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CARDIOLOGY

Long QT syndrome - usually due to loss-of-function/blockage of K+ channels

Magnesium sulphate - monitor reflexes + respiratory rate

Most common clinical feature of hypermagnesemia = Hypotension ( FCPS July 22)

Atrial fibrillation is associated more with atrial septal defects

Most common cause of endocarditis:

 Staphylococcus aureus
 Staphylococcus epidermidis if < 2 months post valve surgery

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

 A 28-year-old woman presents with palpitations. Her heart rate is


160/min and irregular. Her blood pressure is 123/65 mmHg, and her
oxygen saturation is 97% on breathing room air. Her chest is clear on
auscultation. Her ECG shows irregular broad complex monomorphic
tachycardia with a stable axis. She has no previous medical history and
has never been to a hospital before. What is the most appropriate
treatment?

 Diltiazem3%Bisoprolol13%Amiodarone58%Magnesium14%Adenosine1
2%

The correct answer is amiodarone. This a haemodynamically stable
patient with irregular broad complex tachycardia. As the broad-
complex tachycardia is irregular it is most likely atrial fibrillation with
left bundle branch block or an alternative aberrant conduction pathway
such as Wolff-Parkinson-White syndrome. Diltiazem, bisoprolol and
adenosine are all contraindicated as they could enhance the aberrant
pathway leading to ventricular fibrillation. Magnesium would be
appropriate for torsades de pointes but is unlikely as the rhythm is
monomorphic.

The patient reports no chest pain or pre-syncope. The initial ECG shows a
regular broad complex tachycardia (QRS 152) with a rate of 110. P-waves are
visible and appear associated with QRS complexes. RS waves are seen in the
precordial leads. The RS duration is less than 100ms. There is an RSR'
pattern in V1 and V2.

What is the most appropriate initial management for this patient?

Adenosine8%Amiodarone46%DC cardioversion6%Digoxin3%Vagal
manoeuvres36%

Atrioventricular dissociation suggests VT rather than SVT with aberrant


conduction
Important for meLess important
The patient has present with a tachyarrhythmia with no adverse features.
The ECG findings suggest a regular broad complex tachycardia. The main
distinction to make here is whether this is ventricular tachycardia (VT) or
supraventricular tachycardia (SVT) with aberrant conduction as the
management is different.

The Brugada algorithm can be used to differentiate between SVT with


aberrant conduction and VT. An absence of RS complexes (i.e. either
monophasic R or S waves) in all precordial or an R to S interval is >100ms in
one precordial lead is suggestive of VT. Importantly, if there is AV
dissociation then this is also suggestive of VT.

In the ECG presented there are RS waves in the precordial leads with AV
association. There is also an RSR' pattern seen. This is suggestive therefore
of an SVT with RBBB.

As per the ALS algorithm, the patient should therefore be treated as an SVT.
The first line for SVT would be vagal manoeuvres followed by adenosine. As
vagal manoeuvres have not yet been tried this would be the first treatment
option.

Amiodarone would be indicated in VT.

Aortic regurgitation typically causes an early diastolic murmur and is seen


in tertiary cardiovascular syphilis and rheumatoid arthritis. Aortic
regurgitation is the most frequent complication of syphilitic aortitis, occurring
in 60% of those with cardiovascular syphilis. Aortic incompetence secondary
to connective tissue diseases including rheumatoid arthritis has a relatively
accelerated course rapidly leading to severe left ventricular failure.

Severe pre-eclampsia is associated with hyperreflexia and clonus. A low


platelet count may indicate the patient is developing HELLP syndrome

Fondaparinux works in a similar way to low-molecular weight


heparin – activates Anti Thrombin 3

The recommended dose of adrenaline to give during advanced ALS is 1mg

HOCM - poor prognostic factor on echo = septal wall thickness of > 3cm

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