Indications for AICD
- 2o Prevention: Hx VT/VF arrest, sustained/symptomatic VT
- Hereditary cardiac conditions w High risk SCD: HOCM, LQT, ARVD, Brugada
- LVEF <30%, >1month post MI
- CCF/CM- LVEF <35%
Indications for PPM
- Irreversible symptomatic Bradycardiac
- CHB, 2nd degree HB
- Bi, Tri fascicular block + recurrent syncope
Indications for CRT
- EF<35%
- SR
- QRS>150
- NYHA II despite OMT
can use in AF but has to have another indication for pacing and high expected need for pacing
Heart Transplant referral Indications
Intractable HF NYHA III-IV
When you have to start downtitrating HF management
Heart Transplant contraindications
Malignancy
Other organ failure
Active infection
Poor compliance
Torsades-de-points ECG findings
VT with multiple ventricular foci
QRS complexes varying in amplitude, axis and duration
Long QT ECG findings
Men: >0.45
Women: >0.47
correct for HR + age. QRS must be normal
KVLQT1/KCNQ1
Long QT 1 - regulates K channels
HERG
Long QT2 - regulates K channels
SCN5A Increase
Long QT3- regulates Na channels
SCN5A Decrease
Brugada Syndrome
LQT1 ECG
Hill like/peaked T wave
LQT2 ECG
U wave within T wave
LQT3 ECG
long ST segment
Brugada ECG + Inheritance
Right precordial ST Elevation on ECG
Autosomal Dominance
ARVD ECG findings
- Epsilon wave
- T wave inversion in V1-3
- Prolonged S-wave upstroke of 55ms in V1-3
- Localised QRS widening of 110ms in V1-3
Severe Mitral Stenosis
Mean gradient >10mmHg
Valve Area <1.0 cm2
Severe Aortic Stenosis
Mean Gradient > 40mmHg
Valve Area <1cm2
Velocity >4m/s
DI <0.25
Impaired Diastolic filling
Abnormal septal motion
Exaggerated x descent
Pericardial Tamponade
Rapid early diastolic filling, delayed late diastolic filling Kussmaul sign Septal bounce Ventricular interdependence Exaggerated x descent Sharp y descent
Constrictive Pericarditis
Impaired Diastolic filling
Kussmaul sign
LVEDP > RVEDP by 5mmHg
Restrictive cardiomyopathy
MoA of Ezetimibe
down-regulates ABCA-1 transporter (gut absorption)
Target of Evolocumab
PCSK9
Target of Alirocumab
PCSK9
JVP- Dominant a wave
pulmonary hypertension, TS, PS
JVP- Cannon a wave
complete heart block, VT with AV dissociation
JVP- Dominant v wave
TR
JVP- Sharp y descent
severe TR, constrictive pericarditis
JVP- Prominent x and y descent
RV infarction
Valve Replacement- AR
Severe AR with symptoms
Severe AR with resting LVEF <50% even if asymptomatic Severe AR undergoing CABG or surgery of ascending aorta or another valve
Valve Replacement- AS
- Severe AS with high gradient and symptoms
- Severe AS undergoing CABG or surgery of ascending aorta or of another valve
- Asymptomatic patients with severe AS and LVEF <50% not due to another cause
- AS symptoms with exercise TTE showing symptoms are AS related
Percutaneous Valvuloplasty- MS
- Symptoms + Mod/Sev MS
- Asymptomatic. Mod/Sev MS with:
- -High risk HD compromise (PulmHT, desire for pregnancy)
- -High thromboembolic risk
Aortic Stenosis Examination Findings
Slow rising pulse S4 Paradoxical splitting of the second heart sound Aortic thrill Length and harshness of murmur LVH – displaced apex beat LVF – a late sign
Mitral Stenosis Examination Findings
Small pulse pressure Soft first heart sound Early opening snap Long diastolic murmur Diastolic thrill @ apex PHT signs
Mitral Regurgitation Examination Findings
Small volume pulse Displaced forceful apex Pansystolic murmur -> axilla S3 Soft S1 A2 early Early diastolic rumble AF LVF signs
Aortic Regurgitation Examination Findings
Collapsing pulse Wide pulse pressure Long decrescendo diastolic murmur S3 Soft A2 Austin Flint murmur (low pitched rumbling mid-diastolic and presystolic murmur @ apex) LVF
Mitral Valve Prolapse Examination Findings
Click -> high pitched late-systolic murmur extending throughout systole
Tricuspid Regurgitation Examination Findings
JVP: Large v-waves, elevated Right ventricular heave Pansystolic murmur @ the lower sternal edge (increases with inspiration) Large, pulsatile liver Ascites Peripheral oedema
Pulmonary Stenosis Examination Findings
Ejection systolic murmur peaking late in systole
Absent ejection click
S4
RVF signs
ASD Examination Findings
wide fixed splitting of S2
mid diastolic flow murmur over tricuspid area (when significant shunt present)
VSD Examination Findings
harsh pansystolic murmur @ left sternal edge
systolic thrill
mid diastolic flow murmur over mitral area (when significant shunt present)
Patent Ductus Arteriosus Examination Findings
continuous murmur over pulmonary area
mid diastolic flow murmur over mitral area (when significant shunt present)
Features of a cholesterol emboli
Levido reticularis
Purpura
Renail failure
Eosinophilia
Poor prognostic features of HOCM
syncope
family history of sudden death
young age at presentation
non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring
abnormal blood pressure changes on exercise
Features suggesting VT rather than SVT with aberrant conduction
AV dissociation fusion or capture beats positive QRS concordance in chest leads marked left axis deviation history of IHD lack of response to adenosine or carotid sinus massage QRS > 160 ms