key concepts

• In the context of a tachyarrhythmia, a systolic BP < 90 mmHg → DC cardioversion
• Angiotensin-receptor blockers should be used where ACE inhibitors are not tolerated e.g. with a dry, persistent cough
• Ventricular tachycardia - verapamil is contraindicated
• The most specific ECG finding in acute pericarditis is PR depression
• Aortic regurgitation is associated with Marfan syndrome and typically presents with the triad of angina, syncope and heart failure. The typical sign is slow rising/ collapsing pulse with wide pulse pressure.
• Mobitz type 1 (Wenckebach phenomenon, which typically causes progressively longer PR intervals before an entire QRS is dropped, normally at a regular interval e.g. every third or fourth beat) is a normal variant in an athlete
• Patients with bradycardia and signs of shock require 500micrograms of atropine (repeated up to max 3mg)
• Risk of falls or old age alone is not sufficient reasoning to withhold anticoagulation
• Mitral stenosis - mid-late diastolic murmur, 'rumbling' in character
• Angiotensin-receptor blockers should be used where ACE inhibitors are not tolerated
• Antibiotic prohylaxis to prevent infective endocarditis is not routinely recommended in the UK for dental and other procedures
• A single episode of paroxysmal atrial fibrillation, even if provoked, should still prompt consideration of anticoagulation
• Mechanical valves - target INR:

  • aortic: 3.0
  • mitral: 3.5
• Offer a mineralcorticoid receptor antagonist, in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure
• Hypertrophic obstructive cardiomyopathy (HOCM) may occasionally be associated with a bisferiens pulse
• Dextrocardia is associated with an inverted P wave in lead I, right axis deviation, and loss of R wave progression
• Thiazide diuretics can cause hypercalcaemia and hypocalciuria
• Adenosine may cause iatrogenic chest pain
• Flash pulmonary oedema can occur after acute mitral valve regurgitation due to myocardial infarction
• The Pulmonary Embolism Severity Index (PESI) score is recommended by BTS guidelines to be used to help identify patients with a pulmonary embolism that can be managed as outpatients
• ACS management: nitrates should be used with caution if the patient is hypotensive
• A false lumen is a key finding suggestive of aortic dissection on CT angiography
• NSTEMI management: patients with a GRACE score > 3% should have coronary angiography within 72 hours of admission
• QT interval: Time between the start of the Q wave and the end of the T wave
• Acute heart failure not responding to treatment - consider CPAP
• Risk factors for asystole in bradycardia (? needs transvenous pacing)

  • complete heart block with broad complex QRS
  • recent asystole
  • Mobitz type II AV block
  • ventricular pause > 3 seconds
• Ischaemic changes in leads I, aVL +/- V5-6 - left circumflex
• Antibiotic prohylaxis to prevent infective endocarditis is not routinely recommended in the UK for dental and other procedures
• Hydrazine and nitrate should be considered for Afro-Caribbean patients with heart failure who are not responding to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy
• Aortic stenosis - most common cause:

  • younger patients < 65 years: bicuspid aortic valve
  • older patients > 65 years: calcification
• Collapsing pulse is a feature of aortic regurgitation, PDA, and hyperdynamic states (anaemia, thyrotoxicosis, fever, exercise/pregnancy)
• Diastolic murmur + AF → ?mitral stenosis
• A synchronised cardioversion is the treatment for a unstable patient in VT
• Massive PE + hypotension - thrombolyse with alteplase
• Coarctation of the aorta, a congenital heart defect characterised by narrowing of the descending aorta, is commonly associated with having a bicuspid aortic valve
• Saddle-shaped ST elevation is often seen in the ECG of a patient with acute pericarditis
• Intracranial haemorrhage on warfarin → give IV vitamin K 5mg + prothrombin complex concentrate
• Beta-blockers reduce hypoglycaemic awareness
• In AF with decompensation the correct management is synchronised DC cardioversion
• In ALS, a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered