamic instability
Definite onset of AF within 24-48 hours
Lack of known structural heart disease
Non chronic AF
Correctable/clear precipitant
Patient preference.

ResponseLots of questions ask you to list and justify investigations for each differential. Think about that as you answer these.

ResponseRed flags:
Unheralded
Seated/supine
Exertional
FHx sudden cardiac death
Personal history/prior hx of unexplained history
Congenital cardiac disease

ResponseBP – lying and standing
Heart rate - ? dysrhythmia, bradycardia ?increased on standing
Volume status - ? dehydrated
Pallor suggesting anaemia / blood loss
PR for melaena
Presence of pacemaker
SaO2 – e.g. hypoxia in content of PE (unlikely if patient now asymptomatic)

ResponseComplete heart block – presence of bifascicular block on ECG in ED
VT – Hx MI, frequent non sustained VT in ED
TDP – Long QT on ECG
Severe AS – Loud harsh ejection systolic murmur with poor volume carotid pulse
HOCM – Exercise induced syncope. ECG features LVH with dagger Q waves in lateral leads
ARVC - epsilon waves on ECG, RBBB, FHx sudden cardiac death

ResponseArrhythmia (VT, VF, rAF, etc… - ironically blatant stuff like this not commonly in answer)
Trifascicular block (3^rd degree AV block) or bifascular block (risk of deterioration to 3^rd degree HB)
Long QT (progression to Torsades)
Q waves – Previous MI, risk of VT
Wolf-Parkinson White - Pre-excitation/delta waves, QRS>110, PR <120. Progression to (supraventricular) reentry tachycardias
Brugada syndrome – RBBB with coved/saddleback ST elevation in V2-V3 (progression to VT/VF)
ARVD – TWI V1-V3, epsilon waves (progression to Vt/VF)
Broad QRS >120 ms - risk of VT due to structural heart disease
Deep Q/T inversion- HOCM
ECG features of severe hyper or hypokalaemia
ECG features of severe Na channel blockade
Pacemaker malfunction

ResponseReflex (Neurally mediated) syncope

• Vasovagal – sudden sensation of pain, prolonged standing. (presyncope/heralded, inciting event, post syncopal vagal sx – sweating, n+V, hx of similar)
• Situational – strain with closed glottis, micturition, defecation, swallow
• Carotid sinus – tight collar, head turning

Orthostatic (Recurrent pre-syncope on standing from lying position,)

• Hypovolaemia – blood loss/fluid loss
• Addisons

Vascular

• Aortic dissection (thoracic or abdominal)
• PE
• Subclavian steal

CNS

• Sah, TIA, migraine, shy-Drager, subclavian steal
• Autonomic dysfunction

Medication

• Cardiac: Beta blocker, CCB, nitrates, ACEi, Diuretics
• Non cardiac: Antipsychotics, Antidepressants, Antiparkinsons
• Party – Cocaine, sildenafil, alcohol, poppers

Psychogenic

• 50% in young adults

Others

• Hypoglycaemia
• Diarrhoea/gastro

Anaemia/malena/GI bleed
Ectopic pregnancy in young woman

ResponseMUST Say ECTOPIC PREGNANCY >> positive FAST
Pericardial effusion +/- tamponade (autoimmune stuff can happen in the younger population >> bedside echo showing fluid/RA diastolic collapse
Aortic dissection (marfans in young) >> bedside echo showing intimal flap
Bedside abdo u/s showing aortic hematoma>> CT aortogram, CXR
PE >>-bedside echo, ecg, ABG, CTPA
Cardiac - MI, Dissection, Pericardial Effusion, Arrhythmia (Brady or Tachy)
Respiratory - PE
Abdominal - Ovarian Torsion, AAA (unlikely)
Neurological (CVA, SAH, Seizure)
Other - Vasovagal, Vertebral Dissection/insufficiency, carotid sinus

ResponseECG – dysrhythmia, AV block, PPM dysfunction
Blood sugar - ?hypoglycaemia
Electrolytes / VBG - ?electrolyte dysfunction
Urea & creatinine - ?evidence of dehydration
Hb - ?anaemia, MCV - ?evidence of chronic blood loss (low MCV)
(TSH, BSL, BHCG) - alternative cause
Serial ECG (?dynamic changes) and continuous monitoring (monitor for arrhythmia)
Postural BP
CXR – SOB with focal examination findings eg crackles 
Consider bedside Echo ?alternate cause (PE, effusion, etc although clinically unlikely)
Pacemaker check
Holter monitor – could be arranged on discharge if concerns re dysrhythmia
CT brain – if severe headache (e.g. ?SAH) or concerns that this was a seizure rather than syncope (Note CTB usually doesn’t pay in syncope questions unless trauma as result of syncope. Read Q carefully)

ResponseCT Head – only if signs of trauma indicating possible TBI ie signs of BOS fracture complicating fall OR lateralising neurology/signs of raised ICP
Focal neurological symptoms/signs
Persistent reduced LOC
Further unexplained seizure activity in ED
Bleeding disorder
Fever or suspected CNS infection
Past H/O intracranial pathology or malignancy
Suspected SAH

ResponseCHESS
CHF
Haematocrit <30%
ECG abnormal
Systolic BP <90% at triage
SOB

1 q wanted 3 scoring systems listed (not described) - Canadian syncope score, San Francisco syncope rule, Sris sstratification of syncope in the ED (ROSE), Simplified Boston syncope rules, Short Term prognotis of Syncope (STePS)

ResponseFavouring syncope

• Rapid neurologic recovery, no post ictal period
• Postural symptoms
• Absence of seizure like movements
• Pre-syncope symptoms
• No neurologic symptoms

Favouring seizure

• Hx seizures
• Persistent reduced LOC
• Further unexplained seizure activity in ED
• Bleeding disorder
• Fever or suspected CNS infection
• Past hx of intracranial pathology/malignancy
• Suspected SAH
• Time course – sudden onset/offset, brief – usually less than 2 minutes 
• Description of attack – involuntary movement, incontinence, tongue biting (and location 
• of tongue injury), drooling 
• Amnesia 
• Post ictal period – confusion, lethargy  

ResponseNo indication for admission – ie further seizures, need for urgent treatment of any underlying cause.
Stable – no further seizures or reduced LOC
Time of day
Support at home/NOK
Follow up / further investigation as appropriate for diagnosis
Safety advice – driving, working with machinery as appropriate for diagnosis

ResponseNo indication for admission (no treatment required for underlying cause)
Stable
Time of day
Support at home/NOK
Follow up/further investigations organised as appropriate for diagnosis
Safey advice – driving, machinery work,