Cardiac Tamponade and Pericarditis Overview
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Questions and Answers

What is the defining feature of Beck's triad associated with cardiac tamponade?

  • Hypotension (correct)
  • Increased heart rate
  • Pericardial effusion
  • Wide pulse pressure

    • Which symptom helps to differentiate acute pericarditis from myocardial infarction?

  • Nausea
  • Friction rub on auscultation (correct)
  • Diaphoresis
  • Radiation to the left arm

    • What type of murmur is primarily associated with mitral regurgitation?

  • Mid-diastolic murmur
  • Diastolic decrescendo murmur
  • Continuous machinery murmur
  • Pansystolic murmur (correct)

    • Which condition is characterized by a 'boot-shaped heart' on an X-ray?

    <p>Tetralogy of Fallot</p> Signup and view all the answers

    What is an important potential side effect of amiodarone treatment?

    <p>Pulmonary fibrosis</p> Signup and view all the answers

    Which type of AV conduction block is characterized by dropped beats with a fixed PR interval?

    <p>Second-degree AV block Type II</p> Signup and view all the answers

    Which of the following is a common cause of hypovolemic shock in cardiac tamponade?

    <p>Trauma</p> Signup and view all the answers

    Which medication is primarily used as a first-line treatment for dilated cardiomyopathy?

    <p>ACE inhibitors</p> Signup and view all the answers

    Which congenital heart defect is associated with a continuous machinery murmur?

    <p>Patent ductus arteriosus (PDA)</p> Signup and view all the answers

    What is the initial step in diagnosing infective endocarditis when a new murmur and fever are present?

    <p>Blood culture</p> Signup and view all the answers

    What is a characteristic sign of infective endocarditis?

    <p>Osler nodes</p> Signup and view all the answers

    Which heart sound may indicate the presence of restrictive cardiomyopathy?

    <p>S4 heart sound</p> Signup and view all the answers

    Which of the following is a major criterion for the modified Duke criteria for infective endocarditis?

    <p>Blood culture positive for typical microorganisms</p> Signup and view all the answers

    Which dual effect describes how nitrates work in angina treatment?

    <p>Decreases afterload and myocardial oxygen demand</p> Signup and view all the answers

    What is the primary treatment for ventricular fibrillation?

    <p>Defibrillation</p> Signup and view all the answers

    What is a significant risk factor for the development of infective endocarditis?

    <p>Valvular heart disease</p> Signup and view all the answers

    Which characteristic is associated with atrial fibrillation?

    <p>No discrete P waves</p> Signup and view all the answers

    What is the first-line treatment for Torsades de Pointes?

    <p>IV magnesium sulphate</p> Signup and view all the answers

    Which condition has the potential to result in Eisenmenger syndrome?

    <p>Patent ductus arteriosus (PDA)</p> Signup and view all the answers

    What does a CHA2DS2-VASc score help determine?

    <p>The need for anticoagulation in atrial fibrillation</p> Signup and view all the answers

    Which congenital heart defect is characterized by a continuous machinery murmur?

    <p>Patent ductus arteriosus (PDA)</p> Signup and view all the answers

    What type of tachycardia is defined as having wide QRS complexes and potential progression to ventricular fibrillation?

    <p>Ventricular tachycardia</p> Signup and view all the answers

    In the management of atrial flutter, what treatment is commonly used?

    <p>Electrical cardioversion</p> Signup and view all the answers

    Which electrolyte abnormality is commonly associated with Torsades de Pointes?

    <p>Hypomagnesemia</p> Signup and view all the answers

    Which medication is indicated for acute management of stable ventricular tachycardia?

    <p>Sodium channel blockers</p> Signup and view all the answers

    How does Wolff-Parkinson-White syndrome present on an ECG?

    <p>Delta waves</p> Signup and view all the answers

    What is the primary characteristic of ventricular fibrillation?

    <p>No identifiable QRS complexes</p> Signup and view all the answers

    What is the primary goal in the management of patients with cardiomyopathies?

    <p>Symptom management and prevention of complications</p> Signup and view all the answers

    What is the first-line treatment for a patient with unstable vitals due to ventricular fibrillation?

    <p>Defibrillation</p> Signup and view all the answers

    In the treatment of atrial fibrillation with stable vitals, which of the following is primarily used for rate control?

    <p>Beta-blockers</p> Signup and view all the answers

    Which of the following criteria are used to diagnose infective endocarditis according to the Modified Duke Criteria?

    <p>Two major criteria or five minor criteria</p> Signup and view all the answers

    What is the characteristic ECG finding associated with atrial flutter?

    <p>Sawtooth appearance of P waves</p> Signup and view all the answers

    What treatment is indicated for Torsades de Pointes?

    <p>Correction of electrolyte abnormalities</p> Signup and view all the answers

    For patients with Wolff-Parkinson-White syndrome, what is a notable feature on their ECG?

    <p>Delta waves</p> Signup and view all the answers

    Which of the following conditions is characterized by completely disordered ventricular electrical activity?

    <p>Ventricular fibrillation</p> Signup and view all the answers

    What type of congenital heart defect could potentially lead to Eisenmenger syndrome?

    <p>Ventricular Septal Defect</p> Signup and view all the answers

    In managing symptomatic second-degree Mobitz II AV block, what is the appropriate treatment?

    <p>Pacemaker insertion</p> Signup and view all the answers

    Which type of tachycardia is defined by a narrow QRS complex and has a sudden onset?

    <p>Supraventricular tachycardia</p> Signup and view all the answers

    What is a common clinical manifestation of acute pericarditis?

    <p>Fever and pleuritic chest pain</p> Signup and view all the answers

    What immediate therapy is essential for a patient with symptomatic cardiogenic shock from cardiac tamponade?

    <p>Pericardiocentesis</p> Signup and view all the answers

    Which symptom would suggest hypokalemia could be contributing to a cardiac rhythm disturbance?

    <p>Weakness and fatigue</p> Signup and view all the answers

    What is a noteworthy side effect of Class III antiarrhythmic agents like Amiodarone?

    <p>Pulmonary fibrosis</p> Signup and view all the answers

    What clinical feature is indicative of paradoxical pulse in cardiac tamponade?

    <p>Decreased pulse pressure during inspiration</p> Signup and view all the answers

    What is a common treatment approach for acute pericarditis?

    <p>Corticosteroids or NSAIDs</p> Signup and view all the answers

    Which sound is characteristic of tricuspid regurgitation?

    <p>Pansystolic murmur at the left lower sternal border</p> Signup and view all the answers

    What complication can arise from a chronic ventricular septal defect (VSD)?

    <p>Reversal of shunt (Eisenmenger syndrome)</p> Signup and view all the answers

    In the case of second-degree AV block type I (Wenckebach), what is a distinguishing characteristic?

    <p>Dropped beats with progressive PR interval lengthening</p> Signup and view all the answers

    What is a major concern when using class III anti-arrhythmic medications such as Amiodarone?

    <p>Pulmonary fibrosis and thyroid dysfunction</p> Signup and view all the answers

    What is an essential pre-treatment test before administering amiodarone?

    <p>Thyroid function tests</p> Signup and view all the answers

    Which congenital heart defect is most commonly associated with Eisenmenger syndrome?

    <p>Ventricular Septal Defect</p> Signup and view all the answers

    What are the hallmark signs of infective endocarditis?

    <p>Fever, Roth spots, and Janeway lesions</p> Signup and view all the answers

    What is a common risk factor for the development of hypertension?

    <p>Obesity and sedentary lifestyle</p> Signup and view all the answers

    Which condition would primarily exhibit a wide pulse pressure?

    <p>Aortic regurgitation</p> Signup and view all the answers

    What is a key characteristic of hypertension defined as postural hypotension?

    <p>Blood pressure drop upon standing</p> Signup and view all the answers

    What is the potential side effect of beta-blockers in patients with asthma or COPD?

    <p>Exacerbation of bronchospasm</p> Signup and view all the answers

    What unique feature might be recognized on an ECG for Wolff-Parkinson-White syndrome?

    <p>Delta wave</p> Signup and view all the answers

    What specific side effect is observed with the use of nitrates as anti-anginal agents?

    <p>Tolerance and headache</p> Signup and view all the answers

    Study Notes

    Cardiac Tamponade

    • Fluid accumulation in the pericardial space leading to difficulty for blood entering the ventricles.
    • Causes: acute pericarditis, aortic dissection, trauma.
    • Beck's triad: Hypotension, Muffled heart sounds, raised JVP (prominent x descent, absent y descent)
    • Paradoxical pulse:

      • 10 mmHg inspiratory drop of systolic BP

      • During inspiration, increased blood flow to the right ventricle:
        • Inter ventricular septum bulges towards the left ventricle
        • Left ventricular volume decreases
        • Reduced cardiac output

    Cardiac Tamponade: Diagnosis and Treatment

    • Echocardiography is the investigation of choice.
    • ECG findings: reduced amplitude QRS complexes, electrical alternans.
    • Treatment options: pericardiocentesis, IV fluids (for patients in shock).

    Acute Pericarditis

    • Inflammation of the pericardium.
    • Presentation:
      • Sharp, pleuritic pain: increases during inspiration, relived by leaning forward.
      • Friction rub on auscultation.
      • ECG: widespread saddle-shaped ST elevation.

    Acute Pericarditis: Causes and Treatment

    • Causes:
      • Viral infection (e.g., coxsackievirus B).
      • Post-MI (fibrinous pericarditis) and Dressler syndrome.
      • Autoimmune (SLE, RA).
      • Uraemia.
      • Radiation therapy.
    • Treatment: NSAIDs, colchicine, corticosteroids.

    Cardiac Murmurs: Mitral Valve Disorders

    • Mitral Stenosis:
      • Mid diastolic murmur at cardiac apex.
      • Associated with opening snap.
    • Mitral regurgitation:
      • Pansystolic murmur at apex radiating to axilla.

    Cardiac Murmurs: Aortic Valve Disorders

    • Aortic Stenosis:
      • Crescendo-decrescendo systolic murmur.
    • Aortic Regurgitation:
      • Diastolic decrescendo murmur.
      • Bounding pulse.
      • Wide pulse pressure.

    Cardiac Murmurs: Other Defects

    • Ventricular Septal Defect (VSD):
      • Pansystolic murmur.
      • Chronic VSD: Possible shunt reversal (Eisenmenger syndrome)
    • Tricuspid regurgitation:
      • Pansystolic murmur at left lower sternal boarder.
    • Patent Ductus Arteriosus:
      • Continuous machinery murmur.
      • Best heard in left infraclavicular area.

    Cardiac Murmurs: Hypertrophic Obstructive Cardiomyopathy

    • Crescendo-decrescendo systolic murmur.
    • Murmur increases with:
      • Valsalva maneuver.
      • Standing up (decreased preload).

    Cardiomyopathy: Types and Features

    • Dilated cardiomyopathy:
      • Causes: alcohol, viral myocarditis, doxorubicin.
      • Features: Systolic dysfunction, heart failure, S3 heart sound.
    • Hypertrophic cardiomyopathy:
      • Cause: Autosomal dominant mutation.
      • Features: Diastolic dysfunction, syncope during exercise.
    • Restrictive cardiomyopathy:
      • Causes: Amyloidosis, sarcoidosis, post radiation fibrosis.
      • Features: Diastolic dysfunction, right sided symptoms (edema, ascites).

    Cardiomyopathy: Treatment

    • Dilated cardiomyopathy: ACE inhibitors, beta blockers, diuretics.
    • Hypertrophic cardiomyopathy: Beta blockers or calcium channel blockers, ICD (for arrhythmias).
    • Restrictive cardiomyopathy: Beta blockers, diuretics, digoxin.

    AV conduction Block: First-Degree

    • Prolonged PR interval (> 200ms).
    • All P waves conducted.
    • No treatment required.

    AV conduction Block: Second-Degree Mobitz Type I

    • PR interval lengthens progressively until a beat is missed.
    • Variable RR interval.
    • Treatment: If hypotension or bradycardia is present, treat with atropine.

    AV conduction Block: Second-Degree Mobitz Type II

    • Dropped beats (QRS complex).
    • Fixed PR interval.
    • Treatment: Pacemaker.

    AV Conduction Block: Third-Degree (Complete)

    • Atria and ventricles contract independently.
    • No association between P wave and QRS complex.
    • Causes: Myocardial infarction, Lyme disease.
    • Immediate treatment: Atropine 500mcg IV, followed by transcutaneous pacing.
    • Definitive treatment: Pacemaker.

    Anti-arrhythmic Medications: Class I and II

    • Class I (Sodium channel blockers):
      • Drugs: Quinidine, Lidocaine.
      • Uses: Atrial and ventricular arrhythmias.
      • Side effects: Cinchonism (headache, tinnitus).
    • Class II (Beta-blockers):
      • Drugs: Metoprolol.
      • Uses: SVT, rate control for AF and atrial flutter.
      • Side effects: COPD/asthma exacerbation, AV block.

    Anti-arrhythmic Medications: Class III and IV

    • Class III (Potassium channel blockers):
      • Drugs: Amiodarone.
      • Uses: Ventricular tachycardia.
      • Side effects: Pulmonary fibrosis, hepatotoxicity, thyroid dysfunction, corneal desposits.
    • Class IV (Calcium channel blockers):
      • Drugs: Verapamil.
      • Uses: Rate control in AF.
      • Side effects: Edema, constipation, AV block.

    Anti-anginal Medications: Nitrates and CCBs

    • Nitrates:
      • Drugs: Nitroglycerin, Isosorbide dinitrate.
      • Mechanism: Reduces preload, decreases myocardial oxygen requirements.
      • Side effects: Headache, tolerance, interaction with sildenafil.
    • Calcium channel blockers:
      • Drugs: Verapamil, Diltiazem.
      • Mechanism: Decreases cardiac contractility, vasodilation, reduces afterload.
      • Side effects: Bradycardia, transient asystole.

    Anti-anginal Medications: Beta-blockers and Ivabradine

    • Beta blockers:
      • Drugs: Atenolol, Bisoprolol, Metoprolol.
      • Mechanism: Decreases myocardial oxygen requirements by reducing heart rate.
      • Side effects: Bradycardia, AV block.
    • Ivabradine:
      • Mechanism: Reduces heart rate.
      • Side effect: Phosphenes (visual disturbances).

    Amiodarone: Pre-treatment Tests

    • Essential tests before starting amiodarone:
      • Thyroid function tests.
      • Liver function tests.
      • Serum electrolyte and urea measurement.
      • Chest radiography.
      • Electrocardiography.

    Cyanotic Congenital Heart Diseases

    • Tricuspid Atresia: Absent tricuspid valve.
    • Transposition of great arteries: Pulmonary artery exits from left ventricle, aorta leaves from right ventricle.

    Cyanotic Congenital Heart Diseases (Part 2)

    • Tetralogy of Fallot:
      • Four key features: pulmonary stenosis, right ventricular hypertrophy, overriding of aorta, VSD.
      • X-ray: Boot-shaped heart.
      • Clinical: Squatting spells.

    Cyanotic Congenital Heart Diseases (Part 3)

    • Persistent truncus arteriosus: Failure of truncus arteriosus to form pulmonary trunk and aorta.
    • Ebstein anomaly: Atrialization of the right ventricle, associated with lithium use during pregnancy.
    • Total anomalous pulmonary venous connection: Pulmonary veins drain into the right heart.

    Acyanotic Congenital Heart Diseases (Part 1)

    • Ventricular septal defect (VSD): Most common congenital heart defect, pansystolic murmur.
    • Atrial septal defect (ASD): Fixed split S2.
    • Patent ductus arteriosus (PDA): Continuous machinery murmur in the left infraclavicular region.

    Acyanotic Congenital Heart Diseases (Part 2)

    • Coarctation of aorta: Associated with Turner syndrome, hypertension in upper limb with brachiofemoral delay, increased risk of berry aneurysms and cerebral hemorrhage.
    • Eisenmenger syndrome: Long standing left to right shunts (VSD, ASD, PDA), progression: Pulmonary hypertension → shunt reversal → late cyanosis and clubbing.

    Hypertension: Definition and Medications

    • Definition: Clinic BP ≥ 140/90 mmHg, Ambulatory BP measurement ≥ 135/85 mmHg.
    • Medications:
      • ACE inhibitors: Side effects: Cough, angioedema, hyperkalemia.
      • Calcium channel blockers: Side effects: Peripheral edema, dizziness, flushing.
      • Thiazide diuretics: Side effects: Hypokalemia, hyperuricemia, postural hypotension, increased serum lithium levels.

    Postural Hypotension

    • Definition: Drop in blood pressure upon standing.
    • Key consideration: Patients on multiple antihypertensive medications.
    • Clinical pearl: Always consider postural hypotension in hypertensive patients with recurrent falls.

    Infective Endocarditis: Risk Factors and Signs

    • Risk factors: Valvular heart disease, valve replacement, previous episode of IE, intravenous drug use.
    • Signs: Murmur and fever, Roth spots, Osler nodes, Janeway lesions, splinter hemorrhages on nail beds.

    Infective Endocarditis: Etiology & Diagnosis

    • Common causes: Streptococci and Staphylococcus aureus.
    • Mitral valve commonly affected.
    • In IV drug users: Tricuspid valve involvement, often S. aureus.

    Infective Endocarditis

    • Diagnostic Approach: New murmur and fever should prompt consideration of Infective Endocarditis (IE).
    • Initial steps: Blood culture and echocardiography are essential for diagnosis.
    • Modified Duke Criteria: This is a scoring system for diagnosing IE.
      • Two major criteria OR
      • One major and three minor criteria OR
      • Five minor criteria are needed to fulfill the criteria.
    • Management:
      • Native Valve: Amoxicillin and Gentamicin are the preferred medications. Vancomycin and Gentamicin are used for MRSA infections.
      • Prosthetic Valve: Vancomycin, Gentamicin, and Rifampin are the recommended medications.

    Atrial Fibrillation

    • ECG features: Irregular RR intervals, no discrete P waves, and a irregularly irregular pulse rate.
    • Treatment:
      • Unstable vitals: Immediate electrical cardioversion.
      • Stable vitals:
        • Rate Control: Beta-blockers are the primary drugs.
        • Rhythm Control: Amiodarone or flecainide are used for rhythm control.
        • Anticoagulation: Warfarin or non-vitamin K oral anticoagulants (NOACs) are used.
      • Anticoagulation Need: The CHA2DS2-VASc score is used to assess the risk of stroke and determine the need for anticoagulation.

    Atrial Flutter

    • ECG features: Identical, back-to-back P waves with a sawtooth appearance.
    • Treatment: Similar to Atrial Fibrillation, focusing on rate control with beta-blockers and rhythm control with amiodarone or flecainide.

    Torsades de Pointes

    • Definition: A type of polymorphic ventricular tachycardia with QRS complexes that appear to twist around the baseline on ECG.
    • Associated with: QT prolongation.
    • Causes:
      • Long QT syndrome
      • Electrolyte abnormalities (hypomagnesemia, hypokalemia, hypocalcemia)
      • Medications (antipsychotics, erythromycin)
    • Treatment:
      • IV magnesium sulphate
      • Correction of electrolyte abnormalities
      • Removal of the causative drug
      • Defibrillation if the condition progresses to ventricular fibrillation (VF).

    Ventricular Tachycardia

    • ECG features: Wide QRS complex (broad complex tachycardia).
    • Complications: Can potentially progress to ventricular fibrillation.
    • Management:
      • Unstable vitals:
        • With pulse: Cardioversion.
        • Without pulse: Defibrillation.
      • Stable vitals:
        • Beta-blockers
        • Non-dihydropyridine calcium channel blockers
        • Sodium channel blockers

    Ventricular Fibrillation

    • ECG features: Completely disordered ventricular electrical activity, no identifiable QRS complexes, and always pulseless.
    • Treatment: Immediate defibrillation to restore sinus rhythm.
    • Clinical Pearl: For broad complex tachycardia with hemodynamic instability, cardioversion is indicated if a pulse is present; if no pulse is present, defibrillation is the necessary intervention.

    Wolff-Parkinson-White Syndrome

    • ECG features: Pre-excitation on ECG, delta waves, prolonged QRS complex.
    • Clinical presentation: Symptoms often appear suddenly, like pallor, palpitations, and difficulty breathing.
    • Prevalence: Often presents in children or young adults.
    • Resolution: Symptoms may resolve spontaneously.

    Supraventricular Tachycardia (SVT)

    • Definition: A rapid heart rhythm originating above the ventricles.
    • ECG features: Narrow QRS complex (unless aberrant conduction), regular rhythm, sudden onset and termination.
    • Common Types:
      • AV Nodal Reentrant Tachycardia (AVNRT)
      • AV Reentrant Tachycardia (AVRT)
      • Atrial Tachycardia

    Congenital Heart Diseases: Key Points

    • Ventricular Septal Defect (VSD): Presents with a pansystolic murmur and can lead to Eisenmenger syndrome (shunt reversal) in chronic cases.
    • Patent Ductus Arteriosus (PDA): Recognized by a continuous machinery murmur best heard in the left infraclavicular area.
    • Atrial Septal Defect (ASD):
      • Often presents with a fixed splitting of S2 heart sound.
    • Tetralogy of Fallot: Not mentioned in the original document, it is an important congenital heart defect encompassing four defects: VSD, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta.
    • Coarctation of the Aorta:
      • Another significant congenital heart defect not mentioned in the original document.
      • Presents with upper body hypertension and weak femoral pulses.
    • General Considerations: Congenital heart diseases often manifest with varied murmurs and can lead to complications like cyanosis, heart failure, or pulmonary hypertension. Early detection and intervention are crucial for positive outcomes.

    Common Treatments for Cardiac Conditions

    • Cardiac Tamponade: Pericardiocentesis and IV fluids in shock.
    • Acute Pericarditis: NSAIDs, Colchicine, and Corticosteroids are used.
    • Cardiomyopathies:
      • Dilated Cardiomyopathy: ACE inhibitors, beta-blockers, diuretics.
      • Hypertrophic Cardiomyopathy: Beta-blockers, calcium channel blockers, and implantable cardioverter-defibrillator (ICD) for arrhythmia.
      • Restrictive Cardiomyopathy: Beta-blockers, diuretics, digoxin.
    • AV Conduction Blocks:
      • First-degree AV Block: No treatment necessary.
      • Second-degree Mobitz I: Atropine (if symptomatic)
      • Second-degree Mobitz II: Pacemaker.
      • Third-degree AV Block: Immediate – Atropine and transcutaneous pacing; Definitive – Pacemaker.
    • Arrhythmias:
      • Class I Antiarrhythmics: Quinidine, Lidocaine
      • Class II Antiarrhythmics: Beta-blockers (Metoprolol)
      • Class III Antiarrhythmics: Amiodarone
      • Class IV Antiarrhythmics: Calcium Channel Blockers (Verapamil)
    • Angina:
      • Nitrates: Nitroglycerin, Isosorbide dinitrate
      • Calcium Channel Blockers: Verapamil, Diltiazem
      • Beta-blockers: Atenolol, Bisoprolol, Metoprolol
      • Ivabradine

    Side Effects of Cardiac Treatments

    • Antiarrhythmic Medications:
      • Class I: Cinchonism: Headache, tinnitus
      • Class II (Beta-blockers): Exacerbation of COPD and asthma, AV block
      • Class III (Amiodarone): Pulmonary fibrosis, hepatotoxicity, hypo or hyperthyroidism, corneal deposits.
      • Sotalol and Ibutilide: Torsades de pointes
      • Class IV (Calcium Channel Blockers): Edema, constipation, AV block.
    • Other Antiarrhythmics:
      • Adenosine: Hypotension, flushing, bronchospasm.
    • Anti-Anginal Medications:
      • Nitrates: Headache, tolerance, interaction with sildenafil
      • Calcium Channel Blockers: Bradycardia, transient asystole
      • Beta-blockers: Bradycardia, AV block
      • Ivabradine: Phosphenes (visual disturbances)
    • Pacemakers and ICDs: Infection, bleeding, lead displacement, device malfunction.

    Key Points for PLAB-1 Cardiology

    • Remember the modified Duke criteria for infective endocarditis.
    • Differentiate between cyanotic and acyanotic congenital heart diseases.
    • Know the management of atrial fibrillation based on stability.
    • Understand the differences between ventricular tachycardia (VT) and ventricular fibrillation (VF), especially in terms of management.
    • Be familiar with pre-treatment tests for amiodarone.
    • Recognize the importance of electrolyte imbalances in arrhythmias.
    • Understand the basics of ECG interpretation for common arrhythmias.

    Electrolyte Imbalances and Cardiac Conditions for PLAB-1

    • Hypokalaemia (K+): Can lead to arrhythmias like ventricular tachycardia (VT) and torsades de pointes. It can also exacerbate the effects of digoxin.
    • Hyperkalaemia (K+): Can cause bradycardia, heart block, ventricular fibrillation (VF), and cardiac arrest.
    • Hypocalcemia (Ca2+): Can prolong the QT interval, increasing the risk of torsades de pointes.
    • Hypercalcemia (Ca2+): Can lead to bradycardia, heart block, and arrhythmias.
    • Hypomagnesemia (Mg2+): Can cause arrhythmias, especially torsades de pointes. It can also worsen hypokalemia.
    • Hypermagnesemia (Mg2+): Can lead to bradycardia, heart block, and cardiac arrest. The effects of hypermagnesemia are usually seen in patients with renal failure.

    Cardiac Tamponade

    • Accumulation of fluid in the pericardial space, obstructing blood flow into ventricles.
    • Causes: Acute pericarditis, aortic dissection, trauma.
    • Beck's Triad: Hypotension, muffled heart sounds, raised jugular venous pressure (prominent "x" descent, absent "y" descent).
    • Paradoxical pulse: >10 mmHg inspiratory drop in systolic blood pressure.
    • Mechanism of paradoxical pulse: During inspiration, increased blood flow to the right ventricle causes the interventricular septum to bulge towards the left ventricle, decreasing left ventricular volume and reducing cardiac output.

    Cardiac Tamponade: Diagnosis and Treatment

    • Diagnosis: Echocardiography (investigation of choice), reduced amplitude QRS complexes on ECG, electrical alternans on ECG.
    • Treatment: Pericardiocentesis, intravenous fluids (if patient is in shock).

    Acute Pericarditis

    • Inflammation of the pericardium.
    • Presentation: Sharp, pleuritic chest pain that intensifies during inspiration, relieved by leaning forward.
    • Auscultation: Friction rub.
    • ECG: Widespread saddle-shaped ST elevation.

    Acute Pericarditis: Causes and Treatment

    • Causes: Viral infections (e.g., coxsackievirus B), post-myocardial infarction (fibrinous pericarditis) and Dressler syndrome, autoimmune disorders (systemic lupus erythematosus, rheumatoid arthritis), uremia, radiation therapy.
    • Treatment: Non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, corticosteroids.

    Cardiac Murmurs: Mitral Valve Disorders

    • Mitral stenosis: Mid-diastolic murmur at cardiac apex, associated with opening snap.
    • Mitral regurgitation: Pansystolic murmur at apex radiating to the axilla.

    Cardiac Murmurs: Aortic Valve Disorders

    • Aortic stenosis: Crescendo/decrescendo systolic murmur.
    • Aortic regurgitation: Diastolic decrescendo murmur, bounding pulse, wide pulse pressure.

    Cardiac Murmurs: Other Defects

    • Ventricular septal defect (VSD): Pansystolic murmur, chronic VSD - possible shunt reversal (Eisenmenger syndrome).
    • Tricuspid regurgitation: Pansystolic murmur at the left lower sternal border.
    • Patent ductus arteriosus: Continuous machinery murmur, best heard in the left infraclavicular area.

    Cardiac Murmurs: Hypertrophic Obstructive Cardiomyopathy

    • Crescendo/decrescendo systolic murmur.
    • Murmur increases with: Valsalva maneuver, standing up (decreased preload).

    Cardiomyopathy: Types and Features

    • Dilated cardiomyopathy: Causes: Alcohol, viral myocarditis, doxorubicin. Features: Systolic dysfunction, heart failure, S3 heart sound.
    • Hypertrophic cardiomyopathy: Cause: Autosomal dominant mutation. Features: Diastolic dysfunction, syncope during exercise.
    • Restrictive cardiomyopathy: Causes: Amyloidosis, sarcoidosis, post-radiation fibrosis. Features: Diastolic Dysfunction, right-sided symptoms (edema, ascites).

    Cardiomyopathy: Treatment Approaches

    • Dilated cardiomyopathy: ACE inhibitors, beta-blockers, diuretics.
    • Hypertrophic cardiomyopathy: Beta-blockers or calcium channel blockers, implantable cardioverter-defibrillator (ICD) for arrhythmias.
    • Restrictive cardiomyopathy: Beta-blockers, diuretics, digoxin.

    AV Conduction Block: First-Degree

    • Prolonged PR interval (>200ms).
    • All P waves conducted.
    • Treatment: No treatment required.

    AV Conduction Block: Second-Degree Mobitz Type I

    • PR interval lengthens progressively until a beat is missed.
    • Variable RR interval.
    • Treatment: If hypotension or bradycardia present, treat with atropine.

    AV Conduction Block: Second-Degree Mobitz Type II

    • Dropped beats (QRS complex).
    • Fixed PR interval.
    • Treatment: Pacemaker.

    AV Conduction Block: Third-Degree (Complete)

    • Atria and ventricles contract independently.
    • No association between P wave and QRS complex.
    • Causes: Myocardial infarction, Lyme disease.
    • Treatment: Immediate: Atropine 500 mcg IV followed by transcutaneous pacing. Definitive: Pacemaker.

    Anti-arrhythmic Medications: Class I and II

    • Class I (Sodium channel blockers): Drugs: Quinidine, lidocaine. Uses: Atrial and ventricular arrhythmias. Side effects: Cinchonism (headache, tinnitus).
    • Class II (Beta-blockers): Drug: Metoprolol. Uses: Supraventricular tachycardia (SVT), rate control for atrial fibrillation (AF) and atrial flutter. Side effects: COPD/asthma exacerbation, AV block.

    Anti-arrhythmic Medications: Class III and IV

    • Class III (Potassium channel blockers): Drug: Amiodarone. Uses: Ventricular tachycardia. Side effects: Pulmonary fibrosis, hepatotoxicity, thyroid dysfunction, corneal deposits.
    • Class IV (Calcium channel blockers): Drug: Verapamil. Uses: Rate control in AF. Side effects: Edema, constipation, AV block.

    Anti-anginal Medications: Nitrates and CCBs

    • Nitrates: Drugs: Nitroglycerin, Isosorbide dinitrate. Mechanism: Reduces preload, decreases myocardial oxygen requirements. Side effects: Headache, tolerance, interaction with sildenafil.
    • Calcium Channel Blockers: Drugs: Verapamil, Diltiazem. Mechanism: Decreases cardiac contractility, vasodilation, reduces afterload. Side effects: Bradycardia, transient asystole.

    Anti-anginal Medications: Beta-blockers and Ivabradine

    • Beta-blockers: Drugs: Atenolol, Bisoprolol, Metoprolol. Mechanism: Decreases myocardial oxygen requirements by reducing heart rate. Side effects: Bradycardia, AV block.
    • Ivabradine: Mechanism: Reduces heart rate. Side effect: Phosphenes (visual disturbances).

    Amiodarone: Pre-treatment Tests

    • Essential tests before starting amiodarone: Thyroid function tests, liver function tests, serum electrolyte and urea measurement (crucial), chest radiography, electrocardiography.

    Cyanotic Congenital Heart Diseases

    • Tricuspid atresia: Absent tricuspid valve, associated with ASD and VSD.
    • Transposition of great arteries: Pulmonary artery exits from the left ventricle, aorta leaves from the right ventricle.
    • Tetralogy of Fallot: Four key features: Pulmonary stenosis, right ventricular hypertrophy, overriding of the aorta, VSD. X-ray: Boot-shaped heart. Clinical: Squatting spells.
    • Persistent truncus arteriosus: Failure of truncus arteriosus to form pulmonary trunk and aorta.
    • Ebstein anomaly: Atrialization of the right ventricle, associated with lithium use during pregnancy.
    • Total anomalous pulmonary venous connection: Pulmonary vein drains into the right heart.

    Acyanotic Congenital Heart Diseases

    • Ventricular septal defect (VSD): Most common congenital heart defect, pansystolic murmur.
    • Atrial septal defect (ASD): Fixed split S2.
    • Patent ductus arteriosus (PDA): Continuous machinery murmur in the left infrascapular region.
    • Coarctation of aorta: Associated with Turner Syndrome. Hypertension in the upper limb with brachiofemoral delay. Increased risk of berry aneurysms and cerebral hemorrhage.
    • Eisenmenger syndrome: Long-standing left-to-right shunts (VSD, ASD, PDA). Progression: Pulmonary hypertension → Shunt reversal → Late cyanosis and clubbing.

    Hypertension: Definition and Medications

    • Definition: Clinic BP ≥ 140/90 mmHg, Ambulatory BP measurement ≥ 135/85 mmHg.
    • Medications: ACE inhibitors, calcium channel blockers, thiazide diuretics.
    • Side effects: ACE inhibitors: Cough, angioedema, hyperkalemia. Calcium channel blockers: Peripheral edema, dizziness, flushing. Thiazide diuretics: Hypokalemia, hyperuricemia, postural hypotension, increased serum lithium levels.

    Postural Hypotension

    • Definition: A drop in blood pressure upon standing.
    • Key consideration: Patients on multiple antihypertensive medications.
    • Clinical pearl: Always consider postural hypotension in hypertensive patients with recurrent falls.

    Infective Endocarditis: Risk Factors and Signs

    • Risk factors: Valvular heart disease, valve replacement, previous episode of IE (highest risk), intravenous drug use.
    • Signs: Murmur and fever, Roth spots (white spots on retina surrounded by hemorrhage), Osler nodes (raised and tender lesions on fingers), Janeway lesions (painless, erythematous lesions on palm or sole), splinter hemorrhages on nail beds.

    Infective Endocarditis: Etiology and Diagnosis

    • Common causes: Streptococci and Staphylococcus aureus.
    • Mitral valve commonly affected.
    • In injection drug users: Tricuspid valve involvement, often Staphylococci.

    Infective Endocarditis

    • Diagnostic Approach:
      • New murmur and fever should raise suspicion of Infective Endocarditis (IE).
      • Initial steps involve blood culture followed by Echocardiography.
    • Modified Duke Criteria:
      • Diagnosis of IE requires either:
        • Two major criteria OR
        • One major criterion and three minor criteria OR
        • Five minor criteria.

    Infective Endocarditis: Management

    • Native Valve:
      • Amoxicillin + Gentamicin are the standard antibiotics.
      • For Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin + Gentamicin are used.
    • Prosthetic Valve:
      • Vancomycin + Gentamicin + Rifampin are the preferred antibiotics.

    Atrial Fibrillation

    • Characteristics:
      • Irregular RR interval.
      • No discrete P waves.
      • Irregularly irregular pulse rate.
    • Treatment:
      • Unstable vitals: Electrical cardioversion, beta-blockers, and anticoagulation.
      • Stable vitals: Rate control with beta-blockers, rhythm control with amiodarone or flecainide, and anticoagulation with warfarin or NOACs.
      • CHA2DS2-VASc Score determines the need for anticoagulation.

    Atrial Flutter

    • Characteristics:
      • Identical and rapid back-to-back P waves.
      • Sawtooth appearance on ECG.
    • Treatment:
      • Similar to atrial fibrillation.

    Torsades de Pointes

    • Definition:
      • A type of polymorphic ventricular tachycardia.
      • QRS complexes appear to twist around the baseline on ECG.
      • Associated with QT prolongation.
    • Causes:
      • Long QT syndrome.
      • Electrolyte abnormalities (hypomagnesemia, hypokalemia, hypocalcemia).
      • Medications (antipsychotics, erythromycin).
    • Treatment:
      • IV magnesium sulphate.
      • Correction of electrolyte abnormalities.
      • Removal of causative drug.
      • Defibrillation if it progresses to ventricular fibrillation (VF).

    Ventricular Tachycardia (VT)

    • Features:
      • Wide QRS complex (broad complex tachycardia).
      • Can progress to VF.
    • Management:
      • Unstable vitals: Cardioversion if pulse is present; Defibrillation if no pulse.
      • Stable vitals: Beta-blockers, non-dihydropyridine calcium channel blockers (CCB), sodium channel blockers.

    Ventricular Fibrillation (VF)

    • Characteristics:
      • Completely disordered ventricular electrical activity.
      • No identifiable QRS complexes.
      • Always pulseless.
    • Treatment:
      • Immediate defibrillation to restore sinus rhythm.
    • Clinical Pearl:
      • In broad complex tachycardia with hemodynamic instability:
        • If pulse present, cardioversion.
        • If no pulse, defibrillation (unsynchronized cardioversion).

    Wolff-Parkinson-White Syndrome

    • Characteristics:
      • Pre-excitation on ECG.
      • Delta waves.
      • Prolonged QRS complex.
    • Clinical Presentation:
      • Sudden onset of symptoms (pallor, palpitations, difficulty breathing).
      • Often presents in children or young adults.
      • Symptoms may resolve spontaneously.

    Supraventricular Tachycardia (SVT)

    • Definition:
      • Rapid heart rhythm originating above the ventricles.
    • Characteristics:
      • Narrow QRS complex (unless aberrant conduction).
      • Regular rhythm.
      • Sudden onset and termination.
    • Common Types:
      • AV Nodal Reentrant Tachycardia (AVNRT).
      • AV Reentrant Tachycardia (AVRT).
      • Atrial Tachycardia.

    Congenital Heart Diseases: Key Points

    • Ventricular Septal Defect (VSD):
      • Characterized by a pansystolic murmur.
      • In chronic cases, can lead to Eisenmenger syndrome (shunt reversal).
    • Patent Ductus Arteriosus (PDA):
      • Presents with a continuous machinery murmur.
      • Best heard in the left infraclavicular area.
    • Atrial Septal Defect (ASD):
      • Often presents with a fixed splitting of the S2 heart sound.
    • Tetralogy of Fallot:
      • Consists of four defects: VSD, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta.
    • Coarctation of the Aorta:
      • Presents with upper body hypertension and weak femoral pulses.
    • General Considerations:
      • Congenital heart diseases can present with various murmurs.
      • May lead to complications like cyanosis, heart failure, or pulmonary hypertension.
      • Early detection and intervention are crucial for better outcomes.

    Common Treatments for Cardiac Conditions

    • Cardiac Tamponade:
      • Pericardiocentesis.
      • IV fluids (if patient is in shock).
    • Acute Pericarditis:
      • NSAIDs.
      • Colchicine.
      • Corticosteroids.
    • Cardiomyopathies:
      • Dilated: ACE inhibitors, beta-blockers, diuretics.
      • Hypertrophic: Beta-blockers, calcium channel blockers, implantable cardioverter-defibrillator (ICD) for arrhythmia.
      • Restrictive: Beta-blockers, diuretics, digoxin.
    • AV Conduction Blocks:
      • First-degree: No treatment required.
      • Second-degree Mobitz I: Atropine if symptomatic.
      • Second-degree Mobitz II: Pacemaker.
      • Third-degree: Immediate - Atropine and transcutaneous pacing, Definitive - Pacemaker.
    • Arrhythmias:
      • Class I antiarrhythmics: (e.g., quinidine, lidocaine)
      • Class II antiarrhythmics: (beta-blockers, e.g., metoprolol)
      • Class III antiarrhythmics: (e.g., amiodarone)
      • Class IV antiarrhythmics: (calcium channel blockers, e.g., verapamil).
    • Angina:
      • Nitrates (e.g., nitroglycerin, isosorbide dinitrate).
      • Calcium channel blockers (e.g., verapamil, diltiazem).
      • Beta-blockers (e.g., atenolol, bisoprolol, metoprolol).
      • Ivabradine.

    Side Effects of Cardiac Treatments

    • Antiarrhythmic Medications:
      • Class I (e.g., Quinidine):
        • Cinchonism: Headache, tinnitus.
      • Class II (Beta-blockers):
        • Exacerbation of COPD and asthma.
        • AV block.
      • Class III (e.g., Amiodarone):
        • Pulmonary fibrosis.
        • Hepatotoxicity.
        • Hypo or hyperthyroidism.
        • Corneal deposits.
      • Class IV (Calcium Channel Blockers):
        • Edema.
        • Constipation.
        • AV block.
    • Other Antiarrhythmics:
      • Adenosine:
        • Hypotension.
        • Flushing.
        • Bronchospasm.
    • Anti-anginal Medications:
      • Nitrates:
        • Headache.
        • Tolerance.
        • Interaction with sildenafil.
      • Calcium Channel Blockers:
        • Bradycardia.
        • Transient asystole.
      • Beta-blockers:
        • Bradycardia.
        • AV block.
      • Ivabradine:
        • Phosphenes (visual disturbances).
    • Pacemakers and ICDs:
      • Infection.
      • Bleeding.
      • Lead displacement.
      • Device malfunction.

    Key Points for PLAB-1 Cardiology

    • Remember the modified Duke criteria for Infective Endocarditis.
    • Differentiate between cyanotic and acyanotic congenital heart diseases.
    • Know the management of Atrial Fibrillation based on stability.
    • Understand the differences between VT and VF, especially in terms of management.
    • Be familiar with pre-treatment tests for amiodarone.
    • Recognize the importance of electrolyte imbalances in arrhythmias.
    • Understand the basics of ECG interpretation for common arrhythmias.

    Electrolyte Imbalances and Cardiac Conditions for PLAB-1

    • Hypokalaemia (K+):
      • Can lead to various arrhythmias, including VT, VF, and Torsades de Pointes.
    • Hypomagnesaemia (Mg2+):
      • Can also contribute to Torsades de Pointes and other arrhythmias.
    • Hypocalcaemia (Ca2+):
      • May cause prolonged QT interval and increased risk of Torsades de Pointes.

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    This quiz covers the essential concepts of cardiac tamponade and acute pericarditis, including their causes, symptoms, and diagnostic methods. Focus areas include Beck's triad, paradoxical pulse, and crucial treatment options. Test your knowledge on the clinical aspects of these conditions.

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