Phosphocreatine in cardiac muscle tissue allows mitochondrial ATP to be used in the cytosol.
Frusemide is the most common drug of cause for leukocytoclastic vasculitis. Others include
penicillins, cephalosporins, sulphonamides, phenytoin, allopurinol
Aspirin should be stopped 7-10 days prior to non cardiac surgery, otherwise just continue
Metoprolol: weakest effect on BP
Hypoxic myocardium release adenosine which causes coronary dilatation
SOB
• IF othorpnoea, pND, weight gain, peripheral edema: probably HF
• If none of the above: lungs, anemia, metabolic
• Don’t forget PE: SOB with clear chest!
Heart failure:
• Clinical syndrome: no echo based diagnosis
o L or R HF
• Once diagnosis established:
o HFREF
§ Causes
§ Evidence based Rx:
• ACEi, B blocker, spironolactone, ivabradine
o HFPEF
§ Causes: beri beri, paget disease, anemia, liver disease
§ No clear evience based Rx:
• More symptomatic treatment
NOTE: steroids can induce exacerbation of CHF due to retention of sodium and hence
leads to CHF exacerbation and even HTN!
• Other acute side effect: hyperglycaemia in diabetes mellitus
Calcium ions involved in actin and myosin cross–bridge cycling in cardiac muscle tissue are
from both the sarcoplasmic reticulum and extracellular fluid
Pulmonary capillary wedge pressure: rough estimate of the LA pressure
Pulmonary artery pressure: measures the exact pressure in the pulmonary artery and
determine if there is pulmonary arterial hypertension
Aortic stenosis
• ESM which radiates to the carotid. Can be heard all over precordium
• Severity: long, late peaking murmur. Low volume, plateau carotid pulse
• Causes: RHD, aortic sclerosis, IE, congenital bivalve
• Indications for intervention: syncope, angina, dyspnoea
• Intervetion optiosn: surgery, TAVI
Mitral regurgitation
• Causes: Barlow syndrome, RHD, atrial dilatation, MVP, dilated cardiomyopathy
• Pan systolic murmur usually best heard at apex which radiates to axilla
• Symtpoms: severe MR and heart failure symptoms
• Management
Chest pain
• If reliably on exertion and relieved by rest
o Ischemia
o ?PE
• If prolonged (several hours, >20 mins) severe pain without troponin elevation: not
ischemia
• Multiple differentials but exclude:
, o Heart: ACS, myopericarditis, takotsubo cardiommyopathy
o Aorta: acute aortic syndrome
o Lungs: PE, pneumothorax, pneumonia
Coronary disease
• Pathophysiology: thin fibrous cap and thick lipid core
• Risk factors: SNAPW
• Which test: stress echo or stress nuclear, angiogram
• ?significant stenosis
• Treatment:
o STEMI: opening artery (PCI)
o NSTEMI: depends on cause
o Stable coronary disease: to avoid further complications
Chest pain DDx
• Ischemia: ACS (STEMI, NSTEMI, Unstable angina)
o Central crushing chest pain
o Exertion, emotion, eating
o Relieved with pain/GTN
• ACS:
o Rest angina
o Creascendo pattern
o Does not help with rest
• Non-ischemia
o Aortic dissection
o Aortic aneurysm
o Pericarditis
o Valvular heart valve
o IE
o Myocarditis
o PE: sudden onse and risk factors
o Penumonia
o Pleurisy
o Pneumothorax
o Trauma
o Costochondritis: sharp if touching hurts etc (treitze syndrome OR bornholmes
disease if costochondritis after a viral illness: viral illness with myalgia in
lower chest and upper abdomen)
o Herpes zoster
o Hernia and PUD
o Pancreatitis
o GORD: burning retrosternal chest pain and yucky taste, water brash
o Esophageal spasm
• Others:
o Xiphodynia: pain on moderate pressure on xiphoid process and adjacent
areas
o Slipping rib sydrome: Movement of floating ribs (F>M), indicating a damage
or injury of the ligaments/fibrous tissues holding the floating ribs
o Precordial catch syndrome: sharp stabbing pains In chest, pleuritic in nature.
Unclear cause. Typically begins at rest and other symptoms absent.
6 causes of chest pain that cannot be missed!
1. AMI
a. DAPT: aspirin 300mg + Ticagrelor 180mg then 90mg BD OR clopidogrel
600mg then 75mg OD
b. PCI is preferred within 90 mins of first medical contact
c. PCI Door to ballon time: within 1h
d. Fibrinolysis door to needle time: within 20mins (fibrinolysis takes 30 mins to
occur)
, i. Alteplase indications:
1. Anterior AMI, large inferoposterior AMI
2. <75y ago
3. Streptokinase >3d ago
4. People with previous rheumatic fever (streptokinase is a
protein from streptococcus agalactiae
ii. Streptokinase indications:
1. All others
e. PCI would require DAPT and periprocerdural anticoagulation (heparin,
enoaparin, bivalirudin)
f. Fibrinolytic therapy
i. Absolute contraindications: Thrombolysis
1. Any prior intracranial hemorrhage
2. Known cerebral vascular lesion (AV malformation)
3. Known malignant intracranial neoplasm
4. Ischaemic stroke within 3 months, except acute ischaemic
stroke within 4.5h
5. Suspected aortic dissection
6. Active bleeding or bleeding diathesis
7. Significant close head or facial trauma within 3 months
ii. Relative contraindication:
1. History of chronic severe poorly controlled elevated blood
pressure
2. Severely elevated BP on presentation (>180mmHg sBP or
>110mHg dBP)
3. Ischaemic stroke >3m ago, dementia, or known intracranial
abnormality not covered
4. Traumatic or prolonged CPR (>10mins)
5. Recent surgery (within 3 weeks)
6. Recent internal bleeding (GI/Renal tract within 4 weeks)
7. Noncompressible vascular punctures in the past 24 hours
(liver biopsy, lumbar puncture)
8. Pregnancy or within 1 week postpartum
9. Active peptic ulcer disease
10. Current use of anticoagulants
11. Advanced liver disease
12. Infective endocarditis
13. TIA In preceding 6 months
2. Saddle PE
a. Virchow triad: risk factors
b. Enoxaparin 1mg/kg BD or 1.5mg/kg OD
c. Thrombectomy
3. Tension pneumothorax
a. Clinical diagnosis: treat 2nd ICS mid clavivular line for decompression before
taking XR after chest tube placement
4. Cardiac tamponade
a. Mainly caused by infection and malignancy
b. Pericardial effusion if accumulate enough can cause tamponade
c. Issue is when pressure build up obstructs the filling of the heart by occluding
the SVC and IVC
d. Pericardiocentesis:
i. Subxiphoid approach: insert 18-22G needle between xiphoid and left
costal margin and point towards the let shoulder at 40 degree angle
to skin
ii. Parasternal approach: 5-6th intercostal space at left sternal border at
cardiac notch
5. Aortic dissection
a. Stanford A (proximal/ascending aorta) or B (descending aorta)
i. DeBakey 1: Ascending, arch and proximal descending
ii. DeBakey B: Ascending only
, iii. DeBakey C: Descending only
b. Main difference from the rest is the MIGRATION OF SYMPTOMS:
i. Dissect into aortic root: Severe aortic regurgitation with congestion
symptoms
ii. Dissect into brachiocephalic trunk: stroke/UMN symptoms on left and
weak R hand/lower BP
iii. Dissect into left carotid: R stroke/UMN symptoms
iv. Dissect into left subclavian: disparate/low BP on left hand
v. Dissect into descending aorta: abdominal/back pain
vi. Dissect into spinal arteries from aorta: UMN symptoms bilaterally due
to spinal infarcts
c. Stanford A: immediate surgery, Stanford B: medical management ONLY
6. Esophageal rupture (booerhave syndrome)
a. Most commonly caused by vomiting patients, alcoholics
b. GI cocktail/Green Goddess: Antacid, viscous Lidocaine and anticholinergic to
helps with dyspepsia
i. Anginine usually added: helps with chest pain/angina
ii. Very good pain relief as a mixture than any of its components acting
alone
iii. Hepls to rule out other causes of abdo and chest pain
c. Odynophagia: inability to swallow with intractable regurgitaion and comiting
d. Mediastinitis: sepsis and multiorgan failure
e. Air on XR: Around cardiac shadow, air in abdomen, chest, pleural spaces,
mediastinum
i. Classically see a meniscus line when fluids and air enters the pleural
spaces, due to presence of surface tension
Fatigue DDx:
• Cardio:
o CHF, IHD, Arrhythmia, Valvular heart disease, Cardiomyopathy
• Respiratory:
o COPD, asthma, respiratory failure, ILD
• Abdominal:
o IBD, GORD, Colon cancer, Liver disease, poor diet, malnutrition, vitamin
deficiency
• Rheumatology:
o RA, psoriasis, vasculitis, Gout
• Hematological:
o Anemia, leukemia, lymphoma, chronic infections
• Endocrine:
o Hyper/hypothyroidism, Diabetes, Cushing, Addison, Conn,
Phaeochromocytoma, hypercalcemia, hyperparathyroidism
• Infection:
o Flu, EBV, sexually transmitted, Hepatitis B/C, HIV, tuberculosis,
toxoplasmosis
• Psych:
o Insomnia, parasomnia, depression, mania
• Women:
o Menorrhagia, dysmenorrhea menopause, pregnancy
• FATIGUED:
o Failure of any organ
o Anemia
o Tumours
o Infections
o GI: GI disease, mlaabsoprtion, poor diet
o Unrest
o Endocrine
o Drugs/diabetes/depression
Frusemide is the most common drug of cause for leukocytoclastic vasculitis. Others include
penicillins, cephalosporins, sulphonamides, phenytoin, allopurinol
Aspirin should be stopped 7-10 days prior to non cardiac surgery, otherwise just continue
Metoprolol: weakest effect on BP
Hypoxic myocardium release adenosine which causes coronary dilatation
SOB
• IF othorpnoea, pND, weight gain, peripheral edema: probably HF
• If none of the above: lungs, anemia, metabolic
• Don’t forget PE: SOB with clear chest!
Heart failure:
• Clinical syndrome: no echo based diagnosis
o L or R HF
• Once diagnosis established:
o HFREF
§ Causes
§ Evidence based Rx:
• ACEi, B blocker, spironolactone, ivabradine
o HFPEF
§ Causes: beri beri, paget disease, anemia, liver disease
§ No clear evience based Rx:
• More symptomatic treatment
NOTE: steroids can induce exacerbation of CHF due to retention of sodium and hence
leads to CHF exacerbation and even HTN!
• Other acute side effect: hyperglycaemia in diabetes mellitus
Calcium ions involved in actin and myosin cross–bridge cycling in cardiac muscle tissue are
from both the sarcoplasmic reticulum and extracellular fluid
Pulmonary capillary wedge pressure: rough estimate of the LA pressure
Pulmonary artery pressure: measures the exact pressure in the pulmonary artery and
determine if there is pulmonary arterial hypertension
Aortic stenosis
• ESM which radiates to the carotid. Can be heard all over precordium
• Severity: long, late peaking murmur. Low volume, plateau carotid pulse
• Causes: RHD, aortic sclerosis, IE, congenital bivalve
• Indications for intervention: syncope, angina, dyspnoea
• Intervetion optiosn: surgery, TAVI
Mitral regurgitation
• Causes: Barlow syndrome, RHD, atrial dilatation, MVP, dilated cardiomyopathy
• Pan systolic murmur usually best heard at apex which radiates to axilla
• Symtpoms: severe MR and heart failure symptoms
• Management
Chest pain
• If reliably on exertion and relieved by rest
o Ischemia
o ?PE
• If prolonged (several hours, >20 mins) severe pain without troponin elevation: not
ischemia
• Multiple differentials but exclude:
, o Heart: ACS, myopericarditis, takotsubo cardiommyopathy
o Aorta: acute aortic syndrome
o Lungs: PE, pneumothorax, pneumonia
Coronary disease
• Pathophysiology: thin fibrous cap and thick lipid core
• Risk factors: SNAPW
• Which test: stress echo or stress nuclear, angiogram
• ?significant stenosis
• Treatment:
o STEMI: opening artery (PCI)
o NSTEMI: depends on cause
o Stable coronary disease: to avoid further complications
Chest pain DDx
• Ischemia: ACS (STEMI, NSTEMI, Unstable angina)
o Central crushing chest pain
o Exertion, emotion, eating
o Relieved with pain/GTN
• ACS:
o Rest angina
o Creascendo pattern
o Does not help with rest
• Non-ischemia
o Aortic dissection
o Aortic aneurysm
o Pericarditis
o Valvular heart valve
o IE
o Myocarditis
o PE: sudden onse and risk factors
o Penumonia
o Pleurisy
o Pneumothorax
o Trauma
o Costochondritis: sharp if touching hurts etc (treitze syndrome OR bornholmes
disease if costochondritis after a viral illness: viral illness with myalgia in
lower chest and upper abdomen)
o Herpes zoster
o Hernia and PUD
o Pancreatitis
o GORD: burning retrosternal chest pain and yucky taste, water brash
o Esophageal spasm
• Others:
o Xiphodynia: pain on moderate pressure on xiphoid process and adjacent
areas
o Slipping rib sydrome: Movement of floating ribs (F>M), indicating a damage
or injury of the ligaments/fibrous tissues holding the floating ribs
o Precordial catch syndrome: sharp stabbing pains In chest, pleuritic in nature.
Unclear cause. Typically begins at rest and other symptoms absent.
6 causes of chest pain that cannot be missed!
1. AMI
a. DAPT: aspirin 300mg + Ticagrelor 180mg then 90mg BD OR clopidogrel
600mg then 75mg OD
b. PCI is preferred within 90 mins of first medical contact
c. PCI Door to ballon time: within 1h
d. Fibrinolysis door to needle time: within 20mins (fibrinolysis takes 30 mins to
occur)
, i. Alteplase indications:
1. Anterior AMI, large inferoposterior AMI
2. <75y ago
3. Streptokinase >3d ago
4. People with previous rheumatic fever (streptokinase is a
protein from streptococcus agalactiae
ii. Streptokinase indications:
1. All others
e. PCI would require DAPT and periprocerdural anticoagulation (heparin,
enoaparin, bivalirudin)
f. Fibrinolytic therapy
i. Absolute contraindications: Thrombolysis
1. Any prior intracranial hemorrhage
2. Known cerebral vascular lesion (AV malformation)
3. Known malignant intracranial neoplasm
4. Ischaemic stroke within 3 months, except acute ischaemic
stroke within 4.5h
5. Suspected aortic dissection
6. Active bleeding or bleeding diathesis
7. Significant close head or facial trauma within 3 months
ii. Relative contraindication:
1. History of chronic severe poorly controlled elevated blood
pressure
2. Severely elevated BP on presentation (>180mmHg sBP or
>110mHg dBP)
3. Ischaemic stroke >3m ago, dementia, or known intracranial
abnormality not covered
4. Traumatic or prolonged CPR (>10mins)
5. Recent surgery (within 3 weeks)
6. Recent internal bleeding (GI/Renal tract within 4 weeks)
7. Noncompressible vascular punctures in the past 24 hours
(liver biopsy, lumbar puncture)
8. Pregnancy or within 1 week postpartum
9. Active peptic ulcer disease
10. Current use of anticoagulants
11. Advanced liver disease
12. Infective endocarditis
13. TIA In preceding 6 months
2. Saddle PE
a. Virchow triad: risk factors
b. Enoxaparin 1mg/kg BD or 1.5mg/kg OD
c. Thrombectomy
3. Tension pneumothorax
a. Clinical diagnosis: treat 2nd ICS mid clavivular line for decompression before
taking XR after chest tube placement
4. Cardiac tamponade
a. Mainly caused by infection and malignancy
b. Pericardial effusion if accumulate enough can cause tamponade
c. Issue is when pressure build up obstructs the filling of the heart by occluding
the SVC and IVC
d. Pericardiocentesis:
i. Subxiphoid approach: insert 18-22G needle between xiphoid and left
costal margin and point towards the let shoulder at 40 degree angle
to skin
ii. Parasternal approach: 5-6th intercostal space at left sternal border at
cardiac notch
5. Aortic dissection
a. Stanford A (proximal/ascending aorta) or B (descending aorta)
i. DeBakey 1: Ascending, arch and proximal descending
ii. DeBakey B: Ascending only
, iii. DeBakey C: Descending only
b. Main difference from the rest is the MIGRATION OF SYMPTOMS:
i. Dissect into aortic root: Severe aortic regurgitation with congestion
symptoms
ii. Dissect into brachiocephalic trunk: stroke/UMN symptoms on left and
weak R hand/lower BP
iii. Dissect into left carotid: R stroke/UMN symptoms
iv. Dissect into left subclavian: disparate/low BP on left hand
v. Dissect into descending aorta: abdominal/back pain
vi. Dissect into spinal arteries from aorta: UMN symptoms bilaterally due
to spinal infarcts
c. Stanford A: immediate surgery, Stanford B: medical management ONLY
6. Esophageal rupture (booerhave syndrome)
a. Most commonly caused by vomiting patients, alcoholics
b. GI cocktail/Green Goddess: Antacid, viscous Lidocaine and anticholinergic to
helps with dyspepsia
i. Anginine usually added: helps with chest pain/angina
ii. Very good pain relief as a mixture than any of its components acting
alone
iii. Hepls to rule out other causes of abdo and chest pain
c. Odynophagia: inability to swallow with intractable regurgitaion and comiting
d. Mediastinitis: sepsis and multiorgan failure
e. Air on XR: Around cardiac shadow, air in abdomen, chest, pleural spaces,
mediastinum
i. Classically see a meniscus line when fluids and air enters the pleural
spaces, due to presence of surface tension
Fatigue DDx:
• Cardio:
o CHF, IHD, Arrhythmia, Valvular heart disease, Cardiomyopathy
• Respiratory:
o COPD, asthma, respiratory failure, ILD
• Abdominal:
o IBD, GORD, Colon cancer, Liver disease, poor diet, malnutrition, vitamin
deficiency
• Rheumatology:
o RA, psoriasis, vasculitis, Gout
• Hematological:
o Anemia, leukemia, lymphoma, chronic infections
• Endocrine:
o Hyper/hypothyroidism, Diabetes, Cushing, Addison, Conn,
Phaeochromocytoma, hypercalcemia, hyperparathyroidism
• Infection:
o Flu, EBV, sexually transmitted, Hepatitis B/C, HIV, tuberculosis,
toxoplasmosis
• Psych:
o Insomnia, parasomnia, depression, mania
• Women:
o Menorrhagia, dysmenorrhea menopause, pregnancy
• FATIGUED:
o Failure of any organ
o Anemia
o Tumours
o Infections
o GI: GI disease, mlaabsoprtion, poor diet
o Unrest
o Endocrine
o Drugs/diabetes/depression
