30 types cardiovascular system disease treatment investigation finding differential diagnosis contraindication ICUmanagement OPD prescription detail summary

Reading File

Finding Sources

Given the broad scope of this request (30 cardiovascular diseases with treatment, investigation, findings, differential diagnosis, contraindications, ICU management, and OPD prescription), I have sufficient foundational knowledge from the textbooks identified. Let me now deliver a comprehensive, well-structured clinical reference.

30 Cardiovascular System Diseases — Complete Clinical Summary

Sources: Braunwald's Heart Disease (9780323722193), Fuster and Hurst's The Heart 15e (9781264257560), Textbook of Clinical Echocardiography (9780323882088), Textbook of Family Medicine 9e (9780323239905)

1. HEART FAILURE (HFrEF — Reduced Ejection Fraction)

Definition: EF < 40%, reduced cardiac output

Clinical Findings: Dyspnoea, orthopnoea, PND, bilateral ankle oedema, S3 gallop, elevated JVP, basal crepitations, cardiomegaly, displaced apex beat

Investigations:

ECG: LBBB, LVH, Q waves
CXR: Cardiomegaly, pulmonary oedema, Kerley B lines
Echo: EF < 40%, dilated LV
BNP/NT-proBNP: elevated (>100 pg/mL BNP, >300 pg/mL NT-proBNP)
FBC, U&E, LFT, TFT, ferritin

Differential Diagnosis: Pulmonary hypertension, COPD, nephrotic syndrome, liver cirrhosis, constrictive pericarditis

OPD Prescription:

ACE inhibitor (Ramipril 2.5–10 mg OD) or ARB (Candesartan 4–32 mg OD)
Beta-blocker: Carvedilol 3.125–25 mg BD or Bisoprolol 1.25–10 mg OD
MRA: Spironolactone 25–50 mg OD
SGLT2i: Dapagliflozin 10 mg OD or Empagliflozin 10 mg OD
Loop diuretic: Furosemide 20–80 mg OD (for fluid overload)
Ivabradine if HR >70 bpm on max beta-blocker

ICU Management:

IV Furosemide (bolus or infusion 5–10 mg/hr)
Vasodilators: IV GTN (1–10 mg/hr) or IV Nitroprusside
Inotropes if cardiogenic shock: Dobutamine 2.5–20 mcg/kg/min
Noradrenaline if hypotensive
Mechanical support: IABP, Impella, ECMO
Daily weights, fluid balance, electrolyte monitoring

Contraindications:

ACEi/ARB: Bilateral renal artery stenosis, pregnancy, K+ >5.5
Beta-blockers: Acute decompensated HF (relative), severe bradycardia, cardiogenic shock
Spironolactone: K+ >5.0, GFR <30

2. HEART FAILURE WITH PRESERVED EF (HFpEF)

EF ≥ 50%, diastolic dysfunction

Findings: Same as HFrEF but normal/hyperdynamic LV function; E/e' ratio >14 on echo; BNP elevated; hypertensive heart disease most common cause

Investigations: Echo (Grade II/III diastolic dysfunction), BNP, stress echo

Differential: Restrictive cardiomyopathy, constrictive pericarditis, cardiac amyloidosis

OPD Prescription:

SGLT2i: Empagliflozin 10 mg OD (Class IIa)
Diuretics for congestion: Furosemide 20–40 mg OD
Treat underlying hypertension, AF, diabetes aggressively
MRA (Spironolactone) — modest benefit

ICU: Careful diuresis, avoid hypotension, rate control if AF

Contraindications: Excessive diuresis (preload dependent), vasodilators causing hypotension

3. ACUTE MYOCARDIAL INFARCTION — STEMI

Findings: Severe crushing chest pain, diaphoresis, radiation to left arm/jaw; ST elevation in ≥2 contiguous leads (>1 mm limb, >2 mm precordial); new LBBB; troponin elevated

Investigations:

Serial ECG (0, 3, 6h)
hs-Troponin T/I (rises 2–4h, peaks 12–24h)
Echo, CXR, FBC, coagulation, U&E, glucose, lipids

Differential: NSTEMI, aortic dissection, pericarditis, pulmonary embolism, oesophageal spasm

OPD Prescription (post-MI):

Aspirin 75 mg OD lifelong
P2Y12 inhibitor: Ticagrelor 90 mg BD or Clopidogrel 75 mg OD (12 months)
Beta-blocker: Metoprolol 25–100 mg BD
ACEi: Ramipril 2.5–10 mg OD
High-intensity statin: Atorvastatin 80 mg ON
Eplerenone 25–50 mg if EF <40% with symptoms

ICU Management:

Primary PCI within 90 min (door-to-balloon)
If PCI not available: Fibrinolysis (Tenecteplase/Alteplase) within 12h
Dual antiplatelet + anticoagulation (UFH/Enoxaparin/Fondaparinux)
Oxygen if SpO2 <94%
Morphine 2–4 mg IV PRN; GTN IV
Treat complications: VF (defibrillation), cardiogenic shock (IABP, inotropes)

Contraindications:

Fibrinolysis: Prior haemorrhagic stroke, active bleeding, recent surgery, severe hypertension
Clopidogrel: Poor metabolisers (CYP2C19); prefer Ticagrelor

4. NSTEMI / UNSTABLE ANGINA

Findings: Rest pain >20 min; no ST elevation; ± ST depression, T-wave inversion; Troponin positive (NSTEMI) or negative (UA)

Investigations: Serial troponin, ECG, echo, coronary angiography (GRACE score guided)

Differential: STEMI, stable angina, aortic dissection, pericarditis, GORD

OPD Prescription:

Aspirin + Ticagrelor/Clopidogrel (12 months)
Beta-blocker, ACEi, high-dose statin
Ranolazine 500 mg BD if refractory angina

ICU Management:

Early invasive strategy (<24h) if high-risk (GRACE >140, troponin +ve, STEMI)
LMWH (Enoxaparin 1 mg/kg BD) or Fondaparinux 2.5 mg OD
GTN infusion for ongoing chest pain
Monitoring for recurrent ischaemia, arrhythmias

Contraindications: Fibrinolysis NOT indicated in NSTEMI/UA; Fondaparinux preferred over UFH (less bleeding)

5. STABLE ANGINA

Findings: Predictable exertional chest tightness/pressure, relieved by rest or GTN within 5 min; normal resting ECG; ST depression on exercise stress test

Investigations: ECG, exercise stress test, coronary CT angiography or coronary angiography

Differential: GORD, musculoskeletal, anxiety, variant angina

OPD Prescription:

PRN sublingual GTN 0.5 mg SL (relief within 3 min)
Beta-blocker: Atenolol 25–100 mg OD or Bisoprolol 5–10 mg OD
CCB: Amlodipine 5–10 mg OD (if beta-blocker contraindicated)
Long-acting nitrate: Isosorbide mononitrate 30–60 mg OD
Aspirin 75 mg OD + Statin
Ranolazine or Ivabradine as add-on

Contraindications: GTN with PDE5 inhibitors (Sildenafil — severe hypotension); Beta-blockers in variant (Prinzmetal) angina

6. HYPERTENSIVE HEART DISEASE / HYPERTENSION

Findings: BP >140/90 mmHg; LVH on ECG (Sokolow-Lyon criteria); 4th heart sound; retinal changes (Keith-Wagener classification); microalbuminuria

Investigations: ECG, Echo, U&E, urinalysis, lipid profile, fasting glucose, fundoscopy

Differential: White coat hypertension, secondary hypertension (Conn's, phaeochromocytoma, renal artery stenosis, CKD)

OPD Prescription (Step therapy):

ACEi/ARB + CCB (e.g., Amlodipine 5–10 mg + Ramipril 5–10 mg)
Add thiazide: Indapamide 1.5 mg OD
Add MRA: Spironolactone 25 mg OD (resistant HTN)
Alpha-blocker (Doxazosin) or Beta-blocker (Bisoprolol) as 4th agent

Target BP <130/80 (diabetics, CKD) or <140/90

ICU Management (Hypertensive Emergency, BP >180/120 + end-organ damage):

IV Labetalol (20 mg bolus then infusion) or IV Nicardipine (5–15 mg/hr)
IV Hydralazine (if eclampsia)
IV Nitroprusside (hypertensive encephalopathy)
Reduce MAP by max 25% in first hour, then gradually to 160/100 over 2–6h

Contraindications:

ACEi/ARB: Bilateral RAS, pregnancy, hyperkalaemia
Beta-blockers: Asthma/COPD, heart block, Raynaud's
Thiazides: Gout

7. ATRIAL FIBRILLATION (AF)

Findings: Irregularly irregular pulse, palpitations, dyspnoea, fatigue; no P waves on ECG; fibrillatory baseline

Investigations: ECG, Holter monitor, Echo (LA size, thrombus, LV function), TFT, FBC

Differential: Atrial flutter, multifocal atrial tachycardia, frequent ectopics, AF with accessory pathway (WPW)

OPD Prescription:

Rate control: Bisoprolol 2.5–10 mg OD or Digoxin 0.125–0.25 mg OD (elderly/sedentary)
Rhythm control: Flecainide, Amiodarone, Dronedarone
Anticoagulation (CHA₂DS₂-VASc ≥1 in men, ≥2 in women):
- Apixaban 5 mg BD or Rivaroxaban 20 mg OD or Warfarin (INR 2–3)
Pill-in-the-pocket: Flecainide 200–300 mg PRN (paroxysmal AF)

ICU Management:

Haemodynamically unstable: Emergency DC cardioversion (200J biphasic)
Stable AF >48h: Rate control, anticoagulate 3 weeks before cardioversion
If <48h: Can cardiovert after anticoagulation
IV Amiodarone 300 mg bolus over 1h then 900 mg over 24h

Contraindications:

Flecainide: Structural heart disease, post-MI, severe LVD
Digoxin: Accessory pathway (WPW), hypokalaemia (toxicity risk)
Dronedarone: Permanent AF, decompensated HF, severe hepatic disease

8. ATRIAL FLUTTER

Findings: Regular 150 bpm (2:1 block); sawtooth flutter waves at 300 bpm in II, III, aVF; regular pulse

OPD: Rate control (Bisoprolol/Diltiazem); anticoagulation same as AF; ablation (cavotricuspid isthmus) — curative

ICU: DC cardioversion 50–100J; IV Amiodarone; treat underlying cause

Contraindications: Flecainide/propafenone contraindicated without AV nodal blocker (can convert to 1:1 with rapid conduction)

9. SUPRAVENTRICULAR TACHYCARDIA (SVT — AVNRT/AVRT)

Findings: Sudden onset palpitations 150–250 bpm; narrow complex regular tachycardia; P waves buried in QRS (AVNRT) or retrograde P waves

Differential: AF, atrial flutter, VT with aberrancy, junctional tachycardia

OPD Prescription:

Vagal manoeuvres first (Valsalva, carotid sinus massage)
Adenosine 6 mg IV rapid push (then 12 mg if no response)
Verapamil 5–10 mg IV (if adenosine contraindicated)
Maintenance: Verapamil 40–120 mg TDS or Diltiazem or Metoprolol
Radiofrequency ablation: Curative >95% success

ICU Management: DC cardioversion if haemodynamically compromised (50–100J)

Contraindications: Adenosine: WPW/accessory pathway (can precipitate VF), asthma; Verapamil: WPW, VT, hypotension, HF

10. VENTRICULAR TACHYCARDIA (VT)

Findings: Wide complex regular tachycardia (QRS >120ms); AV dissociation; fusion beats; capture beats; HR 100–250 bpm; haemodynamic compromise

Differential: SVT with aberrancy, pre-excited AF (WPW), AVRT

OPD Prescription (recurrent VT):

Beta-blocker: Metoprolol 50–200 mg BD
Amiodarone 200 mg OD (maintenance)
ICD implantation if EF <35% or sustained VT

ICU Management:

Pulseless VT: CPR + defibrillation (200J biphasic)
Pulse present, unstable: Synchronised DC cardioversion (100–200J)
Stable: IV Amiodarone 150 mg over 10 min, then 1 mg/min x 6h
Correct K+, Mg2+ (target K+ >4.5, Mg2+ >0.8)

Contraindications: Procainamide/Flecainide avoided in structural heart disease; avoid class IC agents post-MI

11. VENTRICULAR FIBRILLATION (VF)

Findings: Chaotic irregular electrical activity; no discernible QRS; cardiac arrest; no pulse

ICU Management (BLS/ALS):

CPR: 30:2 ratio, 100–120 compressions/min
Defibrillation: 200J biphasic immediately, repeat every 2 min
Adrenaline 1 mg IV every 3–5 min (after 3rd shock)
Amiodarone 300 mg IV (after 3rd shock), repeat 150 mg
Treat reversible causes (4Hs and 4Ts)
Post-ROSC: Targeted temperature management 36°C for 24h; PCI if STEMI

Contraindications: Do not delay defibrillation for IV access; thrombolytics during CPR only in suspected massive PE

12. COMPLETE HEART BLOCK (3rd Degree AV Block)

Findings: HR 30–45 bpm (junctional escape) or 25–40 (ventricular escape); P waves unrelated to QRS (AV dissociation); syncope, Stokes-Adams attacks; cannon A waves in JVP

Differential: Mobitz II, 2nd degree AV block, accelerated junctional rhythm

ICU Management:

Temporary pacing (transcutaneous or transvenous)
Atropine 0.5–1 mg IV (if junctional rate, may have partial response)
Isoprenaline infusion (2–10 mcg/min) as bridge to pacing
Permanent pacemaker (PPM) — definitive

OPD: Permanent pacemaker (dual chamber DDD preferred); review/stop causative drugs (beta-blockers, digoxin)

Contraindications: Digoxin, beta-blockers, CCBs, amiodarone contraindicated until paced

13. SICK SINUS SYNDROME (SSS)

Findings: Sinus bradycardia, sinus pauses, sinoatrial block, tachycardia-bradycardia syndrome; syncope, presyncope, palpitations

ICU: Temporary pacing for symptomatic bradycardia; withdraw offending drugs

OPD: Permanent pacemaker (AAI or DDD); anticoagulation if tachy-brady syndrome

Contraindications: Rate-slowing drugs (beta-blockers, digoxin, CCBs) without pacemaker

14. DILATED CARDIOMYOPATHY (DCM)

Findings: Dilated LV (LVEDD >55mm in men, >50mm in women), EF <40%; S3 gallop, mitral regurgitation; family history in 35%

Investigations: Echo, CMR, genetic testing, endomyocardial biopsy (if myocarditis suspected), coronary angiography (to exclude ischaemic)

Differential: Ischaemic cardiomyopathy, myocarditis, alcohol/peripartum cardiomyopathy, sarcoidosis, haemochromatosis

OPD Prescription: Same as HFrEF (ARNI/ACEi + beta-blocker + MRA + SGLT2i); ICD if EF <35% despite 3-month GDMT; CRT if LBBB + EF ≤35%

ICU: As per decompensated HF; inotropes if cardiogenic shock; LVAD as bridge to transplant

Contraindications: Alcohol (abstinence mandatory); NSAIDs worsen DCM; avoid Class I antiarrhythmics

15. HYPERTROPHIC CARDIOMYOPATHY (HCM)

Findings: LVOT obstruction gradient >30 mmHg; asymmetric septal hypertrophy (IVS >15mm); systolic anterior motion (SAM) of mitral valve; dynamic obstruction worsened by dehydration/Valsalva; sudden cardiac death (SCD) risk

Investigations: Echo (IVS thickness, LVOT gradient, SAM), CMR (LGE pattern), 24h Holter, genetic testing (MYH7, MYBPC3 mutations), exercise stress test

Differential: Hypertensive LVH, athlete's heart, Fabry disease, Friedreich's ataxia, glycogen storage disease

OPD Prescription:

Beta-blocker: Metoprolol 50–200 mg BD or Propranolol 40–160 mg TDS
CCB: Verapamil 120–480 mg daily (if beta-blocker not tolerated)
Mavacamten 5–15 mg OD (cardiac myosin inhibitor — new agent for obstructive HCM)
ICD if high-risk for SCD (≥1 major risk factor)
Avoid competitive sports, dehydration

ICU: IV phenylephrine (vasoconstrictor) for haemodynamic compromise; IV fluid loading; avoid inotropes and vasodilators (worsen obstruction); consider septal myectomy or alcohol septal ablation

Contraindications: Nitrates, ACEi, diuretics (reduce preload → worsen obstruction); Digoxin; positive inotropes

16. RESTRICTIVE CARDIOMYOPATHY

Findings: Normal/near-normal LV size and EF; severely impaired diastolic filling; markedly elevated filling pressures; Kussmaul's sign possible; rapid y-descent in JVP; "square root sign" on cardiac catheterisation

Differential: Constrictive pericarditis (key differential — may need CT/CMR/cardiac catheterisation to differentiate)

Causes: Amyloidosis, sarcoidosis, haemochromatosis, endomyocardial fibrosis, Fabry disease

Investigations: Echo (granular sparkling pattern in amyloid), CMR, endomyocardial biopsy, Congo red staining, serum/urine protein electrophoresis, bone marrow biopsy (AL amyloid), TTR gene testing (ATTR)

OPD:

Amyloid: Tafamidis 61 mg OD (ATTR-CM); Doxycycline + TUDCA (ATTR); chemotherapy (AL)
Sarcoid: Prednisolone 20–40 mg OD
Haemochromatosis: Phlebotomy, Desferrioxamine
Diuretics carefully (preload dependent)

ICU: Cautious diuresis, treat AF, permanent pacemaker for conduction disease

Contraindications: Digoxin in amyloidosis (binds amyloid fibrils → high risk toxicity); aggressive diuresis

17. AORTIC STENOSIS (AS)

Findings: Ejection systolic murmur radiating to carotids; slow rising pulse; narrow pulse pressure; LVH; AS triad — angina, syncope, dyspnoea; severe AS: valve area <1 cm², mean gradient >40 mmHg, peak velocity >4 m/s

Investigations: Echo (valve area, gradient, EF), CXR (LVH, calcified aortic valve), cardiac catheterisation (if discordant findings)

Differential: HOCM, supravalvular AS, subvalvular AS, MR (different radiation)

OPD Prescription:

No medical therapy proven to slow progression
Annual echo surveillance; optimise CVD risk factors
Statin use — no longer recommended to slow AS progression
Treat hypertension carefully (ACEi/ARB reasonable)
Surgical AVR (SAVR) or TAVI when symptomatic or asymptomatic with EF <50%

ICU: TAVI/SAVR; vasopressors (phenylephrine) for hypotension; avoid tachycardia; diuretics for pulmonary oedema; IABP as bridge

Contraindications: Vasodilators (ACEi, nitrates) in severe symptomatic AS (cause severe hypotension); avoid tachycardia (reduces diastolic filling time)

18. AORTIC REGURGITATION (AR)

Findings: Wide pulse pressure; collapsing (water hammer) pulse; early diastolic murmur; De Musset's, Corrigan's, Quincke's signs; Austin-Flint murmur (severe AR); LV dilatation

Investigations: Echo (regurgitant volume, vena contracta, LV dimensions), CMR

Differential: Pulmonary regurgitation, Graham Steell murmur (PR from pulmonary hypertension)

OPD Prescription:

Vasodilators: Amlodipine 5–10 mg OD or ACEi if symptomatic
ACEi/ARB for LV enlargement with symptoms
Surgery (AVR): Symptomatic AR, or asymptomatic with LVESD >50mm or LVEDD >70mm or EF <50%

ICU: IV Vasodilators (nitroprusside), inotropes; avoid beta-blockers (worsen regurgitation by reducing HR); urgent AVR if acute AR (Endocarditis/Aortic dissection)

Contraindications: Beta-blockers in acute AR (bradycardia allows more regurgitation); pure inodilators preferred

19. MITRAL STENOSIS (MS)

Findings: Mitral facies; tapping apex; loud S1; opening snap; mid-diastolic rumble (best at apex, left lateral decubitus); exertional dyspnoea; haemoptysis; AF; pulmonary hypertension; Wilkins score on echo

Investigations: Echo (MVA by planimetry, pressure half-time, Wilkins score, PA pressure), CXR (left atrial enlargement, double right heart border, pulmonary oedema)

Differential: Cor triatriatum, left atrial myxoma, mitral annular calcification

OPD Prescription:

Diuretics: Furosemide 20–40 mg OD for congestion
Rate control: Bisoprolol 5–10 mg OD or Digoxin (if AF)
Anticoagulation if AF or prior embolism: Warfarin (INR 2–3) or NOAC
Percutaneous mitral balloon valvotomy (PMBV) if MVA <1.5 cm² + Wilkins score ≤8
MVR if not suitable for PMBV

ICU: IV diuretics; rate control (avoid tachycardia — critical); treat AF; haemoptysis management

Contraindications: Vasodilators (worsen forward flow); positive inotropes (minimal benefit); PMBV contraindicated if LA thrombus, MR >2+, Wilkins score >8

20. MITRAL REGURGITATION (MR)

Findings: Pansystolic murmur at apex radiating to axilla; laterally displaced apex; soft S1; S3; hyperdynamic LV

Investigations: Echo (EROA, vena contracta, regurgitant volume, LV dimensions), CMR, TOE

Differential: VSD, TR, AS (different timing/location)

OPD Prescription:

Vasodilators (ACEi, ARB) for LV dysfunction
Diuretics for congestion
Mitral valve repair (preferred) or replacement:
- Symptomatic severe MR
- Asymptomatic with LVEF <60% or LVESD >40mm
MitraClip (transcatheter) for high surgical risk

ICU: IV nitroprusside (reduces afterload, reduces regurgitant fraction); IABP; avoid vasoconstrictors

Contraindications: Pure vasoconstrictors; beta-blockers not first-line in acute MR

21. INFECTIVE ENDOCARDITIS (IE)

Findings: Duke criteria (major + minor); fever, new murmur, Osler nodes, Janeway lesions, Roth spots, splinter haemorrhages, positive blood cultures, embolic phenomena; commonest organisms: Strep. viridans (native), Staph. aureus (IV drug users, prosthetic)

Investigations: 3 sets blood cultures (before antibiotics), Echo (TOE gold standard — vegetation, abscess), FBC, CRP, ESR, urinalysis (haematuria)

Differential: Marantic endocarditis, Libman-Sacks (SLE), rheumatic carditis, atrial myxoma, septicaemia

OPD: 4–6 weeks IV antibiotics (outpatient IV via PICC line)

ICU Management:

Native valve, Strep: Benzylpenicillin 1.2g IV 4-hourly + Gentamicin 1 mg/kg TDS x 2 weeks
Staph. aureus: Flucloxacillin 2g IV 6-hourly x 4–6 weeks; add Rifampicin for prosthetic
MRSA: Vancomycin (target trough 15–20 mcg/mL)
Surgical indications: Severe HF, abscess, uncontrolled infection, large vegetation (>10 mm), embolism on therapy

Contraindications: Prophylactic antibiotics no longer routinely recommended (NICE); Aminoglycosides avoided in renal impairment

22. PERICARDITIS (ACUTE)

Findings: Sharp pleuritic chest pain, better sitting forward; pericardial friction rub; saddle-shaped ST elevation (concave up) in most leads; PR depression; fever

Investigations: ECG (serial), CRP/ESR elevated, troponin mildly elevated (myopericarditis), Echo (pericardial effusion), TTE, CXR

Differential: STEMI (localised vs diffuse ST changes), myocarditis, aortic dissection, pleuritis

OPD Prescription:

NSAIDs: Aspirin 750–1000 mg TDS x 2 weeks (taper) or Ibuprofen 600 mg TDS
Colchicine 0.5 mg BD x 3 months (prevents recurrence — COPE trial)
Avoid strenuous exercise until symptom-free + normalised CRP
Corticosteroids only if NSAID failure, autoimmune, or specific indication (Prednisolone 0.25–0.5 mg/kg/day)

ICU: As per cardiac tamponade if effusion develops; pericardiocentesis

Contraindications: Anticoagulation should be used cautiously (haemorrhagic conversion risk); steroids increase recurrence risk if used early; avoid in purulent pericarditis

23. CARDIAC TAMPONADE

Findings: Beck's triad: hypotension + muffled heart sounds + raised JVP; pulsus paradoxus >10 mmHg; electrical alternans on ECG; globular heart on CXR; echo (RA/RV diastolic collapse, IVC plethora, respiratory variation in Doppler)

Investigations: ECG (electrical alternans), Echo (diagnostic + guidance), CXR

Differential: Constrictive pericarditis, tension pneumothorax, cardiogenic shock, RV failure

ICU Management:

Emergency pericardiocentesis (subxiphoid approach, echo-guided)
IV fluid bolus as temporising measure
Avoid IPPV (can worsen haemodynamics)
Surgical pericardial window if recurrent (malignancy, TB)

Contraindications: Diuretics (reduce preload → haemodynamic collapse); Avoid antihypertensives

24. CONSTRICTIVE PERICARDITIS

Findings: Kussmaul's sign (JVP rises on inspiration); pericardial knock; rapid y-descent; Friedreich's sign; hepatomegaly, ascites, peripheral oedema; CT/CMR shows pericardial thickening >4mm; equalisation of diastolic pressures on catheterisation; ventricular interdependence

Investigations: Echo (septal bounce, hepatic vein expiratory diastolic reversal), CT chest (calcification), CMR, cardiac catheterisation (gold standard differentiation from RCM)

Differential: Restrictive cardiomyopathy, right heart failure, hepatic cirrhosis, nephrotic syndrome

OPD: Pericardiectomy (surgical stripping) — definitive treatment; diuretics for symptom control; treat underlying cause (TB — anti-TB therapy x 6 months with steroids)

ICU: Haemodynamic monitoring; diuretics; surgical consultation

Contraindications: Aggressive diuresis (preload dependent)

25. PULMONARY HYPERTENSION (PH)

Findings: mPAP >20 mmHg at rest on catheterisation; dyspnoea, fatigue, right heart failure signs; loud P2, RV heave, TR murmur, elevated JVP; WHO functional class I–IV

Investigations: ECG (RV strain, RBBB), CXR (enlarged PA, pruning), Echo (RVSP estimation, RV dilatation), right heart catheterisation (gold standard), CT pulmonary angiography, V/Q scan, PFTs, 6-minute walk test, BNP

Differential: Pulmonary embolism, COPD, cardiac disease (Group 2 PH), left heart disease

OPD Prescription (Group 1 — PAH):

Vasoreactivity test positive: CCB (Nifedipine, Diltiazem)
PDE5i: Sildenafil 20 mg TDS or Tadalafil 40 mg OD
ERA: Ambrisentan 5–10 mg OD or Bosentan 62.5–125 mg BD
Prostacyclin analogues: Iloprost inhaled, Selexipag 200–1600 mcg BD, IV Epoprostenol (severe)
Combination therapy for higher risk
Anticoagulation (Warfarin) in idiopathic PAH
Diuretics, oxygen if hypoxic

ICU: IV Epoprostenol; inhaled NO; avoid hypoxia; right heart catheterisation; heart-lung transplant

Contraindications: ACEi/ARBs not effective; ERA (Bosentan) teratogenic, hepatotoxic; CCBs only in vasoreactive PAH; Sildenafil with nitrates (severe hypotension)

26. AORTIC DISSECTION

Findings: Sudden tearing/ripping chest/back pain; BP differential >20 mmHg between arms; pulse deficit; aortic regurgitation (Type A); neurological deficits; CXR widened mediastinum (>8 cm)

Stanford Classification: Type A (ascending) — surgical emergency; Type B (descending) — medical management (unless complicated)

Investigations: CT aortography (gold standard), TOE, MRI; ECG (exclude STEMI), CXR, D-dimer (high sensitivity low specificity)

Differential: STEMI/NSTEMI (critical — thrombolysis can be fatal in dissection), pulmonary embolism, pericarditis, Marfan syndrome related

ICU Management:

Type A: Emergency surgical repair
Type B: IV Labetalol (HR <60, SBP 100–120 mmHg); IV Esmolol (0.5 mg/kg bolus then infusion); IV Nicardipine add-on if needed
Target HR <60, SBP <120 mmHg
Pain control: IV Morphine
Type B complicated (malperfusion, enlarging): TEVAR (endovascular stenting)

Contraindications: Anticoagulation in uncomplicated aortic dissection; vasodilators without adequate beta-blockade first (reflex tachycardia worsens dissection); thrombolysis contraindicated (catastrophic)

27. DEEP VEIN THROMBOSIS (DVT) AND PULMONARY EMBOLISM (PE)

Findings (PE): Pleuritic chest pain, haemoptysis, dyspnoea; sinus tachycardia most common ECG finding; S1Q3T3 (classic but uncommon); right heart strain on echo; CT-PA diagnostic; Wells score ≥4 (probable PE); D-dimer (<500 mcg/L excludes if low probability)

Investigations: D-dimer, CT pulmonary angiography (gold standard), V/Q scan (if CKD/contrast allergy), Echo (RV strain, TAPSE), lower limb duplex USS, troponin + BNP (prognosis)

Differential: Pneumonia, pleuritis, pneumothorax, pericarditis, ACS, aortic dissection

OPD Prescription (DVT/low-intermediate risk PE):

Rivaroxaban 15 mg BD x 21 days, then 20 mg OD
Apixaban 10 mg BD x 7 days, then 5 mg BD
Duration: Provoked PE 3–6 months; unprovoked 6–12 months; recurrent/cancer — lifelong (LMWH or Rivaroxaban)

ICU Management (Massive PE):

Systemic thrombolysis: Alteplase 100 mg over 2h (if SBP <90 mmHg or cardiac arrest)
Surgical embolectomy or catheter-directed thrombolysis (EKOS) if thrombolysis fails/contraindicated
Anticoagulation: UFH infusion during and after
Haemodynamic support: IV noradrenaline; vasopressors; ECMO

Contraindications: Thrombolysis: recent surgery (<10 days), recent stroke (<3 months), active bleeding, haemorrhagic stroke; NOAC in antiphospholipid syndrome (use Warfarin INR 2–3 or 3–4)

28. ACUTE RHEUMATIC FEVER (ARF) AND RHEUMATIC HEART DISEASE (RHD)

Findings (Jones criteria): Major — carditis, migratory polyarthritis, Sydenham's chorea, erythema marginatum, subcutaneous nodules; Minor — fever, elevated CRP/ESR, prolonged PR interval; + evidence of preceding Group A Strep infection

Investigations: ASO titre (elevated >200 IU/mL), anti-DNase B, throat swab, ECG, Echo, FBC, CRP, ESR

Differential: Reactive arthritis, septic arthritis, SLE, viral myocarditis, JIA

OPD Prescription:

Benzylpenicillin 1.2 MU IM stat (eradicate Strep)
Aspirin 75–100 mg/kg/day (arthritis) or Naproxen; gradually taper
Prednisolone 1–2 mg/kg/day (severe carditis)
Secondary prophylaxis: Benzathine penicillin G 1.2 MU IM every 3–4 weeks x 10 years or until age 25 (whichever longer); x lifetime if moderate-severe valve disease

ICU: Treat severe carditis and HF; anti-inflammatory therapy; diuretics; valve surgery if acute severe MR/AR

Contraindications: Aspirin in children <16 years (Reye syndrome) — use Naproxen instead; stop prophylaxis only after ensuring no active carditis

29. PERIPHERAL ARTERIAL DISEASE (PAD)

Findings: Intermittent claudication; rest pain; absent/reduced peripheral pulses; ABPI <0.9 (moderate-severe <0.4 critical ischaemia); trophic skin changes; ulcers (punched out, painful, on pressure areas)

Investigations: ABPI (ankle-brachial pressure index), duplex USS, CT angiography or MR angiography, conventional angiography (pre-intervention), FBC, lipids, HbA1c, U&E

Differential: Venous claudication, spinal stenosis (neurogenic claudication), DVT, Buerger's disease

OPD Prescription:

Antiplatelet: Aspirin 75 mg OD + Clopidogrel 75 mg OD (dual after intervention) or Rivaroxaban 2.5 mg BD + Aspirin 100 mg (COMPASS trial)
High-intensity statin: Atorvastatin 40–80 mg ON
ACEi: Ramipril 5–10 mg OD
Supervised exercise programme (first-line for claudication)
Cilostazol 100 mg BD (PDE3 inhibitor) — improves walking distance
Smoking cessation (mandatory)
BP control, diabetes management

ICU (Critical Limb Ischaemia/Acute Limb Ischaemia):

IV UFH bolus 5000 U then infusion (target APTT 60–100s)
Emergency revascularisation: PTA/stenting, surgical bypass (fem-pop, aorto-bifemoral)
Thrombolysis: Alteplase/Urokinase (if onset <14 days)
Fasciotomy if compartment syndrome
Amputation as last resort

Contraindications: Cilostazol: HF (PDE3i increases mortality in HF); avoid beta-blockers in severe PAD (relative); Warfarin alone not recommended over antiplatelet therapy

30. CARDIAC ARREST (Sudden Cardiac Death/SCD)

Findings: Unresponsive, no normal breathing, no pulse; VF/pulseless VT (shockable) or PEA/Asystole (non-shockable); reversible causes — 4Hs (Hypoxia, Hypovolaemia, Hypothermia, Hypo/Hyperkalaemia) and 4Ts (Tension pneumothorax, Tamponade, Thrombosis [PE/MI], Toxins)

Investigations: Post-ROSC: 12-lead ECG, ECHO, ABG, bloods (troponin, BNP, lactate, K+), CT head, CT coronary/chest, continuous EEG if comatose

Differential: Syncope, seizure, respiratory arrest, anaphylaxis, hypoglycaemia

ICU Management (ALS Algorithm):

Shockable (VF/pVT):

Immediate CPR 30:2
Defibrillate 200J (biphasic) asap
Resume CPR 2 min; repeat shock if indicated
Adrenaline 1 mg IV after 3rd shock, then every 3–5 min
Amiodarone 300 mg after 3rd shock; 150 mg after 5th shock

Non-Shockable (PEA/Asystole):

CPR 30:2
Adrenaline 1 mg IV immediately then every 3–5 min
Treat reversible causes

Post-ROSC Care:

Targeted temperature management (TTM) 36°C for 24h
Primary PCI if STEMI or suspected cardiac cause
Avoid hyperoxia (SpO2 94–98%), avoid hypercapnia
Sedation, ventilation, neuroprotection
Assess for ICD implantation

Contraindications: Sodium bicarbonate routine use not recommended; calcium chloride only for specific indications (hyperkalaemia, CCB toxicity); high-dose adrenaline no benefit

QUICK REFERENCE TABLE — 30 CONDITIONS SUMMARY

#	Condition	Key Drug(s)	Key Investigation	ICU Priority	Key Contraindication
1	HFrEF	ACEi + BB + MRA + SGLT2i	BNP, Echo	Dobutamine, diuresis	BB in cardiogenic shock
2	HFpEF	SGLT2i, diuretics	Echo, BNP	Careful diuresis	Aggressive diuresis
3	STEMI	Aspirin, Ticagrelor, PCI	Troponin, ECG	Primary PCI	Fibrinolysis contraindications
4	NSTEMI/UA	DAPT + LMWH	Troponin, Echo	Invasive strategy	Fibrinolysis contraindicated
5	Stable Angina	GTN + BB + Statin	Stress test, CTA	-	GTN + PDE5i
6	Hypertension	ACEi + CCB + Thiazide	ECG, Echo, U&E	IV Labetalol/Nitroprusside	ACEi in pregnancy
7	AF	BB/Digoxin + Anticoagulation	ECG, Echo, TFT	DC Cardioversion	Flecainide in structural disease
8	Atrial Flutter	Rate control, ablation	ECG	DC 50–100J	-
9	SVT	Adenosine	ECG	Cardioversion	Adenosine in WPW/asthma
10	VT	Amiodarone, BB, ICD	ECG	IV Amiodarone/Cardioversion	Class IC post-MI
11	VF	Adrenaline, Amiodarone	CPR monitor	Defibrillate 200J	Delay defibrillation
12	Complete HB	Pacemaker	ECG	Atropine, pacing	Rate-slowing drugs
13	SSS	Pacemaker	Holter	Temporary pacing	Rate-slowing without PM
14	DCM	HFrEF therapy, ICD	Echo, CMR	Inotropes, LVAD	Alcohol, NSAIDs
15	HCM	Metoprolol, Mavacamten	Echo, CMR	Phenylephrine	Nitrates, inotropes
16	RCM	Tafamidis (ATTR)	Echo, CMR, biopsy	Cautious diuresis	Digoxin in amyloid
17	Aortic Stenosis	Surveillance, AVR/TAVI	Echo	Vasopressors	Vasodilators
18	Aortic Regurg	Amlodipine/ACEi, AVR	Echo	Nitroprusside	BB in acute AR
19	Mitral Stenosis	Diuretics + PMBV	Echo	Rate control	PMBV if LA thrombus
20	Mitral Regurg	ACEi, MVR/MitraClip	Echo, CMR	Nitroprusside	Vasoconstrictors
21	Endocarditis	Benzylpenicillin/Fluclox/Vancomycin	Blood cultures, TOE	IV antibiotics, surgery	Aminoglycosides in renal failure
22	Pericarditis	Aspirin + Colchicine	ECG, CRP, Echo	Pericardiocentesis	Anticoagulation (early)
23	Tamponade	Pericardiocentesis	Echo	Pericardiocentesis	Diuretics
24	Constrictive PC	Pericardiectomy	CT, CMR, Catheter	Diuretics	Aggressive diuresis
25	Pulm. HTN	PDE5i/ERA/Prostacyclin	RHC, Echo	Epoprostenol, iNO	CCBs in non-vasoreactive
26	Aortic Dissection	Labetalol (TypeB); Surgery (TypeA)	CT Aortography	Surgical/TEVAR	Anticoagulation (Type A)
27	PE	Rivaroxaban/Apixaban/Alteplase	CT-PA	Alteplase, UFH	Thrombolysis: recent surgery/stroke
28	Rheumatic Fever	Benzyl-Pen + Aspirin	ASO titre, Echo	Anti-inflammatory	Aspirin <16 yrs (Reye's)
29	PAD	Aspirin + Statin + ACEi	ABPI, CT angio	UFH + revascularisation	Cilostazol in HF
30	Cardiac Arrest	Adrenaline + Amiodarone	Post-ROSC ECG, Echo	CPR → Defib → TTM	Routine bicarbonate

References: Braunwald's Heart Disease 12e (Elsevier, ISBN 9780323722193); Fuster and Hurst's The Heart 15e (McGraw-Hill, ISBN 9781264257560); Textbook of Clinical Echocardiography 6e (ISBN 9780323882088); Textbook of Family Medicine 9e (ISBN 9780323239905)

This is a shared conversation. Sign in to Orris to start your own chat.