CARDIOLOGY QUICK REVISION

Infective endocarditis
• Congestive heart failure
Rheumatic fever

O
• Cardiomyopathies
• Heart sounds Coronary artery disease
• JVP Systemic hypertension
• Cardiac murmurs Acute Pericarditis
• Arterial pulse
Constrictive pericarditis
• Mitral stenosis
Cardiac tamponade
• Mitral regurgitation
• Aortic stenosis Image based questions
• Aortic regurgitation Previous year questions
• Mitral valve prolapse
3
as
• Most common cause of Right heart failure  Left heart failure

• Most common cause of acute corpulmonale Massive pulmonary

embolism

• Most common cause of chronic corpulmonale COPD

Classification of Heart failure -EF 55 701

in AREF 40
HfpEF 50
I

I DCMP

HEMP CAD

RCMP MRIAR
As
EMF
Earliest manifestation of left heart failure
• Paroxysmal nocturnal dypnea  orthopnea Dyspnea on exertion
Dyspnea at rest
 NYHA – Fatigue , Palpitations, Dyspnea
Class Patient symptoms

Class 1 No limitation of physical activity.

Ordinary physical activity does not cause
symptoms

O
Class 2 Slight limitation of physical activity .
Comfortable at rest. r
Class 3
e
Ordinary physical activity causes symptoms .
Marked limitation of physical activity.
Less than ordinary activity causes symptoms.

Class 4
e
Unable to carry out any physical activity
without discomfort
Earliest manifestation of right heart failure O

O
• Hepatojugular reflex is positive  JVP raised
Pattern of breathing in congestive heart failure

APN
Name of the criteria for congestive heart failure

• Framinghams criteria
Which CXR is suggestive
of increased Pulmonary
venous pressure ? Alveolar

• A
• B
1
• C
• D

G
Ear Kerley B

f
Cardiac biomarker for congestive heart failure
• NT pro BNP Most sensitive
• ANP
• Adrenomedullin ventricles
• Endothelin
I

vascular resistance
 or
Drug of choice for Acute left ventricular failure

• Furosemide
 Treatment of Acute Heart Failure
Oxygen & Ventilatory Morphine Vasodilators Diuretics Ionotropic agents
support

t CSBP 90

II pre load

NEG
Drugs for chronic heart failure
• Drugs which improve the mortality :-
• Beta blockers
• ACE inhibitors/ARBs
• Aldosterone antagonists B

m Msu ee
low dose
c
Preferred drug for HFrEF
• Valsartan + Secubitril
O
MI ARNI
ARB
 I
What is the drug of choice in heart failure with Atrial
fibrillation ?
• Digoxin
What are the good choice of drugs for diabetes in patients at
risk for heart failure?
• SGLT 2 inhibitors – Dapagliflozin
The image shows presence of:
F
a. Implantable cardioverter
defibrillator

b. Cardiac resynchronization s
therapy

c. Dual pacing 2

d. Transvenous pacemaker 1 2

20
 r

E r
e
Cardiomyopathies

H R
D
t
MC
• 44/F k/c/o of breast cancer is on chemotherapy since 2 yrs. She is
HER2 receptor positive. She presented to the ED with h/o dyspnea.
She takes the drug s/c. Which drug is she taking?
A. Adriamycin
B. Transtuzumab
C. Daunorubicin Damp
D. Cyclophosphamide
Most common toxin causing Dilated cardiomyopathy

O
• Alcohol & Chemotherapeutic drugs

MC
 O
What are the inflammatory causes of DCMP?
• Autoimmune conditions
DA

O
• Post infective
• Selenium deficiency
0
What are the nutritional causes of DCMP?

Keshen
• Thiamine deficiency I
e endocrine causes
What are the endocrine of DCM
causes of DCMP?
Endocrine causes of DCMP
• Diabetes
• Hypo and Hyper thyroidism
What are the hematological causes of DCMP?
O

• sickle cell anaemia

 O
What are the infiltrative causes of DCMP?
• Hemochromatosis

Ramp
30
What are the Neuromuscular causes of
DCMP?
• Muscular dystrophy DMD
• Fredericks ataxia
• Myotonic dystrophy y
What is the criteria for cardiomegaly ?

70.5 Adults

04 Neonates

c
2D Echo -HFrEF Cao t

• Dilated chambers

• Functional MR & TR

T MTPV0 BMP
AMPA

33
 O
Which of the following drugs is not given in dilated cardiomyopathy?
a. Beta blocker
b. Calcium channel blocker
c. Spironolactone
d. ACE inhibitors
 o o
• 24/M patient presented with h/o ataxia of gait with rhombergs sign
positive & dysmetria. He also c/o dyspnea on exeretion. Echo

p
showed EF of 30% with dilated chambers. What would be the
etiology?
A. Cerebellar ataxia
B. Freiderich ataxia
C. SACD
D. Selenium deficiency
Indication of this device in DCMP with LBBB patients?
CRT
A. QRS duration > 110msec
B. QRS duration > 100msec
C. QRS duration > 150msec
D. QRS duration > 120msec
1 3

Damp Refractory
32
to MM
t
Ors 120 for
 BBB Q S
Peripartum Cardiomyopathy

• Defined as:

O
• Features of dilated cardiomyopathy during the last month of pregnancy or
within 6 months of delivery

• Absence of a demonstrable cause for the cardiac failure

37
Risk factors for PPCMP
• Pre-eclampsia
O
• Multiparous females
• Elderly females
• Treatment

O
• Beta-blockers – Sotalol

• Bromocriptine
prolactin
• Diuretics, Hydralazine and Nitrates

u
• Treatment

• Beta-blockers have been administered judiciously to these patients, with

at least anecdotal success.

• Sotalol is acceptable for ventricular or atrial arrhythmias if other

beta-blockers are ineffective.

• Diuretics, hydralazine, and nitrates help treat the heart failure with
minimal risk to the fetus.
 I
• Tako Tsubo cardiomyopathy is a type of ?
A. Dilated cardiomyopathy
B. Restrictive cardiomyopathy
C. Hypertrophic cardiomyopathy
D. Toxic cardiomyopathy
Stress cardiomyopathy, also called :-

apical ballooning syndrome,

broken heart syndrome,

tako-tsubo cardiomyopathy.

42
• Modified Mayo criteria for Takotsubo Cardiomyopathy
(T.C.M)/ Broken heart syndrome

• 1. Transient hypokinesia/ akinesia of Left ventricle

• 2. Absence of any coronary artery occlusion by a thrombus

Q

• 3. ST segment elevation/T wave inversion or modest cardiac troponin

elevation

• 4. Absence of pheochromocytoma or myocarditis

• *Needs all four for diagnosis

43
Treatment
• Immediate therapy is similar to any acute MI.

• Most patients receive aspirin, beta-blockers, and ACE inhibitors until

the LV fully recovers. x
If cardiogenic shock

• Rx:If cardiogenic shock IABP CII AR

A Dissection

45
Drugs avoided :-
• Because causative agent is catecholamine excess 
Dopamine & Dobutamine should not be given.
80
O
so NE,

• SCD can happen

HYPERTROPHIC CARDIOMYOPATHY

AfpEF HEREF
 O
All are true regarding the specimen shown except:

a. Asymmetrical septal hypertrophy

b. Left ventricular outflow tract obstruction

c. Diamond-shaped cavity of left ventricle

d. Diastolic dysfunction I
Banang
Definition
• HFpEF Diastolic dysf
• LV wall is measured at more than 1.5 cm thick on an
echocardiogram.
 HOW
ASI
Banand

50
 Apical
I
Ace of Spades
•Mutations:-
MC - Beta-myosin heavy chain
followed by Myosin-binding protein C and
Troponin T.

It is autosomal dominant

Beta myosin gene - Chromosome 14.

These three genes account for 70% to 80% of all cases of HCM.
 o

o o
54
• Precordial auscultation:

O
• Normal or paradoxically split S2, S4,

P Bisteri

Double carotid

Double Al

55
Murmur
• Harsh systolic diamond-shaped
O murmur at LLSB or apex.

W obsta
l
ESM

volt u
A Lv

vote Ura
I w
I
2D echo
preferred
• EF

• SAM
K J
I
A
µ
A
57
 A
Dagger
q
te Th

O O
t
O O O

58
 ASH

59
Treatment

03
• Medical agents: DOC is Propranolol.

• Verapamil may also be used

60
61
RESTRICTIVE CARDIOMYOPATHY
• Restrictive cardiomyopathy - HFpEF 50 t

Diasto

63
• What is the most common etiology causing RCMP ?

• Amyloidosis MC

64
• How does Fabrys disease causes RCMP ?

O
• Fabrys disease –

• Enzyme deficiency - Alpha-galactosidase A (a-Gal A)

• Fat accumulated - Globotriaosylceramide .

• It is a type of lysosomal storage disorder.

65
 I
What is the antibody in this condition causing Restrictive
cardiomyopathy ?
A. Anti Smith
B. Anti centromere
C. Anti topoisomerase
D. Anti ds DNA

scleroderma
O
What is the adverse effect of the drug used for treatment in

o
the following condition causing RCMP?
A. Peptic ulcers

B. Weight loss

C. Distal muscle weakness

D. Dementia
sarcoidosis
00
 O
Thromboembolic complications

68
• On Examination – JVP:-

• Increased jugular venous pulse.

O
• Abnormal JVP waves – Deep X & Y wave

or
• Kussmaul's sign.

Never have sq

69
ECG:- Low voltage complexes

25mm Liomm
• Echocardiogram :-
Afp Ef

Amyloidosis

it
Treatment
• In acute cases - Excessive Odiuresis
Anticoagulation
• Atrial thrombi
 O
• Digoxin in RCMP may precipitate arrhythmias and should not be
used.
 O
• Q) Which is the location of Erb's point during auscultation?

a. A = 2nd intercostal space right parasternal

line

b. B = 2nd intercostal space left parasternal line

c. C = 3rd intercostal space left parasternal line

d. D = 5th intercostal space left parasternal line

75
• Aortic area —* Second intercostal
space to the right ofthe sternum
(along right upper sternal border).
• Pulmonic area — Second
intercostal space to the left of the
sternum (along left upper sternal
border)
• Erb'spoint — Third intercostal to
the left of the sternum (along left
sternal border).
• Tricuspid area —p Fourth or Fifth
intercostal space to the left of the
sternum (along left lower sternal
border).
• Mitral area (Apex) — Fifth
intercostal space on the left
midclavicular line.

76
O
S1
t
O
S2
t
S3 S4
t
protodiastole Ist rapid and rapid
IVC

filling filling
H
H L L

Dia Bell Bey

Dia
78
Abnormalities of first heart sound
LOUD S1 SOFT S1

Hyperkinetic states Decreased conduction of heart

sounds to the surface of chest
Mitral and Tricuspid stenosis

Calcified MS and TS

short PR interval
120
MR and TR

Prolonged PR interval
7200
Az Pr

Insp split
X
EXP

80
Wide Physiological Splitting of S2

I
Early A2 Delayed P2
Mitral regurgitation ASD
VSD Pulmonary stenosis
RBBB
LV ectopic beat
LV paced beat
A. ASD
t O
Causes of Fixed (wide) split s2 are all except?

Insp
B. VSD
a
variable
C. Pulmonic Stenosis
D. Acute Right Heart Failure
Exp

82
• Second heart sound is best heard at ?
A. Second right intercostal space parasternal line
B. Second left intercostal space parasternal line
C. 3rd left intercostal space parasternal line
D. 5th left intercostal space in mid clavicular line

83
3rd Heart sound are best heard with ?
•A

0
•B
•C
•D
3rd Heart sound is best heard at ?
i. A
ii. P
iii. E
iv. T
v. M

O
Physiological S3 is heard in all except ?
A. Age upto 40yrs
B.
C.
D.
Children
Pregnancy É
Sumo fighters
Athletes
Pathologic S3:

1) Ventricular dysfunction - poor systolic function, increased end-

diastolic and end-systolic volume, decreased ejection fraction, and high
filling pressures.
• Idiopathic dilated cardiomyopathy
• Ischemic heart disease
• Valvular heart disease
• Congenital heart disease
• Systemic and pulmonary hypertension
Fourth heart sound
• S4 is low pitched

• Presystolic sound

• 2nd rapid filling phase caused due to atrial contraction.

• S4 is never present in normal individuals.

• Presence of S4 is always pathological.

• Loudest (Best heard) - Left ventricular Apex

• Accentuated by mild isotonic or isometric exercise in the supine position

88
 O
Causes of Fourth Heart Sound (S4 gallop)

O
• Mnemonic: HOCM

• 1. HOCM/HTN
• 2. Obstruction other than HOCM
• • Aortic stenosis
• • Pulmonary stenosis
• 3. Cardiac tamponade
I
• 4. Myocardial infarction

89
Additional sounds

Ejection click Opening snap Pericardial knock Tumour plop

As PS MS TS C P MYXOMA

H H H Low

D D Diastolic
systolic
Jugular Venous Pulse
• Right heart pressure

• The normal mean jugular venous pressure, determined as the vertical

distance above the midpoint of the right atrium, is 6 to 8 cm H2O.
• The Jugular venous pulse (JVP) reflects phasic pressure changes in the
right atrium and it consists of three positive waves and two negative
troughs.

92
Wave Form Phase of Cardiac cycle Mechanical event

A wave Atrial contraction

End diastole
C wave Cusp bulging
Early systole
X wave Atrial relaxation
Mid is
V wave Venous filling
Late
Y wave Atrial emptying

Early D
94
Abnormalities of A wave

Absent Giant Cannon

t t t
CHEZ
AF RAM
TS J rhythm

pis p HTM
Accentuated
or
Abnormalities of X wave
Reversal of X wave

t t
CP TR

RCMP

L T
96
• ABNORMALITIES OF THE V WAVE
8

• V wave is increased in - TR

97
 Abnormalities of Y wave
O
Early deep Y descent Deep Y descent Absent Y wave Slow Y descent

t t t
c p
c t Es
II RCMP

98
Kussumal Sign Kussumal respiration
I
DIE
A JUD
A RR

Insp Depth
Arterial Pulse
• Pulsus paradoxus:-
C T

• Pulsus alternans:-
t
Severe LVF

• Pulsus parvus ET tardus:-

As
• Pulsus bigeminus:-
Digoxin ALL
 I

Arterial Pulse
• Waterhammer pulse AR

• Dicrotic Pulse:- DUMP

• Pulsus bisferiens:- Hocal

As I AR
Severe AR
 Rsov
• A. Aortic regurgitation
Which condition following • B. ASD
murmur is seen? • C. Transposition of great arteries
• D. Branch pulmonary artery stenosis

PDA
Mammary Souffle

jet
 A. ASD
CONDITIONS? B. VSD Tr
C. PDA
te
D. RSOV te
ME TI
Apex NO
 A. MVPS
CONDITIONS? B. Venous hum
C. Coarctation Aorta
D. Aorto pulmonary window

Mid systolic Click

LSM
 O
CONDITIONS all except ?
A. AS
B. PS
C. HOCM
D. TS

IMPI
t
ESI
Q) Early diastolic murmur is seen in: MDM
a. VSD
b. ASD
c. Mitral stenosis AR MS
d. AR
PR TS

106
• Carey Coombs murmur -Rheumatic fever
3min
• Austin Flint murmur -Aortic regurgitation

• Graham-Steel murmur -Pulmonary regurgitation EDM

• Rytands murmur -Complete heart block

• Docks murmur -Left Anterior Descending (LAD) artery stenosis

o
• Mill wheel murmur -Due to air emboli (air in PV cavity)

107
Mitral Stenosis
Q) Area of mitral orifice in adults is:
A. 6-8 cm2
B. 0.5-2 cm2
C. 4-6 cm2
D. 1-4 cm2
my and

109
 u v

r o
Etiology of Mitral stenosis
• Most common cause of Mitral stenosis is Rheumatic fever.

• Connective Tissue disorders – SLE,RA

• Mucopolysaccharidosis – Hurlers syndrome

111
 Apex TOPPLE
D snap
• S1______________________S2__________________________S1
a win a
t t
t PSI
Loud Loud P2 puppy

soft calcified

variable Af
Complications of MS
One
• Atrial fibrillation

• Dysphagia I

• Wheeze

Hoariness
• Ortners syndrome RLN
 ECG P Mitrode 120msec

•A

O
M shaped
115
 LA

RA
2D echo

117
In symptomatic patients
• In symptomatic patients, some improvement usually occurs with

O
restriction of sodium intake and small doses of oral diuretics.

blocked
B
Which procedure is being done in the image shown?
I
not

a. Percutaneous mitral balloon valvotomy

b. Percutaneous mitral valvuloplasty LE
MS TMR
KED
c. Percutaneous mitral valve repair
d. Percutanous coronary intervention

MUR
Mitral Regurgitation Rf

Iwm a
ALI

120
 M's click

LII

I
72nd
 Hyperdynamic
Af

PSM
PL
Sz
122
 O
Dynamic Auscultation in MVP

I t
Early a
short 123
2D-Echo

124
• Treatment of Mitral regurgitation :-

I Ef 5

Diuretic
Piqo ME
B blocked

125
 N 3 4 Cont

L 26ns
Mcc Child Bicuspid
Adults s calcified
SAD
sept sis
Heaving Az Absent
or
I

127
O

128
 Chronic
Af
BA
SBP F A
20mm It

O
Treatment-AR
• Vasodilators such as an ACE, ARB, or Aldosterone antagonists are the
standard of care.

• Perform surgery when the

00
• ejection fraction is <55% or
• left ventricular systolic diameter is >55 mm.

130
PERICARDIAL DISEASES
A 24-year-old man presents to the emergency department complaining of chest
pain. He reports having substernal chest pain of 2 days’ duration. The pain is worse
with inspiration and is alleviated by maintaining an upright position. He also
reports having had a fever recently. His medical history and physical examination
are unremarkable. An ECG shows 2 mm elevation of the ST segment in precordial
leads, without reciprocal changes and with concomitant PR segment depression.
An echocardiogram is normal.
What is the most likely diagnosis and the most appropriate treatment
approach for this patient?
A. Acute pericarditis; start a nonsteroidal anti-inflammatory drug (NSAID)
B. Acute pericarditis; start prednisone O
C. Acute pericarditis; repeat echocardiogram in 1 week to confirm diagnosis
D. ST elevation myocardial infarction; start thrombolytics
• Acute Pericarditis
• Etiology of Pericarditis/Pericardial Effusion
• 1 . Idiopathic is most common: Usually presumed to be viral.

• 2. Infectious

0
• • Viral: Coxsackie virus A, B (most common), echovirus

133
Signs and Symptoms

O
• Diagnostic triad: Chest pain, friction rub, and ECG changes

• Pleuritic chest pain: Alleviated by sitting up and leaning forward

• Pericardial friction rub - may be uni-, bi- or triphasic

• ± Fever, malaise.

134
PERICARDITIS ECG

135
• Treatment
• Treat the underlying disease

O
• Anti-inflammatory agents (high dose NSAIDs/ ASA, steroids if severe or
recurrent); analgesics

136
CONSTRICTIVE PERICARDITIS
• A 45-year-old woman complains of increasing shortness of breath on
exertion, as well as orthopnoea, for the previous 3–4 months. She had
apparently recovered from pericarditis about a year earlier. On ECG there is
low voltage, especially in the limb leads, and the chest x-ray shows
pericardial calcification. The presumptive diagnosis is constrictive
pericarditis. Which of the following physical signs would be consistent with
this?
• A. Increased jugular distention on inspiration I
• B. Third heart sound KS
• C. Fourth heart sound
• D. Loud first and second heart sounds
• Definition:-
• Pericardium becomes thickened scarred and often calcified.

• This leads to increase in pericardial pressure which limits

diastolic filling of the ventricles.

• Though this condition is quite similar to cardiac tamponade,

there are certain, characteristic differences.

139
 A

4m
Most common cause of Constrictive pericarditis

• C.P is the sequelae of Pyopericardium

• TB pericarditis of

141
d) Takotsubo cardiomyopathy

142
 court

cardiac Blood A
Cath

te
ventricle
f
to press
143
Broad Bent's sign

O
• The apical pulse is reduced and retracts in systole (tapping apex).
(Broad Bent's sign).

144
Ans. is 'c' i.e., Ejection click [Ref: Harrison 18th/e p. 1826,1827&
17/e p. 1385, 1386]

145
 L L lo mm
25mm
L
septal bounce

148
• Cardiac CT and MRI—These imaging
tests are only occasionally helpful.

• Pericardial thickening of more than 4

mm must be present to establish .

or
• Some MRI techniques demonstrate
the septal bounce and can provide
further evidence for ventricular
interaction.
• Treatment
• Medical: Diuretics, salt restriction
E
• Surgical: Pericardiectomy (only if refractory to medical therapy)

150
HYPERTENSION
• A 44-year-old woman presents with episodes of headaches, associated
with anxiety, sweating and a rapid pulse rate. At the time of her initial
consultation, her blood pressure was 150/95 mmHg seated, but 24 hour
ambulatory monitoring shows a peak of 215/130 mmHg, associated with
the symptoms described above. Which of the following would be your
initial diagnostic procedure?
• A. Magnetic resonance imaging (MRI) scans of the abdomen and pelvis
• B. Measurement of random plasma catecholamines Conf
• C. Measurement of urinary metanephrines over several 24 hour periods
• D. Glucose tolerance test
E
Screening
Types of Hypertension

ze
ze

Etiology
y Ost

154
 O
Most common cause of Secondary hypertension is?

• a. Renovascular disease
• b. Pheochromocytoma
• c. Renal parenchymal disease
• d. Hyperthyroidism
a
• Common causes of isolated systolic hypertension are:
• Atherosclerosis
• Aortic regurgitation
• Patent ductus arteriosus
• Thyrotoxicosis
• Coarctation of aorta

156
157
Coanda Effect

É
159
E E


Choice of antihypertensive agent based on demographic considerations 

Resistant hypertension when goal is not achieved ?
A. 4 drugs + diuretics

B. 2 drugs + diuretics

C. 3 drugs + diuretics

D. 5 drugs + diuretics

162
Resistant hypertension Refractory hypertension

3
I 5
Mcc
2 I non compliance
Infective Endocarditis
Definition

• It is the colonisation of the heart valves with microbiologic

organisms, leading to the formation of friable, infected
vegetations and frequently valve injury.

000 2

165
 O
Q) Which of the following have most friable vegetation:

• A. Infective endocarditis
• B. Libman Sack's endocarditis
• C. Rheumatic heart disease
• D. SLE

166
Friability of Vegetations

167
168
Acute Infective Endocarditis Sub Acute Infective IE in IVDA
Endocarditis

Highly virulent organisms Low virulent organisms Skin

s onions strep Rt sided

Native previously Candida

staph
4. Prosthetic valve endocarditis:

• This may be early (symptoms appearing within 60 days of valve

insertion), 00

• Late (symptoms appearing after 60 days of valve insertion), due to

late bacteraemia or earlier infection with microorganisms having a long
incubation period.

170
< 2months 2-12 months >12months

t t t

s epi s epi St vividon

S Ouray
Austrian syndrome or Osler's triad represents an association of

1. pneumonia,
2. meningitis and
3. infective endocarditis(Pneumococcal).

172
173
O

174




Splinter hemorrhages appearing as red lineal streaks under the nail plate and within the nail bed, in
endocarditis, psoriasis, and trauma. 


O




Osler node causing pain within the pulp of the big toe and multiple painless flat Janeway lesions
over the sole of the foot. 


osler's

0 3
Janeway
177
O
178
Roth
BEI

179
• DUKE CRITERIA for IE
• DUKE STAGE for Ca. Rectum
• DUKE SCORE for Chronic stable angina

181
Major criteria 2D Echo

ve
Culture 7,2
so
JO

TO
183
Treatment
• Empiric regimens for endocarditis while culture results
are pending should include agents active against
staphylococci, streptococci, and enterococci.

0
• Vancomycin 1 g every 12 hours intravenously plus
ceftriaxone 2 g every 24 hours provides appropriate
coverage pending definitive diagnosis; consultation with
an infectious disease expert is strongly recommended
when initiating treatment.

184
 D
é
v

y
t
Bad
185
• Fungal Endocarditis:

• Most commonly associated with candida and Aspergillus.

• Most commonly associted with iv. drug abuse and prosthetic
valves and suppressed immunity.
• Antifungal agents do not cure antifungal carditis.
• Both medical and surgical management required.

186
Rheumatic Fever

• Acute, recurrent, inflammatory disease, mainly of children (aged 5–

15 years), typically occurring 1–5 weeks after group A streptococcal
infection.

• Rheumatic fever is not a communicable disease.

• Rheumatic fever occurs as a result of immunological hypersensitivity)

to streptococcal antigens.

• Its TYPE 2 HSR

187
• Most of the manifestations of acute rheumatic fever present
approximately 3 weeks after the precipitating group A
streptococcal infection. Which manifestation may present
several months after the precipitating infection?
• A. Chorea
• B. Erythema marginatum
• C. Fever
• D. Polyarthritis
• E. Subcutaneous nodules
189
190
Jaccoud arthropathy
• Jaccoud arthropathy is a
deforming non-erosive arthropathy
characterized by ulnar deviation of
the second to fifth fingers with
metacarpophalangeal joint
subluxation.
192
• Treatment:-

1. Tab . Aspirin 75–100 mg/kg/day in 4–5 divided doses, till the activity
of the disease subsides (ESR becomes normal).

2. Steroids in dose of 1–2 mg/kg/day if symptoms of RF and/or carditis

persist despite adequate aspirin therapy.

193
Antibiotics
1. Continuous prophylaxis against recurrent RF with
inj. benzathine penicillin 1.2 million units IM every 3–4 weeks.

1. In patients allergic to penicillin, tab. sulfadiazine 1 gm daily or

tab. erythromycin 250 mg twice daily may be given.

2. Prophylaxis must continue, up to the age of 25 years or 5 years

after the last attack, whichever is longer.
195
Coronary Artery Disease
• Spectrum -
ISCHEMIA INFARCTION

Stable Angina Prinzmetal Unstable Angina NSTEMI STEMI

Angina
Chronic stable Angina/Reversible Ischemia
Chest pain <10-15mins

Levine sign Clutching the hand over the fist

Angina equvalents Dyspnea

ECG Non specific ST-T changes

TMT/DSE Diagnostic – ST segment depression >0.1 mv

Contraindications for TMT Uncontrolled cardiac Arrhythmia & Symptomatic AS

Drug of choice Beta blockers

Other drugs Nitrates & Antiplatelets, Statins

Role of Imaging in CAD
Investigations Purpose

Thallium 201/Technetium 99 Detects hibernating myocardium

PET scan (Rubidium 82) Assessment of myocardial metabolism

and stunned myocardium
Electron beam CT scan Coronary artery calcification

Gd MRI Sensitive test to detect and quantify

extent of infection
Prinzmetal Angina Vasospastic angina (Spasm more
than 75% )
Chest pain

MC vessel effected Right coronary artery

ECG changes ST segment elevation during chest

pain
Drug of choice Nitrates

Other drugs CCBs, Fasudil

Unstable Angina NSTEMI

Wellens syndrome:-
• Unstable Angina (UA)/Non-ST Elevation Ml (NSTEMI)

• Unstable angina is clinically defined by any of the following:

• Accelerating pattern of pain: increased frequency, increased
duration, with decreased exertion, decreased response to
treatment.

• Angina at rest

• New onset angina

• Angina post-MI or post-procedure (e.g. PCI, CABG)

• Wellen's syndrome suggests unstable angina:-

• It is an E.C.G manifestation of critical proximal left anterior descending

coronary artery (LAD stenosis) in patients with unstable angina.

• It is characterized by:-
• Deep > 2 mm T wave inversions in the anterior precordial leads.

• Wellens syndrome represent a pre-infarction stage coronary artery

disease (CAD) that often progresses to devastating anterior wall MI.

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• NSTEMI is clinically defined by the presence of 2 of the following 3 criteria:
• Symptoms of angina/ischemia

• Rise and fall of serum markers of myocardial necrosis

• Evolution of ischemic ECG changes (without ST elevation or new LBBB)

STEMI
Type 1 Type 2 Type 3 Type 4 Type 5
• Universal Definition of Ml
• Type 1 : Spontaneous MI related to ischemia due to a primary
coronary event such as plaque rupture, fissuring, or dissection.

• Type 2: MI secondary to ischemia due to either increased oxygen

demand or decreased supply, e.g. coronary artery spasm, coronary
embolism, anemia, arrhythmias, hypertension, or hypotension

• Type 3: Sudden unexpected cardiac death, including cardiac arrest,

often with symptoms suggestive of myocardial ischemia, but death
occurring before blood samples could be obtained, or at a time
before the rise of cardiac biomarkers in the blood
• Type 4: Associated with coronary angioplasty or stents:
• Type 4a: MI associated with PCI (associated with 5 times elevation of troponin I)

• Type 4b: MI associated with stent thrombosis as documented by angiography or

at autopsy

• Type 5: MI associated with CABG (associated with 10 times elevation of

Troponin-I).
Features of STEMI

Chest pain > 20 minutes

ECG ST elevation( >1mm in limb & >2mm in

chest leads)
2D echo RWMA

CAG Thrombus

Cardiac biomarkers Elevated

• ECG changes in MI:-
First cardiac biomarker to raise
New biomarkers
Marker of Reinfarction
Re-infarction after 72hrs
LDH pattern
Cardiac Biomarkers
Biomarkers Appears Peak value Duration D/D
elevated
Trop I & T 2-4 hrs 1-2days Up to 2 weeks MI,CHF,AF,Acute
PE, Myocarditis,
CRF, Sepsis

CK-MB 2-4hrs 1 day 3 days MI,

Myocarditis
Pericarditis
Cardiac
Defibrillation
Treatment of STEMI
First line management Aspirin

Loading dose

Best revascularisation method PCI

Thrombolysis

CABG
Complications of Myocardial infection
Electrical complications Mechanical complications Late complications
Stunned myocardium Hibernating myocardium
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