Master Cardiology
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Core Concepts
Cardiology covers the heart and vascular system, focusing on conditions impacting cardiac function, rhythm, and structural integrity. Key concepts include the cardiac cycle (preload, afterload, contractility, stroke volume, cardiac output), basic ECG interpretation (rhythm, rate, axis, intervals, ST/T changes), and the pathophysiology of common conditions like heart failure, ischemic heart disease, valvular disorders, and arrhythmias. Understanding the distinction between systolic (HFrEF) and diastolic (HFpEF) heart failure, stable angina vs. acute coronary syndromes (ACS), and common valvular lesions is crucial.
Clinical Presentation
- Chest Pain: Ischemic (exertional, retrosternal, radiating, relieved by rest/GTN) vs. non-ischemic (pleuritic, positional, sharp).
- Dyspnoea: Exertional, orthopnoea, paroxysmal nocturnal dyspnoea (PND) suggest heart failure. Acute onset with pleuritic pain and haemoptysis suggests PE.
- Palpitations: Awareness of heart beat. Regular/irregular, fast/slow helps differentiate arrhythmias.
- Syncope/Pre-syncope: Transient loss of consciousness due to global cerebral hypoperfusion. Suspect arrhythmias, severe aortic stenosis, HOCM.
- Oedema: Bilateral pitting lower limb oedema suggests right heart failure.
- Murmurs: Systolic (AS, MR, TR, VSD, HOCM) vs. Diastolic (AR, MS). Timing, location, radiation, character are key.
- JVP: Elevated JVP with hepatojugular reflux in right heart failure, tamponade.
- Peripheral Signs: Cyanosis, clubbing, splinter haemorrhages (endocarditis), radio-femoral delay (coarctation), xanthelasma/corneal arcus (hyperlipidaemia).
Diagnosis (Gold Standard)
The gold standard for diagnosis varies by condition:
- Ischemic Heart Disease (ACS): ECG (ST elevation/depression, T wave inversion), Serial Troponins (cardiac specific, rise and fall pattern). Invasive Coronary Angiography is gold standard for CAD.
- Heart Failure: Echocardiography (assessment of LV function, valvular disease, chamber size). BNP/NT-proBNP are useful biomarkers.
- Valvular Heart Disease: Echocardiography (Doppler assessment of valve function and gradients).
- Arrhythmias: 12-lead ECG for symptomatic events. 24-hour Holter or prolonged ambulatory ECG monitoring for paroxysmal/intermittent arrhythmias.
- Hypertension: 24-hour Ambulatory Blood Pressure Monitoring (ABPM) for diagnosis confirmation and white-coat hypertension exclusion.
- Pericardial Effusion/Tamponade: Echocardiography.
- Cardiomyopathies: Echocardiography, Cardiac MRI (CMR) for detailed tissue characterisation.
Management (First Line)
- Acute Coronary Syndrome (ACS): MONA (Morphine, Oxygen if SpO2 <90%, Nitrates, Aspirin) + Clopidogrel/Ticagrelor/Prasugrel. Reperfusion via Primary PCI (STEMI) or Fibrinolysis (if PCI delayed).
- Heart Failure with Reduced Ejection Fraction (HFrEF): ACE inhibitor (or ARB), Beta-blocker, Mineralocorticoid Receptor Antagonist (MRA) (e.g., Spironolactone), SGLT2 inhibitor (e.g., Dapagliflozin). Diuretics for symptom relief.
- Hypertension: Lifestyle modification. First-line drugs depend on age/ethnicity: ACEi/ARB, Calcium Channel Blocker (CCB), Thiazide-like diuretic.
- Atrial Fibrillation (AF): Rate control (beta-blocker, rate-limiting CCB like diltiazem) vs. Rhythm control (amiodarone, flecainide). Anticoagulation based on CHA2DS2-VASc score (DOACs preferred over Warfarin).
- Valvular Heart Disease: Medical management of symptoms (e.g., diuretics for HF symptoms). Surgical valve repair/replacement or Transcatheter Aortic Valve Implantation (TAVI) for severe symptomatic disease.
- Acute Pericarditis: NSAIDs (e.g., ibuprofen) + colchicine.
Exam Red Flags
- Sudden onset severe tearing chest pain radiating to the back: Aortic Dissection.
- Hypotension, elevated JVP, muffled heart sounds (Beck's Triad): Cardiac Tamponade.
- Systolic ejection murmur radiating to carotids with syncope, angina, dyspnoea: Severe Aortic Stenosis.
- New murmur, fever, positive blood cultures, peripheral stigmata (e.g., Janeway lesions, Osler's nodes, Roth spots): Infective Endocarditis.
- Broad complex tachycardia: Assume Ventricular Tachycardia (VT) until proven otherwise – treat urgently.
- Pulseless Electrical Activity (PEA) arrest: Consider reversible causes (H's and T's: Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia, Hypothermia; Toxins, Tamponade, Tension Pneumothorax, Thrombosis - coronary/pulmonary).
- Patient presenting with worsening HF symptoms post viral illness: Myocarditis.
Sample Practice Questions
A 28-year-old pregnant woman in her second trimester presents with a new-onset pansystolic murmur best heard at the apex, radiating to the axilla. She denies any dyspnoea, chest pain, or palpitations. Her medical history is unremarkable. Echocardiography confirms mild mitral regurgitation. What is the most likely cause of this finding?
A 65-year-old male with a history of hypertension and dyslipidemia presents with exertional chest pain that is relieved by rest. He describes the pain as a pressure-like sensation in his retrosternal area, radiating to his left arm. The pain typically lasts for 5-10 minutes. His ECG at rest shows non-specific ST-T changes. Which of the following is the most appropriate initial management for this patient?
A 72-year-old man, a known diabetic, presents with recurrent episodes of dizziness and syncope. His heart rate is consistently 38 bpm. His ECG shows broad QRS complexes with no discernible P waves and a slow, regular rhythm. His blood pressure is 90/60 mmHg. Which of the following is the most appropriate initial management for this patient?
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