1) This document provides guidelines for the management of atrial fibrillation (AF), including evaluating the underlying causes, classifying the type of AF, assessing risk of complications, and approaches to rate control and rhythm control.
2) Rate control is recommended for most stable patients and involves pharmacological therapies like beta-blockers, calcium channel blockers, or digoxin, while assessing risk of thromboembolism and anticoagulating appropriately.
3) Rhythm control includes pharmacological or electrical cardioversion along with anticoagulation and maintenance medications to prevent AF recurrence, or non-pharmacological options like pacing or ablation for selected patients.
Anticoagulation in atrial fibrillationMashiul Alam
This document discusses anticoagulation for atrial fibrillation (AF). It covers the epidemiology and pathophysiology of AF, as well as the risks of stroke. It describes scoring systems like CHADS2 and CHA2DS2-VASc that are used to determine stroke risk and recommend antithrombotic therapy. Newer oral anticoagulants like apixaban, dabigatran and rivaroxaban are discussed and compared to warfarin. Guidelines for anticoagulation in various clinical scenarios involving AF are provided, such as with stable ischemic heart disease, intracoronary stents, acute coronary syndrome, and cardioversion.
ACC/AHA 2009 Guidelines for STEMI & PCISun Yai-Cheng
ACC/AHA 2009 STEMI/PCI Guidelines
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (STEMI) and the ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (PCI)
J. Am. Coll. Cardiol. 2009;54;2205-2241
Circulation. 2009;120;2271-2306
This document provides an overview of ST-elevation myocardial infarction (STEMI) including its epidemiology, etiology, pathophysiology, risk factors, diagnosis, and current guideline-directed management. It begins with definitions of STEMI and acute coronary syndrome. Key points include that STEMI accounts for 30-40% of myocardial infarctions in the US with a mortality rate of 8.8-18.4%. Risk factors include age, gender, family history, hypertension, diabetes, hyperlipidemia, and tobacco use. Diagnosis is made through ECG showing ST elevations and elevated cardiac biomarkers. Current treatment involves prompt reperfusion therapy with either primary percutaneous coronary intervention or fibrinolytic therapy to restore blood flow to the
Persistent Atrial Fibrillation Management: Case preventationsalah_atta
- The patient is a 40-year-old female with diabetes, hypertension, and persistent atrial fibrillation who was referred for further management.
- She was experiencing shortness of breath and fatigue from her atrial fibrillation. Her risk of stroke was assessed to be high based on her CHA2DS2VASC score of 3.
- After attempting rate control medication, she continued having symptoms. Radiofrequency catheter ablation was performed to isolate the pulmonary veins and eliminate the triggers for atrial fibrillation, with the goal of improving her symptoms long term.
This highly energetic lecture presents the pathophysiology of S-T elevation myocardial infarction in an easy to understand style to help you best identify, triage and treat patients presenting with acute coronary syndromes. Using the latest research behind the AHA Guidelines changes, AHA National Faculty Rom Duckworth will help you better coordinate with you partners along the continuum of cardiac care. Emphasis is placed on risk factors, recognizing truly sick patients and coordinating care with hospital personnel.
Learning Objectives: Students will learn:
-The pathophysiology of S-T elevation myocardial infarction.
-The difference between STEMI, NSTEMI and unstable angina.
-Differing treatment methods and priorities for different cardiac syndromes.
-The function and importance of 12 lead ECG and prehospital diagnostic testing.
-The roles and responsibilities of EMS providers as the key element in “door-to-balloon” and “door-to-needle” time for STEMI patients.
www.romduck.com
www.RescueDigest.com
This document discusses direct oral anticoagulants (DOACs), including their mechanisms of action, pharmacological properties, clinical trials comparing them to standard anticoagulants, and special considerations for their use. It provides details on specific DOACs like dabigatran, rivaroxaban, apixaban, and edoxaban. It also addresses DOAC dosing adjustments for patients with renal or liver impairment, use in pregnancy and lactation, reversal agents, and periprocedural management.
Anticoagulation in atrial fibrillationMashiul Alam
This document discusses anticoagulation for atrial fibrillation (AF). It covers the epidemiology and pathophysiology of AF, as well as the risks of stroke. It describes scoring systems like CHADS2 and CHA2DS2-VASc that are used to determine stroke risk and recommend antithrombotic therapy. Newer oral anticoagulants like apixaban, dabigatran and rivaroxaban are discussed and compared to warfarin. Guidelines for anticoagulation in various clinical scenarios involving AF are provided, such as with stable ischemic heart disease, intracoronary stents, acute coronary syndrome, and cardioversion.
ACC/AHA 2009 Guidelines for STEMI & PCISun Yai-Cheng
ACC/AHA 2009 STEMI/PCI Guidelines
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (STEMI) and the ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (PCI)
J. Am. Coll. Cardiol. 2009;54;2205-2241
Circulation. 2009;120;2271-2306
This document provides an overview of ST-elevation myocardial infarction (STEMI) including its epidemiology, etiology, pathophysiology, risk factors, diagnosis, and current guideline-directed management. It begins with definitions of STEMI and acute coronary syndrome. Key points include that STEMI accounts for 30-40% of myocardial infarctions in the US with a mortality rate of 8.8-18.4%. Risk factors include age, gender, family history, hypertension, diabetes, hyperlipidemia, and tobacco use. Diagnosis is made through ECG showing ST elevations and elevated cardiac biomarkers. Current treatment involves prompt reperfusion therapy with either primary percutaneous coronary intervention or fibrinolytic therapy to restore blood flow to the
Persistent Atrial Fibrillation Management: Case preventationsalah_atta
- The patient is a 40-year-old female with diabetes, hypertension, and persistent atrial fibrillation who was referred for further management.
- She was experiencing shortness of breath and fatigue from her atrial fibrillation. Her risk of stroke was assessed to be high based on her CHA2DS2VASC score of 3.
- After attempting rate control medication, she continued having symptoms. Radiofrequency catheter ablation was performed to isolate the pulmonary veins and eliminate the triggers for atrial fibrillation, with the goal of improving her symptoms long term.
This highly energetic lecture presents the pathophysiology of S-T elevation myocardial infarction in an easy to understand style to help you best identify, triage and treat patients presenting with acute coronary syndromes. Using the latest research behind the AHA Guidelines changes, AHA National Faculty Rom Duckworth will help you better coordinate with you partners along the continuum of cardiac care. Emphasis is placed on risk factors, recognizing truly sick patients and coordinating care with hospital personnel.
Learning Objectives: Students will learn:
-The pathophysiology of S-T elevation myocardial infarction.
-The difference between STEMI, NSTEMI and unstable angina.
-Differing treatment methods and priorities for different cardiac syndromes.
-The function and importance of 12 lead ECG and prehospital diagnostic testing.
-The roles and responsibilities of EMS providers as the key element in “door-to-balloon” and “door-to-needle” time for STEMI patients.
www.romduck.com
www.RescueDigest.com
This document discusses direct oral anticoagulants (DOACs), including their mechanisms of action, pharmacological properties, clinical trials comparing them to standard anticoagulants, and special considerations for their use. It provides details on specific DOACs like dabigatran, rivaroxaban, apixaban, and edoxaban. It also addresses DOAC dosing adjustments for patients with renal or liver impairment, use in pregnancy and lactation, reversal agents, and periprocedural management.
This document discusses supraventricular tachycardias (SVT). It defines different types of SVT including paroxysmal SVT, which is common in emergency rooms. Quality of life is often poor for those with paroxysmal SVT. The document discusses mechanisms of SVT including reentry circuits, enhanced automaticity, and triggered activity. It provides details on differentiating AV nodal reentrant tachycardia from AV reentrant tachycardia using electrocardiogram findings. Treatment options discussed include carotid sinus massage, adenosine, and catheter ablation.
1. AVNRT and AVRT are types of supraventricular tachycardia involving abnormal pathways for electrical conduction between the atria and ventricles.
2. AVNRT is caused by a reentry circuit within the AV node, while AVRT involves an accessory pathway bypassing the AV node.
3. There are different subtypes of AVNRT and AVRT depending on which pathways are involved in the antegrade and retrograde directions. Typical AVNRT involves a slow-fast pathway while typical AVRT involves orthodromic conduction over an accessory pathway.
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
A 56-year-old woman presents with symptoms of hyperthyroidism including palpitations, weight loss, and anxiety. Her pulse is irregular at 140-150 bpm. Examination shows signs of Graves' disease including a goiter and exophthalmos. The diagnosis is hyperthyroidism causing atrial fibrillation. Investigations would include thyroid function tests.
Rhythm control for atrial fibrillation is pursued over rate control when a patient remains symptomatic despite adequate rate control or has a strong preference for restoring normal rhythm.
This document discusses current management of atrial fibrillation including evaluating thromboembolic risk, rate or rhythm control strategies, anticoagulation guidelines, cardio
1. Atrial fibrillation (AF) is a common arrhythmia where abnormal electrical signals in the atria cause an irregular heartbeat.
2. AF increases the risk of stroke by 5 times and is associated with increased mortality, hospitalization, and decreased quality of life.
3. Management involves rate or rhythm control as well as anticoagulation to prevent stroke, with treatment depending on factors like symptoms, age, and stroke risk level.
This document discusses beta blockers for acute myocardial infarction (AMI). It provides an overview of their mechanism of benefit in AMI, indications and recommendations, and evidence supporting their use. The evidence shows beta blockers reduce infarct size, mortality, and arrhythmias when started early after AMI. Intravenous initiation is generally not recommended for fibrinolytic-treated patients, but oral initiation within 24 hours is. Long-term beta blocker therapy for up to 3 years is also indicated to reduce mortality post-AMI.
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
This document provides an overview of secondary hypertension workup. It discusses that secondary hypertension accounts for 5-10% of cases and can be curable. Testing requires a high index of clinical suspicion, such as new onset hypertension under 30 or over 50 years old, or hypertension refractory to 3 or more medications. Routine tests include a urinalysis, blood tests, ECG, and tests for renal, renovascular, adrenal, and thyroid causes. Specific signs or symptoms that should raise suspicion for an underlying secondary cause include hypokalemia without diuretic use, epigastric bruits, differential blood pressures between arms, and episodic hypertension, flushing and palpitations.
This document discusses resistant hypertension. It defines resistant hypertension as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, including a diuretic. It notes that resistant hypertension affects 10-20% of hypertensive patients and is associated with increased risk of cardiovascular events. The document outlines various causes of resistant hypertension including primary factors, secondary causes like obstructive sleep apnea and primary aldosteronism, and lifestyle and medication factors that can contribute. It provides guidance on evaluating and managing patients with resistant hypertension through lifestyle changes, medication optimization, and consideration of device therapies if needed.
This document discusses the management of atrial fibrillation. It provides information on the causes, consequences, classification, and epidemiology of AF. It describes the acute management of AF including assessing hemodynamic status, starting anticoagulation, and deciding between rate and rhythm control strategies. Methods for rhythm control include electrical cardioversion and pharmacological cardioversion with drugs like amiodarone, ibutilide, flecainide, and propafenone. Rate control strategies use drugs like digoxin, beta blockers, calcium channel blockers, and amiodarone. The document also discusses anticoagulation for thromboembolism prevention and newer oral anticoagulants.
Iron Deficiency : An Overlooked Aspect of Heart Failure Managementmagdy elmasry
Iron deficiency: a comorbidity that goes unnoticed in heart failure.Optimization of heart failure treatment.
Types of iron deficiency.Absolute ID &Functional ID.Iron Deficiency in Heart Failure :
A Therapeutic Target
Iron therapy for the treatment of iron deficiency
in chronic heart failure: intravenous or oral?
The document summarizes guidelines from the International Society of Hypertension (ISH), World Health Organization (WHO), American College of Cardiology/American Heart Association (ACC/AHA), and European Society of Cardiology/European Society of Hypertension (ESC/ESH) on the diagnosis and treatment of hypertension. It compares the guidelines on prevalence of hypertension, treatment thresholds and targets, drug choice and sequencing, and targets for specific patient groups. While the guidelines have some differences, they also have many similarities, including treatment targets of under 140/90 mmHg for most patients and under 130/80 mmHg for high-risk groups.
This document summarizes a review on ivabradine, a drug that lowers heart rate by selectively inhibiting funny (If) channels in the sinoatrial node. It discusses the pathophysiology of elevated heart rate and heart rate control. Ivabradine is a selective If current inhibitor that reduces heart rate without affecting contractility or blood pressure. Clinical trials such as BEAUTIFUL showed ivabradine reduced rates of hospitalization for heart failure and myocardial infarction in patients with coronary artery disease and heart rates over 70 beats per minute. Ivabradine may provide benefit as an add-on to standard heart failure therapy in select patient groups.
International Society of Hypertension 2020 guidlinesJAFAR ALSAID
The document outlines key points from a presentation on hypertension given by Dr. Jafar Alsaid at the Iraqi Hypertension Conference in November 2021. It discusses the global burden of hypertension, challenges in low-income countries, definitions and classifications of hypertension, measuring blood pressure, common risk factors, target organ damage, lifestyle modifications, pharmacological treatments, and the importance of patient education.
2022 Guideline for the Management of Heart Failure Clinical Update.pptxsubhankar16
This document summarizes guidelines from the 2022 AHA/ACC/HFSA for the diagnosis and management of heart failure. It defines the stages of heart failure from A to D and discusses evaluation, causes, biomarkers, imaging, and invasive testing. Key recommendations include using biomarkers like BNP and NT-proBNP to diagnose and manage HF. Transthoracic echocardiography is recommended for initial evaluation, and cardiac MRI, CT, or nuclear imaging if echo is inadequate. Invasive procedures are not routinely recommended but may help in select cases. Remote monitoring can benefit some patients with advanced HF.
Anti-platlets from clopidogrel to the new agentsAshraf Reda
This document discusses recent clinical trials and guidelines regarding antithrombotic therapy. It summarizes several major trials that compared new oral anticoagulants like dabigatran, rivaroxaban, and apixaban to warfarin for atrial fibrillation. It also discusses trials comparing newer antiplatelet drugs like prasugrel, ticagrelor, and bivalirudin to clopidogrel for acute coronary syndrome and percutaneous coronary intervention. The document notes challenges with variable drug response, bleeding risk, and duration of dual antiplatelet therapy. It provides guidelines for antithrombotic treatment in atrial fibrillation, STEMI, NSTEMI, and
Viral meningitis is usually self-limiting and caused by viruses like mumps and herpes. Bacterial meningitis has a higher risk of mortality and morbidity and is commonly caused by bacteria like pneumococcus, meningococcus, and H. influenzae depending on age. Diagnosis involves CT scan, lumbar puncture, and CSF analysis looking at cell count, glucose, protein and culture. Treatment for bacterial meningitis involves IV antibiotics targeting the suspected bacteria and supportive care. Complications can include hydrocephalus.
This document appears to be a set of slides for a lecture or teaching session on rapidly interpreting electrocardiograms (ECGs) given by Dr. James Smitt of Monash University on July 25, 2013 for third year medical students. The slides provide instruction on efficiently analyzing ECG readings to identify potential cardiac issues or abnormalities.
This document discusses supraventricular tachycardias (SVT). It defines different types of SVT including paroxysmal SVT, which is common in emergency rooms. Quality of life is often poor for those with paroxysmal SVT. The document discusses mechanisms of SVT including reentry circuits, enhanced automaticity, and triggered activity. It provides details on differentiating AV nodal reentrant tachycardia from AV reentrant tachycardia using electrocardiogram findings. Treatment options discussed include carotid sinus massage, adenosine, and catheter ablation.
1. AVNRT and AVRT are types of supraventricular tachycardia involving abnormal pathways for electrical conduction between the atria and ventricles.
2. AVNRT is caused by a reentry circuit within the AV node, while AVRT involves an accessory pathway bypassing the AV node.
3. There are different subtypes of AVNRT and AVRT depending on which pathways are involved in the antegrade and retrograde directions. Typical AVNRT involves a slow-fast pathway while typical AVRT involves orthodromic conduction over an accessory pathway.
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
A 56-year-old woman presents with symptoms of hyperthyroidism including palpitations, weight loss, and anxiety. Her pulse is irregular at 140-150 bpm. Examination shows signs of Graves' disease including a goiter and exophthalmos. The diagnosis is hyperthyroidism causing atrial fibrillation. Investigations would include thyroid function tests.
Rhythm control for atrial fibrillation is pursued over rate control when a patient remains symptomatic despite adequate rate control or has a strong preference for restoring normal rhythm.
This document discusses current management of atrial fibrillation including evaluating thromboembolic risk, rate or rhythm control strategies, anticoagulation guidelines, cardio
1. Atrial fibrillation (AF) is a common arrhythmia where abnormal electrical signals in the atria cause an irregular heartbeat.
2. AF increases the risk of stroke by 5 times and is associated with increased mortality, hospitalization, and decreased quality of life.
3. Management involves rate or rhythm control as well as anticoagulation to prevent stroke, with treatment depending on factors like symptoms, age, and stroke risk level.
This document discusses beta blockers for acute myocardial infarction (AMI). It provides an overview of their mechanism of benefit in AMI, indications and recommendations, and evidence supporting their use. The evidence shows beta blockers reduce infarct size, mortality, and arrhythmias when started early after AMI. Intravenous initiation is generally not recommended for fibrinolytic-treated patients, but oral initiation within 24 hours is. Long-term beta blocker therapy for up to 3 years is also indicated to reduce mortality post-AMI.
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
This document provides an overview of secondary hypertension workup. It discusses that secondary hypertension accounts for 5-10% of cases and can be curable. Testing requires a high index of clinical suspicion, such as new onset hypertension under 30 or over 50 years old, or hypertension refractory to 3 or more medications. Routine tests include a urinalysis, blood tests, ECG, and tests for renal, renovascular, adrenal, and thyroid causes. Specific signs or symptoms that should raise suspicion for an underlying secondary cause include hypokalemia without diuretic use, epigastric bruits, differential blood pressures between arms, and episodic hypertension, flushing and palpitations.
This document discusses resistant hypertension. It defines resistant hypertension as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, including a diuretic. It notes that resistant hypertension affects 10-20% of hypertensive patients and is associated with increased risk of cardiovascular events. The document outlines various causes of resistant hypertension including primary factors, secondary causes like obstructive sleep apnea and primary aldosteronism, and lifestyle and medication factors that can contribute. It provides guidance on evaluating and managing patients with resistant hypertension through lifestyle changes, medication optimization, and consideration of device therapies if needed.
This document discusses the management of atrial fibrillation. It provides information on the causes, consequences, classification, and epidemiology of AF. It describes the acute management of AF including assessing hemodynamic status, starting anticoagulation, and deciding between rate and rhythm control strategies. Methods for rhythm control include electrical cardioversion and pharmacological cardioversion with drugs like amiodarone, ibutilide, flecainide, and propafenone. Rate control strategies use drugs like digoxin, beta blockers, calcium channel blockers, and amiodarone. The document also discusses anticoagulation for thromboembolism prevention and newer oral anticoagulants.
Iron Deficiency : An Overlooked Aspect of Heart Failure Managementmagdy elmasry
Iron deficiency: a comorbidity that goes unnoticed in heart failure.Optimization of heart failure treatment.
Types of iron deficiency.Absolute ID &Functional ID.Iron Deficiency in Heart Failure :
A Therapeutic Target
Iron therapy for the treatment of iron deficiency
in chronic heart failure: intravenous or oral?
The document summarizes guidelines from the International Society of Hypertension (ISH), World Health Organization (WHO), American College of Cardiology/American Heart Association (ACC/AHA), and European Society of Cardiology/European Society of Hypertension (ESC/ESH) on the diagnosis and treatment of hypertension. It compares the guidelines on prevalence of hypertension, treatment thresholds and targets, drug choice and sequencing, and targets for specific patient groups. While the guidelines have some differences, they also have many similarities, including treatment targets of under 140/90 mmHg for most patients and under 130/80 mmHg for high-risk groups.
This document summarizes a review on ivabradine, a drug that lowers heart rate by selectively inhibiting funny (If) channels in the sinoatrial node. It discusses the pathophysiology of elevated heart rate and heart rate control. Ivabradine is a selective If current inhibitor that reduces heart rate without affecting contractility or blood pressure. Clinical trials such as BEAUTIFUL showed ivabradine reduced rates of hospitalization for heart failure and myocardial infarction in patients with coronary artery disease and heart rates over 70 beats per minute. Ivabradine may provide benefit as an add-on to standard heart failure therapy in select patient groups.
International Society of Hypertension 2020 guidlinesJAFAR ALSAID
The document outlines key points from a presentation on hypertension given by Dr. Jafar Alsaid at the Iraqi Hypertension Conference in November 2021. It discusses the global burden of hypertension, challenges in low-income countries, definitions and classifications of hypertension, measuring blood pressure, common risk factors, target organ damage, lifestyle modifications, pharmacological treatments, and the importance of patient education.
2022 Guideline for the Management of Heart Failure Clinical Update.pptxsubhankar16
This document summarizes guidelines from the 2022 AHA/ACC/HFSA for the diagnosis and management of heart failure. It defines the stages of heart failure from A to D and discusses evaluation, causes, biomarkers, imaging, and invasive testing. Key recommendations include using biomarkers like BNP and NT-proBNP to diagnose and manage HF. Transthoracic echocardiography is recommended for initial evaluation, and cardiac MRI, CT, or nuclear imaging if echo is inadequate. Invasive procedures are not routinely recommended but may help in select cases. Remote monitoring can benefit some patients with advanced HF.
Anti-platlets from clopidogrel to the new agentsAshraf Reda
This document discusses recent clinical trials and guidelines regarding antithrombotic therapy. It summarizes several major trials that compared new oral anticoagulants like dabigatran, rivaroxaban, and apixaban to warfarin for atrial fibrillation. It also discusses trials comparing newer antiplatelet drugs like prasugrel, ticagrelor, and bivalirudin to clopidogrel for acute coronary syndrome and percutaneous coronary intervention. The document notes challenges with variable drug response, bleeding risk, and duration of dual antiplatelet therapy. It provides guidelines for antithrombotic treatment in atrial fibrillation, STEMI, NSTEMI, and
Viral meningitis is usually self-limiting and caused by viruses like mumps and herpes. Bacterial meningitis has a higher risk of mortality and morbidity and is commonly caused by bacteria like pneumococcus, meningococcus, and H. influenzae depending on age. Diagnosis involves CT scan, lumbar puncture, and CSF analysis looking at cell count, glucose, protein and culture. Treatment for bacterial meningitis involves IV antibiotics targeting the suspected bacteria and supportive care. Complications can include hydrocephalus.
This document appears to be a set of slides for a lecture or teaching session on rapidly interpreting electrocardiograms (ECGs) given by Dr. James Smitt of Monash University on July 25, 2013 for third year medical students. The slides provide instruction on efficiently analyzing ECG readings to identify potential cardiac issues or abnormalities.
Hyperthyroidism can be caused by Graves' disease, multinodular goiter, toxic adenoma, or thyroiditis. It presents with symptoms affecting the goiter, gastrointestinal tract, cardiovascular system, neuromuscular and dermatological systems, and reproduction. Investigations include thyroid function tests, thyroid receptor antibodies, and thyroid ultrasound. Management involves antithyroid medications, radioactive iodine therapy, surgery, beta blockers, and treatment of complications like thyrotoxic crisis or ophthalmopathy. Special considerations include hyperthyroidism in pregnancy and periodic paralysis.
HIV/AIDS data Hub Asia Pacific -Malaysia 2014Dr. Rubz
This document provides a summary of HIV/AIDS data for Malaysia across multiple indicators:
- HIV prevalence is highest among key populations like people who inject drugs, female sex workers, and men who have sex with men. Condom use and safe injection practices have increased over time but remain below optimal levels.
- The number of reported HIV infections and AIDS-related deaths has declined in recent years. Most HIV transmissions are through heterosexual contact and injecting drug use.
- Vulnerability remains high as many key populations lack comprehensive HIV knowledge and access to prevention programs, testing, and treatment.
- Government spending on HIV has increased but more funding needs to be directed towards programs for key populations at higher
Acromegaly is caused by excessive growth hormone (GH) secretion from the pituitary gland, usually presenting in adults aged 30-50 years old. Signs and symptoms include enlarged features of the face, hands, and feet; joint pain; headaches; and increased sweating. Treatment options include trans-sphenoidal surgery to remove the pituitary tumor, radiation therapy, and medication like somatostatin analogues to control GH levels. Complications can develop if acromegaly goes untreated and includes heart failure, arthritis, sleep apnea, and visual impairments.
This document provides a regional overview of HIV/AIDS trends in Asia and the Pacific from 1990-2013. It summarizes that there are currently 4.8 million people living with HIV in the region, with new infections declining significantly since 2001 but remaining largely unchanged in the past 5 years. Treatment coverage has increased substantially, with 1.56 million people now on ART, however this is still only about one-third of those in need. The challenges ahead include addressing gaps in prevention for key populations and along the treatment cascade.
Nephrotic syndrome is defined by hypoalbuminemia, proteinuria, and edema. It is caused by primary glomerular diseases like minimal change nephropathy or secondary diseases like diabetes. Complications include infections due to immunosuppression, thrombosis due to hypercoagulability, decreased blood volume, hyperlipidemia, hypocalcemia, and negative nitrogen balance. Investigations include blood tests to check for causes and urine tests to measure proteinuria. Management involves diet, diuretics, treating infections, hyperlipidemia, and hypertension, with corticosteroids often used for minimal change disease.
Testicular cancer for public awareness by Dr RubzDr. Rubz
A presentation prepared for Charity Dinner with Fun Charity. All the profits of the event will go to FReHA (a NGO which supports women's and reproductive health.)
PUO refers to a fever that lasts for more than 3 weeks and whose cause cannot be determined after 1 week of investigations. Common causes include infections affecting the lungs, heart, liver or GU/GI tract, as well as certain bacterial, fungal, parasitic and viral infections. Other potential causes are neoplasms, connective tissue diseases, and other inflammatory conditions. A thorough history, physical examination, and laboratory tests are needed to arrive at a diagnosis, including blood cultures, serological tests, sputum analysis, urine analysis, stool exams, imaging studies and biopsies. Empiric treatment may involve antibiotics, antifungals, antitubercular drugs, or a trial of steroids or aspirin while
The document announces an e-mail auction to raise funds for the United Learning Centre, which provides education and meals to 140 refugee children in Malaysia. The auction includes donations of a Rado watch, porcelain vases, paintings, a lamp, and other items. Proceeds will help the learning center continue offering refugee children education, nutrition, and boarding for those whose parents work far away. The auction encourages supporting this charity auction to help children in need.
Rheumatoid arthritis is a chronic inflammatory joint disease that commonly affects the small joints of the hands and feet in a symmetrical pattern. It is characterized by persistent synovitis that can lead to joint damage and deformity over time if left untreated. Diagnosis is based on meeting at least 4 out of 7 criteria defined by the American Rheumatism Association, including morning stiffness, arthritis of 3 or more joints, arthritis of hand joints, symmetrical arthritis, rheumatoid nodules, positive rheumatoid factor, and radiographic changes. Treatment involves disease-modifying drugs such as methotrexate, sulfasalazine, hydroxychloroquine, and biologics to reduce inflammation and prevent further joint damage.
This document discusses CAPD peritonitis and provides guidelines and recommendations for treatment. It begins by defining CAPD peritonitis and describing the typical incidence rate. It then outlines the ISPD guidelines for empiric antibiotic therapy and treatment strategies based on culture results. The document also describes a clinical audit of peritonitis at Hospital Pulau Pinang that found a peritonitis rate of 1 in 36 patient-months, with gram-negative organisms being the most common causative agents and 60.7% of cases resolving with treatment.
Anaemia is defined as a low haemoglobin level. It can be classified based on the mechanism (decreased red blood cell production or increased red blood cell loss) and mean corpuscular volume (MCV). Common symptoms include fatigue, dyspnea, and palpitations. Signs include pallor, jaundice, and heart murmurs. History should focus on iron loss, diet, medications, and family history. Investigations include full blood count, reticulocyte count, blood film, iron studies, folate, B12, and bone marrow biopsy if needed. The most common cause is iron deficiency due to blood loss. Treatment depends on the underlying cause.
The document outlines the process for conducting a gynaecological history and physical examination. It details obtaining a patient's medical, menstrual, sexual and family history. The physical exam involves inspection and palpation of the abdomen and pelvis, as well as a speculum and bimanual digital examination of the external genitalia, vagina, cervix and uterus. The goal is to identify any masses, abnormalities, tenderness or discharge that could indicate medical issues.
1) The document outlines several emergency procedures including rapid sequence intubation, chest tube insertion, femoral line insertion, CVP line insertion, and peritoneal tap.
2) It provides detailed steps for each procedure including necessary equipment, patient positioning, anesthesia, insertion technique, and post-procedure care.
3) The procedures are commonly assessed in OSCE exams and require careful preparation, sterile technique, knowledge of anatomy, and verification of correct placement.
The document discusses various aspects of human sexuality including:
1) The normal sexual response cycle of desire, excitement and orgasm in men and women.
2) Several types of sexual dysfunctions that can occur including decreased libido, erectile dysfunction, delayed ejaculation and anorgasmia.
3) Paraphilias or abnormal sexual interests involving non-consenting partners or objects. Examples given include fetishism, voyeurism and pedophilia.
4) Gender identity disorders where one's identity does not match their biological sex.
1) This document provides guidance on evaluating and diagnosing the cause of proteinuria. It outlines a three step approach to determine the amount, condition, and type of protein being excreted.
2) Transient proteinuria is usually benign, while persistent proteinuria over 1g/day requires further investigation including renal biopsy to diagnose underlying renal disorders like glomerulonephritis.
3) Management involves controlling blood pressure, reducing cardiovascular risk factors, and treating any identified underlying conditions like diabetes or renal disease.
This document summarizes different types of shock including hypovolemic, cardiogenic, neurogenic, septic, anaphylactic, and obstructive shock. It provides details on definitions, signs and symptoms, investigations, and management for each type of shock. General management includes maintaining the airway, providing oxygen, establishing intravenous access, monitoring vital signs, and administering fluids with or without vasopressors depending on the type and severity of shock. Specific investigations and treatments are outlined for each shock type.
This document discusses various causes of thrombocytopenia including bone marrow disorders, increased platelet consumption, and hypersplenism. It specifically describes idiopathic thrombocytopenic purpura (ITP) and thrombotic thrombocytopenic purpura (TTP). ITP is characterized by autoantibodies against platelets that cause their premature destruction. It commonly presents with purpura and mucosal bleeding. Treatment involves corticosteroids, IVIG, or splenectomy. TTP is a thrombotic microangiopathy associated with a deficiency in a protease that breaks down fibrin. It presents with a pentad of thrombocytopenia, microangiopathic hemolytic an
This document discusses heart failure, including:
1. Definitions of heart failure and classifications including systolic vs diastolic, acute vs chronic, and left vs right sided failure.
2. Causes of heart failure including ischemic heart disease, cardiomyopathy, and hypertension.
3. Clinical features such as exertional dyspnea, orthopnea, fatigue, edema, and crackles.
4. Investigations including blood tests, electrocardiogram, echocardiogram, and cardiac catheterization to diagnose and evaluate heart failure.
This document discusses myocardial infarction (MI), including:
1. Definitions, epidemiology, risk factors, pathophysiology, signs and symptoms, investigations, differential diagnosis, treatment and management.
2. Complications of MI can include arrhythmias, congestive heart failure, recurrent ischemia, cardiogenic shock, acute mitral regurgitation, ventricular rupture, and pericarditis.
3. Prognosis depends on the extent of infarction, residual left ventricular function, and revascularization. The mortality rate within the first year after MI is 5-10% and half of all MI patients are rehospitalized within one year.
Evaluation and Initial Treatment of Supraventricular TachycardiaSun Yai-Cheng
This document provides information to help differentiate types of supraventricular tachycardia, including:
1. The initial differential diagnosis should focus on regularity, rate, and onset rather than atrial activity on ECG.
2. Regular types include sinus tachycardia, atrial flutter, AV nodal reentrant tachycardia, AV reciprocating tachycardia, and atrial tachycardia. Irregular types include atrial fibrillation, atrial flutter with irregular conduction, and multifocal atrial tachycardia.
3. Adenosine can help distinguish types by terminating rhythms dependent on AV node conduction like AV nodal reentrant
Stroke ( concise long case approach ) summaryDr. Rubz
The document provides guidance on evaluating and managing patients presenting with suspected stroke. It outlines an approach to answering 6 key questions from the history, physical exam, and investigations to determine if the patient is having a stroke, identify the location and type of stroke, understand the mechanism, assess functional impairment, and identify risk factors. Principles of acute management include aspirin, thrombolysis if eligible, controlling blood pressure and blood glucose, and preventing hyperthermia. Secondary prevention involves antiplatelet therapy, anticoagulation if indicated, carotid endarterectomy for severe stenosis, controlling hypertension and lipids, smoking cessation, and managing diabetes risk factors.
This document discusses palpitations, which refer to abnormal awareness of one's heartbeat. Palpitations can be caused by rapid, slow, or irregular heart rhythms and may result from primary cardiac diseases or systemic conditions affecting the heart. Common causes include anxiety, hyperthyroidism, caffeine, smoking, sinus tachycardia, supraventricular tachycardia, ventricular tachycardia, atrial fibrillation, extrasystoles, and Wolff-Parkinson-White syndrome. A thorough history and electrocardiogram can help diagnose the underlying rhythm abnormality.
1) Arrhythmias are abnormalities in heart rate or rhythm and can be classified as tachyarrhythmias (fast heart rate), bradyarrhythmias (slow heart rate), or irregular heart rhythms.
2) Atrial fibrillation is the most common sustained tachyarrhythmia, characterized by a chaotic atrial rate of 400-700 beats per minute. It can be asymptomatic or cause palpitations and low blood pressure symptoms.
3) Management of arrhythmias depends on whether they are recent or chronic and includes cardioversion, medication, anticoagulation, ablation procedures, and pacemaker implantation in some cases of bradyarrhythmia.
1. Syncope is often related to cardiac causes in adults. Common cardiac causes include structural heart disease, arrhythmias, and obstructive lesions.
2. Long QT syndrome is an inherited condition that can cause syncope, seizures, or sudden cardiac death, especially with exercise or emotions. It is diagnosed by an elongated QT interval on ECG.
3. Congenital heart defects can cause left-to-right shunts, obstructive lesions, or valvular issues, each with their own pathophysiology that can potentially lead to syncope.
(1) Echocardiography is useful for diagnosing heart failure by assessing ventricular function, sizes, wall thickness, and valve function. It can determine if systolic or diastolic dysfunction is present.
(2) Biplane measurements using the Simpson's method and M-mode allow calculation of ejection fraction and evaluation of wall motion abnormalities to identify ischemic or non-ischemic causes.
(3) Segmental wall motion analysis can reveal hypokinetic, akinetic, or aneurysmal regions indicating prior infarction or global dysfunction in dilated cardiomyopathy.
This document provides an overview of cardiac arrhythmias including their classification, mechanisms, clinical manifestations, diagnostic approaches and management strategies. It discusses various specific arrhythmias in detail such as atrial fibrillation, atrial flutter, supraventricular tachycardia, ventricular arrhythmias, sick sinus syndrome and heart block. Treatment options covered include pharmacological therapies using different classes of antiarrhythmic drugs, procedures like cardiac ablation and use of devices like pacemakers.
This document provides an overview of narrow complex tachycardias, including:
- Types are categorized based on origin in the atria or AV junction. Common types include sinus tachycardia, atrial fibrillation, AV nodal reentry tachycardia.
- Mechanisms include automaticity, triggered activity, and reentry. Reentry requires two pathways with unidirectional block in one pathway.
- ECG interpretation focuses on regularity, presence of P waves, RP interval, and relationship of P waves to QRS. This guides diagnosis of types like AVNRT, atrial flutter, atrial fibrillation.
- Acute management depends on type and includes
This document provides an overview of atrial fibrillation (AF) and paroxysmal supraventricular tachycardia (PSVT). It defines these conditions and describes their typical ECG patterns, mechanisms, clinical presentations, diagnostic evaluations, and treatment approaches including medications, procedures like cardioversion and ablation. Key points include: AF can be paroxysmal, persistent or permanent, and is caused by mechanisms like reentry and ectopic automaticity; evaluation involves assessing thromboembolic risk with scores like CHA2DS2-VASc; treatment focuses on rate or rhythm control with medications or ablation, while preventing thromboembolism with anticoagulation; PSVT often presents with abrupt
Perioperative arrhythmias are common and can be caused by patient factors, anesthesia, or surgery. The document defines and classifies different types of arrhythmias including sinus, atrial, junctional, and ventricular rhythms. It describes the characteristic electrocardiogram patterns of normal sinus rhythm as well as abnormal rhythms like sinus bradycardia, premature atrial contractions, atrial fibrillation, and premature ventricular contractions. Perioperative management strategies are discussed for select arrhythmias depending on their stability and symptoms. Continuous ECG monitoring is important for arrhythmia detection during the perioperative period.
Palpitations are defined as an uncomfortable awareness of the heartbeat. They can be caused by cardiac arrhythmias, psychiatric conditions like anxiety, or other miscellaneous factors like drugs or hyperthyroidism. The goal in evaluating patients with palpitations is to determine if they are caused by a potentially life-threatening arrhythmia. The physician takes a history on the nature of the palpitations and performs an examination and initial testing like an ECG or holter monitor. Depending on the results, further testing with echocardiogram, event recorder, or mobile cardiac telemetry may be used to diagnose the underlying cause, which is important to guide management and reassurance of the patient.
This document provides an overview of cardiac arrhythmias that may be seen in the surgical intensive care unit (SICU). It begins with definitions of normal sinus rhythm and mechanisms of arrhythmias including automaticity, ectopic foci, and reentry. Common arrhythmias are then described in more detail such as sinus bradycardia, atrial fibrillation, ventricular tachycardia, and various forms of heart block. Causes and management of arrhythmias are discussed with a focus on the relevant medical literature. Antiarrhythmic drug classes and their uses and side effects are also reviewed.
This document discusses the diagnosis and management of cardiac arrhythmias. It begins with an introduction stating that cardiac arrhythmias lead to sudden cardiac death for 250,000 people annually in the United States. The document then covers the history of understanding arrhythmias, the major types of arrhythmias and heart blocks, how to analyze arrhythmias, evaluate patients presenting with arrhythmias, investigate arrhythmias, and manage common arrhythmias like atrial fibrillation, supraventricular tachycardia, and ventricular tachycardia. Treatment options discussed include medical management, surgical correction, ablation, pacemakers, and defibrillators.
Cardiac rhythm disorders in neonates can include sinus arrhythmias, tachyarrhythmias like atrial tachycardia and supraventricular tachycardia, and ventricular arrhythmias like premature ventricular contractions and ventricular tachycardia. The document discusses how to read an ECG, defines various normal and abnormal rhythms like sinus bradycardia, and outlines their evaluation and treatment approaches. Genetic arrhythmia syndromes are also mentioned.
1. Supraventricular tachycardia (SVT) refers to a group of tachyarrhythmias originating above the ventricles. Paroxysmal SVT is characterized by episodes of tachycardia with abrupt onset and termination.
2. The main types of PSVT are atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), and focal atrial tachycardia. They have different mechanisms and ECG patterns that can help determine the underlying rhythm.
3. Acute management involves vagal maneuvers, medications like adenosine or beta blockers, or cardio
This document defines and discusses the management of supraventricular tachyarrhythmias. It begins by defining terms like tachyarrhythmia, tachycardia, and supraventricular tachyarrhythmia. It then discusses various types of supraventricular tachycardias that arise from different areas of the heart including the sinoatrial node, atrioventricular node, atria, and accessory pathways. The document provides guidance on clinical evaluation, ECG patterns, mechanisms, and treatment approaches for common supraventricular tachycardias such as AV nodal reentrant tachycardia, AV reentrant tachycardia, atrial fibrillation, atrial flutter, and atrial
This document defines peripartum cardiomyopathy (PPCM) as heart failure that occurs for the first time in the last month of pregnancy or within five months after delivery. It discusses the normal and abnormal cardiac findings, diagnostic criteria, incidence and risk factors, signs and symptoms, differential diagnosis, treatment, mode of delivery, prognosis, risk in subsequent pregnancies, length of treatment, and contraception considerations for patients with PPCM. The key points are that PPCM has an incidence of 1 in 4000 pregnancies, presents clinically in the third trimester or postpartum, and has a variable prognosis depending on initial left ventricular ejection fraction and degree of recovery.
Critical Care Summit Egypt 2015 Common Arrhythmias in the ICUDr.Mahmoud Abbas
Lecture presented by Dr Khaled Farouk at Egyptian Critical Care Summit 2015, the leading ICU event and medical exhibition in Egypt. www.criticalcareegypt.com
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1. Management of Atrial Fibrillation ♦ Assess the need to convert to sinus rhythm
Causes of Atrial Fibrillation Physical Exam
Cardiac ♦ Valvular dz – MR, MS ♦ Sick sinus syndrome ♦ confirm AF (4 signs)
♦ IHD ♦ Post-cardiac surgery o IR IR pulse
♦ HPT ♦ Peri-/myo-carditis o Single flicker JVP - absence of ‘a’ wave
♦ Post MI ♦ Pre-excitation syndrome o pulse deficit
♦ CCF ♦ Acute pul. Embolism o varying loudness of 1st heart sound
♦ ASD ♦ Lone AF (no known ♦ signs of underlying causes of AF– BP, goiter and signs of thyrotoxicosis,
♦ Cardiomyopathy etiology or structural heart auscultation for murmurs (MR/MS)
dz. Dx of exclusion)
♦ complications – CCF, previous stroke
Non-Cardiac ♦ Hyperthyroidism ♦ DM
♦ Sepsis esp pneumonia ♦ Alcohol
Investigations
ECG ♦ to document AF, any evidence of MI, LVH/LAH
Morbidities of AF CXR ♦ chamber size, heart failure
♦ ↓ cardiac output – malaise and effort intolerance
FBC
♦ aggravation of MI and heart failure
U/E
♦ ↑ risk of Thromboembolism and stroke
TFT ♦ hyperthyroidism
Transthoracic ♦ structural HD (CMP, valvular dz, intracardiac shunt, pericardial
Types of AF: echocardiogram HDz),
♦ 1st detected episode - may not need tx if episode is brief/ known reversible cause (TTE) ♦ chamber sizes
♦ Acute AF – detected within 24-48h, has high chance of pharm/electrical cardioversion ♦ LV size and function.
♦ Paroxysmal AF – AF lasting less than 7 days Additional Invxs
♦ Persistent AF – >7 days 24h Holter ♦ Quantify freq & duration of symptomatic & asymp. AF episodes
♦ Permanent AF – previous attempts to restore sinus rhythm have failed/ AF lasted >1y. ♦ Look for sinus node dysf(x) or sick sinus syndrome
The probability of successful cardioversion is very low ♦ Assess adequacy of rhythm or rate control
♦ Assess time of onset of AF (eg night in vagally-mediated AF)
Clinical Presentations ♦ Identify PTs with frequent atrial ectopics & nonsustained atrial
♦ Palpitations tachycardia suitable for catheter ablation
♦ CP Transesophageal ♦ Gives better visualization of LA thrombus cf TTE)
♦ Dyspnoea echocardiogram ♦ Use before elective cardioversion in PTs w/o prior 3wks
♦ Fatigue (TEE) warfarin
♦ Light headedness Exercise stress test ♦ Assess PT with AF ppted by exertion, IHD or MI
♦ Syncope ♦ Routinely done for PTs ≥40YO or with significant coronary risk
♦ Cxs of AF – heart failure, haemodynamic impairments, stroke factors.
♦ Asymptomatic (25%) Electrophysiological ♦ For PTs w hx of syncope to exclude sick sinus syndrome and
study (EPS) Wolff-Parkinson-White syndrome
Evaluation of AF
♦ stable or unstable Management of AF:
♦ confirm diagnosis of AF with 12 lead ECG ♦ Aims: • Improve symptoms
♦ classify type of AF o Control ventricular rate • Reduce TE stroke risk
♦ determine underlying cause/factors contributing to AF (eg structural and ischaemic o Reestablish sinus rhythm • Prevent cardiac remodeling
HDz, estimating LVEF, valvular HDz, CMP, HPT) o Anticoagulate to prevent Thromboembolism and hence HFailure & CMP
♦ look for complications of AF
♦ determine risk of future complications, i.e. stroke, from AF Unstable:
o HTN/ old age/ IHD/ heart failure / previous stroke/ DM o immediate sync. Cardioversion
♦ Assess adequacy of control of ventricular rate during AF o f/u with anticoagulation therapy for 4 weeks
2. Stable:
a) Acute AF (<48h)
♦ Can be cardioverted (pharm/electrical) without prior long-term anticoagulation Rhythm Control:
♦ Give IV heparin before proceeding ♦ Spontaneous cardioversion occurs in 50-70% of PTs w/in 24 to 48 hrs, but unlikely to
♦ And switch to oral, maintain INR at 2-3 for 4 weeks whatever the outcome occur if AF persisted for > a week. Drug/electrical cardioversion will be necessary.
♦ Success rate of cardioversion decrease as duration of AF increase, therefore perform
b) Persistent/ Recurrent Paroxysmal AF early
If minimal symptoms, ♦ Problems: failure in maintenance of sinus rhythm in >50% of PTs, significant SE of
1) Rate control drugs used
o Beta-blocker
o Ca blockers e.g. diltiazem/ verapamil ♦ Pharmacological Cardioversion:
o Digoxin (esp if concurrent HF) Drug Comments SE
o Sotalol Class IC arrhythmics ♦ Contraindications ♦ conversion to atrial flutter
2) Assess for risk of thromboembolism and anticoagulate as necessary (propafenone 300- - IHD ♦ ventricular tachycardia
This is the recommended management for most patients, unless acute onset (<48h), or 600mg PO stat, - CCF ♦ enhanced AV nodal
symptomatic, or complicated flecainide150-200mg - Lt vent dysf(x) conduction
PO stat) - major conduction ♦ CCF
disturbances
c) Symptoms/ complications (e.g. syncope, heart failure, stroke)
Amiodarone ♦ Takes days to wks for onset ♦ Hepatotoxic
♦ Rate control initially followed by cardioversion, with anticoagulation
(600-800mg/day PO) ♦ Safe for PT with structural heart ♦ Thyroid dysfunction
♦ Then,
o anticoagulate for 3 weeks with warfarin (keep INR 2-3) before cardioversion
dz or heart failure ♦ GI upset
♦ Monitor LFT & TFT 6 mthly for SE ♦ Bradycardia
♦ Amiodarone
♦ Flecainide ♦ Torsades de pointes
♦ Propafenone ♦ polyneuropathy
o Alternatively, do TEE to look for LA thrombus. If none, give IV Heparin and Dofetilide & ibutilide ♦
perform DC cardioversion w/o prior anticoagulation. Quinidine ♦ Hypotension
♦ Post cardioversion, maintain INR at 2-3 for 4 weeks ♦ Torsades de pointes
♦ Maintenance of sinus rhythm (Flecainide, propafenone, sotalol, amiodarone) Sotalol ♦ NOT for cardioversion ♦ Torsades de pointes
♦ Only for maintaining sinus rhythm ♦ CCF
AF ♦ Exacerbation of COPD
♦ Electrical cardioversion:
Unstable Stable o PT must be fasted and sedated, with good IV access and airway Mx
o Check electrolyte and anticoagulation status
♦ Sync cardioversion Monophasic AF 200 joules, increments up to 360 joules
♦ 4 wks anticoagulation Atrial flutter 50 joules
Biphasic AF 100 joules initially
o Cxs: Thromboembolism, arrhythmia, myocardial injury, heart failure, skin burns.
st
1 episode / Acute AF (<48hrs) Persistant / recurrent
paroxysmal AF ♦ Other non-pharmacological rate control therapies
♦ Pharm / electrical cardioversion w/o prior anticoagulation o Permanent Pacing
♦ 4 wks anticoagulation o Catheter ablation – for PTs with paroxysmal AF due to atrial ectopics, PT with
♦ long-term anticoagulation not necessary SVT or atrial flutter
o Surgical ablation – “Maze” procedure: consider concomitant Sx ablation in PTs
going for open heart Sx for valvular, ischaemic or congenital heart dz.
Asymptomatic Symptomatic / complicated
♦ Maintenance of Sinus Rhythm
♦ Rate control ♦ Rate control & anticoagulation o Flecainide, propafenone and sotalol are first line drugs
♦ Long-term anticoagulation ♦ Cardioversion & maintain sinus rhythm o Amiodarone superior to previous drugs, but last choice of drug due to long term
♦ Long term anticoagulation extracardiac SE.
• Treat ppt factor if present
• Failure of drug therapy to achieve rate control or maintain sinus rhythm – consider
pacemakers, defibrillator or catheter ablation
3. o Choice of drug in heart dz:
Heart failure: use amiodarone ♦ Contraindications to anticoagulation
CAD: use sotalol ♦ Significant bleeding or fall risk ♦ PT unlikely to comply with diet &
HPT with LVH ≥1.4cm: use amiodarone ♦ Recent surgery / trauma monitoring regimen
♦ Thrombocytopenia ♦ Active peptic ulcer dz
Rate Control:
♦ Similar efficacy to rhythm control, but drugs used are safer and there is no problems ♦ Antithrombotic strategies
wrt maintenance of sinus rhythm Any high-risk factors present Long-term oral anticoagulation (target INR2.5;
♦ Pharmacological rate control: >60YO with one other range 2.0-3.0)
Drug Comments SE moderate risk factor
β-blockers ♦ First line Rx ♦ Bronchoconstriction. CI in <60YO + one moderate risk Either aspirin 100mg/day or warfarin depending on
(propranolol, atenolol, ♦ Caution in PTs with heart asthma factor PT preference, risk of blding and access to
sotalol) failure ♦ Heart failure 60-75YO with no risk factor anticoagulation monitoring
♦ Hypotension Male >75 with no risk factor
♦ Heart block Low risk or warfarin is CI Aspirin (100-300mg/day). Alternatives: ticlopidine,
♦ Bradycardia clopidogrel, dipyridamole
CCB (verapamil, ♦ IV CCB useful in ♦ Hypotension <60YO with no risk factors & Long term aspirin or no Rx
diltiazem) emergencies ♦ Heart block normal left atrial size
♦ Preferred over β-blockers ♦ Heart failure *always consider PT factors in determining target INR level (eg fall risk in elderly, recurrent
in PT with COPD TE events despite anticoagulation, prosthetic heart valves) & modify Rx accordingly
♦ Caution in PTs with heart
failure ♦ Monitoring: wkly INR initially, then 6-8wkly once INR stabilizes.
Digoxin ♦ Good for PT with heart ♦ Digitalis toxicity ♦ Adjustment of warfarin dose:
failure ♦ Heart block o after change in drugs that interact with warfarin (eg amiodarone)
♦ Caution in elderly and PT ♦ Bradycardia o surgery (stop warfarin for 5 days prior to surgery)
with renal dysf(x)
Amiodarone ♦ Good for PT with heart ♦ Thyroid dysfunction
failure ♦ Hepatotoxicity
♦ Not first line due to SEs – ♦ Torsades de pointes
require monitoring of LFT ♦ Warfarin & digoxin
and TFT interaction
*combination therapies are possible eg digoxin & β-blockers
♦ Non-pharmacological rate control:
Permanent pacing Digitally signed by DR WANA HLA SHWE
DN: cn=DR WANA HLA SHWE, c=MY,
AV nodal ablation & permanent pacing: o=UCSI University, School of Medicine, KT-
Campus, Terengganu, ou=Internal Medicine
Group, email=wunna.hlashwe@gmail.com
Reason: This document is for UCSI year 4
students.
Anticoagulation: Date: 2009.02.24 10:15:03 +08'00'
♦ Prevent thromboembolic Cxs eg stroke & peripheral arterial thromboembolism
♦ Risk factors
High risk factors ♦ Prior stroke/ TIA/ systemic embolism
♦ Prosthetic heart valve
♦ Rheumatic mitral stenosis
♦ >75YO
Moderate risk factors ♦ 60-75YO ♦ LVEF ≤35%
♦ HPT ♦ DM
♦ CCF ♦ Thyrotoxicosis
♦ Coronary artery dz
Low risk factors ♦ <60YO