Cardiology telemedicine Flashcards
M/40 developed central chest pain, BP 98/52mmHg 100bpm
Striking abnormalities?
- Inferoposterior MI
- Inferior STEMI (II, III, aVF)
- reciprocal changes of ST depression in lead I, aVR, V1-3 (anteroseptal leads) –> posterior MI
- V1-3 = anteroseptal, V1-4 = anteiror, V1-5= anterolateral)
Management of infero-posterior MI?
- Oxygen
- Morphine
- DAPT and anticoagulation: aspirin + clopdigorel + LMWH
- B blocker
- Transfer to PCI hospital (if PCI hospital not available –> do thrombolytics (clopidogrel))
- ACEI
- High dose statin
Nitrates not indicated in inferior posterior MI as the territory involved is large (RCA) –> RV infarct –> if gives nitrates –> will lead to vasodilation and reduced preload (RV infarct is reliant to preload to continue blood supply)
M/66 severe ischemic cardiomyopathy without revasucularization option, on CRT, entreso, empagliflozin, statin and clopidogrel
BP 82/48, HR 65
What would you assess?
Mean arterial BP: diastolic blood pressure +1/3 (systolic blood pressure - DBP)
MBP that is sufficient for vital organs perfusion = 60
Important to assess baseline BP and HR. If any BP abnormalities always measure bP again
Assess clinical symptoms
* Any postural dizziness (postural hypotension)
* Syncope
* Resting chest pain: manage at ACS. NSTEMI: DAPT and enoxaparin (anticoagulant) to prevent complete occlusion of coronary vesel and early PCI (within the same admission within 48 hours)
* Fever: septic shock (exacerbate heart failure)
* Heart failure symptoms (cardiogenic shock): SOB at rest (orthopnea/ PND, SOB whenever moves around (class 3 HF), lower limb edema
* Tarry stool/ blood in stool –> hypovolemic shock
* Hypovolemic shock can also be caused by self medication: diuretics (as often diuretics is not regularly taken) —> ask about drop in body weight
In this patient had diuretics and had 3kg weight loss
Mx: drink water
What is important to assess in cardiac patients?
Triage first: ask about vitals and ensure patient is safe now (if not call ambulance)
Ask about drug compliance: prescribed medication, other medication from other clinics, self medication/administration
Cardiac resynchronization therapy report (CRTD)
S3, S1 effect in heart failure?
What are causes for worsening heart failure in this case?
S3 will increase in heart failure due to volume overload
S1 will be softer in heart failure
Thoracic impendence will drop when there is more fluid retention
Worsening heart failure
* Infection
* Non compliance to medication
* Natural deterioration
* Tachycarrhythmia: AF –> reduced cardiac output due to reduction in diastolic filling –> reduced preload (decreased output)
* Pacing: lead dislodgement, lead fracture, lead failure
Obligatory mode vs on demand mode
Obligatory mode: may pace on the T wave –> leading to R on T phenemonon –> Torsade de Pointes
On demand mode will sense the patients HR and only pace when no QRS complex: loss of pacing when the patient HR too fast
F/65 HT, history of atrial flutter with ablation performed. Recurrent palpitation associated with SOB
interpret ECG
Irregular narrow complex tachyarrhythmia –> atrial fibrillation
Flutter waves will be equal distance and similar morphology
Here the T waves too big and mimics flutter wave
Upon called back
* ECG
* Blood tests: CBC, LRFT, cardiac markers
What needs to be done?
Start on life long anticoagulation (CHADVASc score)
Indications for warfarin usage
* At least moderate MS (not indicated in MR, AS or any other valvular lesions)
* Mechanical valve replacement
AF pattern, how to manage?
- HR< 100 not too fast so no need rate control
- Manage by rhythm control. As patient has already tried flecainide cardioversion the 2nd line tends to be catheter ablation (being considered 1st line in some centers). Amiodarone is not used as the AE is permanent (interstitial lung disease, skin pigmentation, eye disorders)
- Rhythm control only by class 1c and 3 antiarrhythmics
- So catheter ablation done (pulmonary vein isolation) –> where most AF originate
Patient with AF had post catheter ablation ECG done, what is shown and cause?
Sinus tachycardia (p waves seen in most leads)
- Complications associated with pulmonary vein isolation/catheter ablation
- Cardiac tamponade
- Periprocedural stroke (dislodgement of plaque)
- AV block
- Pericarditis (can be dressler syndrome): or any transmural lesion will cause inflammatory reaction
- Transient phrenic nerve paresis
Localized trauma
* Esophageal injury (perforation/fistula formation)
* Haemothorax
* Retroperitoneal bleeding
* Subclavian bleeding
During catheter ablation part of the vagal plexus is burned –> HR often increased after cryoablation
Drugs that cause increased HR: NSAID (contains phenylephrine)
What drugs can be used in WPW?
- Antiarrhythmics (i.e. amiodarone)
- But cannot use rate control drugs
What are the causes and mx?
- Cardioembolic stroke: AF/ Flutter. Complication of PCI: dislodgement of plaque from aorta/ carotid artery stenosis
- Carotid artery stenosis: plaque dislodgement –> antiplatelet therapy followed by either carotid endarterectomy or carotid artery stenting (if contraindicated to CAD)
- DVT: SC LMWH and anticoagulant for 3 months (if provoked), if unprovoked 6 months Tx
- If from AF (clot): lifelong anticoagulation (CHADVASc score) and implant a recorder to check paroxymal AF
What hx taking?
Assess other HF symptoms
* Dyspnea, orthopnea, PND (must ask these 3)
* Chest pain
* Syncope
Other medications used
* Desmopressin prescribed by other doctors to manage patients nocturia due to BPH
* Stopped followed by lasix use
Causes of regular bradycardia with no P waves?
- Sinus bradycardia
- Junctional bradycardia
- Complete heart block
- AF with AV dissocation (escape rhythm from conduction system)
- If worry about complete heart block/MI –> call ambulance
Most important for bradycardia –> assess if regular or irregular
Causes of irregular bradycardia
- 1st degree/2nd degree heart block
- Sinus bradycardia with PAC
