Cardiology

Ischaemic Heart Disease & ACS · Hypertension · Arrhythmias & Conduction Disorders · Heart Failure & Cardiomyopathies · Valvular Heart Disease · Pericardial Disease & Cardiac Masses · Aorta & Great Vessels · Congenital Heart Disease · Pulmonary Embolism & Pulmonary Hypertension · Infective Endocarditis & Rheumatic Fever · Cardiovascular Pharmacology · Clinical Examination & ECG · Cardiac Investigations & Imaging · Special Situations & Emergencies

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Ischaemic Heart Disease & ACS

Cardiac Enzymes and Protein Markers — Myoglobin is the first marker to rise (1-2 h); troponin T and I have largely superseded the older enzymes
Acute Coronary Syndrome: Management of NSTEMI — All patients: aspirin 300 mg loading dose as soon as possible, continued indefinitely unless contraindicated · offer pai
Angina Pectoris: Drug Management — All patients: aspirin + statin (unless contraindicated), plus sublingual GTN to abort attacks.
Acute Coronary Syndrome: Prognostic Factors — GRACE regression models predict in-hospital and post-discharge death in acute coronary syndrome.
STEMI: Fibrinolysis — If primary PCI cannot be delivered within 120 minutes of when fibrinolysis could be given → give fibrinolysis (e.g. alte
Coronary Circulation — Left aortic sinus → left coronary artery (LCA → LAD + circumflex); right aortic sinus → right coronary artery (RCA → pos
Myocardial Infarction: Complications — Ventricular fibrillation is the most common cause of death post-MI → manage per ALS with defibrillation; AV block is com
Percutaneous Coronary Intervention — PCI restores myocardial perfusion in stable angina and ACS; stents are implanted in ~95% of patients (balloon angioplast
Myocardial Infarction: Secondary Prevention — Offer all post-MI patients four core treatments: dual antiplatelet therapy · ACE inhibitor (continued indefinitely) · be
Myocardial Infarction: STEMI Management — All patients (no contraindications): aspirin + P2Y12 antagonist (ticagrelor now often favoured over clopidogrel — better
NSTEMI — Intermediate-or-higher-risk NSTEMI (GRACE predicted 6-month mortality > 3%) → coronary angiography (with follow-on PCI i
Chest Pain: Assessment of Patients with Suspected Cardiac Chest Pain — Suspected ACS — immediate management: glyceryl trinitrate + aspirin 300 mg (NICE: do NOT give other antiplatelets such a

Hypertension

Hypertension: Management — Stages: stage 1 clinic ≥ 140/90 and ABPM/HBPM ≥ 135/85 · stage 2 clinic ≥ 160/100 and ABPM/HBPM ≥ 150/95 · severe clinic
Malignant Hypertension — Severe hypertension (e.g. > 200/130 mmHg) with fibrinoid necrosis of vessels → retinal haemorrhages/exudates, proteinuri
Isolated Systolic Hypertension — Isolated systolic hypertension (raised systolic with normal diastolic) is common in older people, affecting around half
Hypertension: Secondary Causes — Primary hyperaldosteronism (including Conn's syndrome) is found in 5–10% of patients diagnosed with hypertension — the s
Hypertension in Pregnancy — Definition: systolic >140 mmHg or diastolic >90 mmHg, or an increase above booking of >30 mmHg systolic or >15 mmHg dias
Diabetes Mellitus: Hypertension Management — NICE BP targets for diabetics: <130/80 mmHg if end-organ damage (renal disease, retinopathy), otherwise <140/80 mmHg.
Centrally Acting Antihypertensives — Methyldopa: used for hypertension during pregnancy.
Hypertension: Diagnosis — NICE NG136: classify hypertension into stages and confirm with ambulatory (ABPM) or home (HBPM) blood pressure monitorin

Arrhythmias & Conduction Disorders

Atrial Fibrillation: Anticoagulation — CHA2DS2-VASc (superseded CHADS2): CHF 1 · hypertension 1 · age ≥ 75 = 2 · age 65-74 = 1 · diabetes 1 · prior stroke/TIA
Atrial Fibrillation: Cardioversion — Haemodynamically unstable with acute AF → emergency electrical (DC) cardioversion, without delaying for anticoagulation.
Atrial Fibrillation: Rate Control and Maintenance of Sinus Rhythm — NICE NG196: offer RATE control as the first-line strategy for most people with AF — unless AF has a reversible cause, he
Atrial Fibrillation: Post-Stroke — AF with acute ischaemic stroke or TIA: a DOAC is the anticoagulant of choice under NICE NG196 — this replaces the older
Peri-Arrest Rhythms: Tachycardia — Resuscitation Council UK (2021): a single adult tachycardia algorithm covers all tachyarrhythmias; assess with ABCDE and treat reversible causes.
Wolff-Parkinson White Syndrome — Congenital accessory conducting pathway between atria and ventricles → atrioventricular re-entry tachycardia (AVRT) · th
Long QT Syndrome — Inherited delayed ventricular repolarisation → VT/collapse/sudden death; LQT1 & LQT2 = alpha subunit of slow delayed rec
Supraventricular Tachycardia — Paroxysmal SVT: sudden-onset narrow-complex tachycardia, typically AVNRT; also AVRT and junctional tachycardias.
Atrial Fibrillation: A Very Basic Introduction — AF is the most common sustained cardiac arrhythmia: ~5% of 70–75 y olds, ~10% of 80–85 y olds.
Multifocal Atrial Tachycardia — MAT: irregular rhythm from ≥ 3 different atrial sites (≥ 3 morphologically distinct P waves).
Ventricular Tachycardia: Management — Peri-arrest broad complex tachycardia is assumed ventricular in origin (ERC advice).
Pacemakers: Temporary — Indications: symptomatic/haemodynamically unstable bradycardia not responding to atropine.
Torsades de Pointes — Torsades ('twisting of the points'): rare polymorphic VT associated with long QT; may deteriorate into VF → sudden death
Ventricular Tachycardia — VT = broad-complex tachycardia from a ventricular ectopic focus; can precipitate VF → urgent treatment. Monomorphic VT i
Peri-Arrest Rhythms: Bradycardia — Resuscitation Council UK (2021): management guided by adverse features and risk of asystole; atropine 500 mcg IV to max 3 mg, then pacing/second-line drugs
Brugada Syndrome — Inherited (autosomal dominant) cardiovascular disease that may present with sudden cardiac death; prevalence ~1:5,000–10
Atrial Fibrillation: Pharmacological Cardioversion — Agents with proven efficacy for pharmacological cardioversion: flecainide (only if there is NO structural or ischaemic h
Complete Heart Block — Features: syncope · heart failure · regular bradycardia 30–50 bpm · wide pulse pressure · JVP cannon waves · variable in
Broad Complex Tachycardia — Features suggesting VT rather than SVT with aberrant conduction: AV dissociation · fusion or capture beats · positive QR
Atrial Fibrillation: Classification — ESC 2024 / NICE NG196 (2021) simplified AF into 3 patterns.
Atrial Flutter — SVT with rapid regular atrial depolarisation waves — 'sawtooth' ECG.
Implantable Cardiac Defibrillators — ICD indications: long QT syndrome.
Investigating Palpitations — Possible causes: arrhythmias · stress · increased awareness of normal heart beat / extrasystoles
Catecholaminergic Polymorphic Ventricular Tachycardia — Form of inherited cardiac disease associated with sudden cardiac death; inherited in an autosomal dominant fashion with

Heart Failure & Cardiomyopathies

Arrhythmogenic Right Ventricular Cardiomyopathy — Inherited (autosomal dominant, variable expression); ~50% have a desmosome gene mutation; RV myocardium replaced by fatt
HOCM: Features — Autosomal dominant disorder of contractile protein genes — most commonly β-myosin heavy chain or myosin binding protein
Heart Failure: NYHA Classification — NYHA I: no symptoms — ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
Dilated Cardiomyopathy — Dilated heart leading to systolic (± diastolic) dysfunction · all 4 chambers affected but LV more than RV · features inc
B-Type Natriuretic Peptide — Hormone produced mainly by the left ventricular myocardium in response to strain
Heart Failure: Drug Management — HFrEF first-line is now the "four pillars" together: ACE inhibitor (or ARNI) + beta-blocker (bisoprolol, carvedilol or n
Heart Failure: Non-Drug Management — Cardiac resynchronisation therapy (biventricular pacing) for HF with wide QRS.
HOCM: Prognostic Factors — HOCM: autosomal dominant; defects in genes encoding contractile proteins (beta-myosin, alpha-tropomyosin, troponin T); s
Restrictive Cardiomyopathy — Amyloidosis (e.g. secondary to myeloma) is the most common cause of restrictive cardiomyopathy in the UK.
Takotsubo Cardiomyopathy — Also known as 'broken heart syndrome' and Takotsubo apical ballooning syndrome — a cardiomyopathy induced by severe stre
Heart Failure: Diagnosis — NICE NG106: measure NT-proBNP in EVERYONE with suspected heart failure — the older pathway that sent people with a previ
HOCM: Management — Hypertrophic cardiomyopathy: autosomal dominant, caused by sarcomere protein gene mutations; prevalence around 1 in 500.
Myocarditis — Causes: viral (coxsackie, HIV) · bacteria (diphtheria, clostridia) · spirochaetes (Lyme disease) · protozoa (Chagas' dis

Valvular Heart Disease

Aortic Stenosis — Symptomatic disease: chest pain · dyspnoea · syncope — symptomatology guides the timing of surgery
Aortic Regurgitation — Features: early diastolic murmur · collapsing pulse · wide pulse pressure
Mitral Valve Prolapse — MVP is common (5–10% of population); usually idiopathic.
Mitral Stenosis — Causes: rheumatic fever (× 3!); rarer — mucopolysaccharidoses, carcinoid, endocardial fibroelastosis.
Tricuspid Regurgitation — Signs: pan-systolic murmur · giant V waves in JVP · pulsatile hepatomegaly · left parasternal heave.
Prosthetic Heart Valves — Mechanical valves need long-term warfarin — target INR: aortic 3.0, mitral 3.5; DOACs are not used with mechanical valve
Bicuspid Aortic Valve — Occurs in 1-2% of the population; usually asymptomatic in childhood

Pericardial Disease & Cardiac Masses

Acute Pericarditis — Features: pleuritic chest pain often relieved by sitting forwards · non-productive cough, dyspnoea, flu-like symptoms ·
Cardiac Tamponade — Features: dyspnoea · tachycardia · hypotension · muffled heart sounds · pulsus paradoxus
Atrial Myxoma — 75% occur in the left atrium; more common in females.

Aorta & Great Vessels

Takayasu's Arteritis — Large vessel vasculitis causing occlusion of the aorta — questions commonly refer to an absent limb pulse · more common
Cholesterol Embolisation — Cholesterol emboli may break off causing renal disease · seen more commonly in arteriopaths and abdominal aortic aneurys
Aortic Dissection — Associations: hypertension · trauma · bicuspid aortic valve · Marfan's/Ehlers-Danlos · Turner's/Noonan's · pregnancy · s
Coarctation of the Aorta — Congenital narrowing of the descending aorta; more common in males (despite Turner's association).

Congenital Heart Disease

Eisenmenger's Syndrome — Reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension
Patent Foramen Ovale — PFO present in ~20% of the population.
Atrial Septal Defects — ASDs are the most likely congenital heart defect found in adulthood; 50% mortality by age 50.
Ventricular Septal Defect — VSDs are the most common cause of congenital heart disease and close spontaneously in around 50% of cases.
Paradoxical Embolisation — A right-sided thrombus (e.g. DVT) causing a left-sided embolism (e.g. stroke) must pass right-to-left through the heart.

Pulmonary Embolism & Pulmonary Hypertension

Pulmonary Embolism: Management — Haemodynamically unstable PE (hypotension, shock, cardiac arrest) → systemic thrombolysis (e.g. IV alteplase) is first-l
Pulmonary Arterial Hypertension — Defined as a resting mean pulmonary artery pressure of ≥ 25 mmHg · endothelin thought to play a key role in pathogenesis
Pulmonary Embolism: Investigation — NICE NG158: history, examination and CXR for all suspected PE, then a two-level PE Wells score. Wells > 4 = PE likely →
Aortic Dissection: Management — Stanford classification: type A = ascending aorta (2/3 of cases); type B = descending aorta, distal to the left subclavi
Pregnancy: DVT/PE Investigation — Suspected DVT in pregnancy: compression duplex ultrasound.

Infective Endocarditis & Rheumatic Fever

Infective Endocarditis: Prophylaxis — NICE CG64 (2008, amended 2016): antibiotic prophylaxis against infective endocarditis is NOT recommended routinely — the word 'routinely' was added in 2016 to allow individualised clinical judgement and shared decision-making.
Infective Endocarditis — Strongest risk factor: previous endocarditis. Groups: previously normal valves (50%, acute) · rheumatic valve disease (3
Infective Endocarditis: Prognosis and Management — Mortality by organism: staphylococci 30% · bowel organisms 15% · streptococci 5% — streptococcal (e.g. viridans) infecti
Infective Endocarditis: Features — Diagnosis (Duke criteria; the major/minor structure is retained in the 2023 Duke-ISCVID update): DEFINITE endocarditis = pathological criteria, OR 2 major, OR 1 major + 3 minor, OR 5 minor.
Rheumatic Fever: Features — Follows an immunological reaction to Streptococcus pyogenes infection 2-6 weeks earlier.

Cardiovascular Pharmacology

Warfarin — Inhibits reduction of vitamin K to its active hydroquinone form → cofactor for carboxylation of clotting factors II, VII
Dabigatran — Oral direct thrombin inhibitor developed as an alternative to warfarin — advantage: no routine monitoring required.
Warfarin: Management of High INR — Major bleeding: stop warfarin · IV vitamin K 5mg · prothrombin complex concentrate (FFP if unavailable — PCC preferred i
Adenosine — Causes transient heart block in the AV node · A1 receptor agonist — inhibits adenylyl cyclase, reducing cAMP and causing
Statins — Inhibit HMG-CoA reductase — the rate-limiting enzyme in hepatic cholesterol synthesis (decreases intrinsic cholesterol s
Loop Diuretics — Furosemide and bumetanide inhibit the Na-K-Cl cotransporter (NKCC2) in the thick ascending limb of the loop of Henle, re
Amiodarone — Class III antiarrhythmic: blocks potassium channels → inhibits repolarisation → prolongs action potential (also class I
Beta-Blockers — Indications: angina · post-MI · heart failure (improve symptoms AND mortality) · arrhythmias (now replace digoxin as rat
ACE Inhibitors — MOA: inhibit conversion of angiotensin I → angiotensin II.
Clopidogrel — Thienopyridine P2Y12 ADP-receptor antagonist, inhibiting platelet activation (class: prasugrel, ticagrelor, ticlopidine).
Thiazide Diuretics — MOA: inhibit Na⁺ reabsorption at the start of the distal convoluted tubule (block thiazide-sensitive Na⁺-Cl⁻ symporter);
Warfarin: Dental Procedures — Warfarinised patient needing dental extraction: check INR 72 hours before the procedure.
Nicotinic Acid — Used in hyperlipidaemia: lowers cholesterol and triglyceride concentrations and raises HDL — the most effective way to i
Dipyridamole — Antiplatelet used mainly WITH aspirin after ischaemic stroke or TIA.
Hydralazine — Older antihypertensive; still used in hypertension in pregnancy and severe hypertension.
Hyperlipidaemia: Xanthomata — Palmar xanthoma: remnant hyperlipidaemia (less commonly familial hypercholesterolaemia).
Antiplatelets: Summary of Latest Guidance — NSTEMI/ACS: aspirin (lifelong) plus a second antiplatelet — ticagrelor, or prasugrel if PCI — for 12 months; if aspirin is contraindicated, clopidogrel lifelong.
Combination Antiplatelet and Anticoagulant Therapy — Patients increasingly have an indication for BOTH an antiplatelet (established cardiovascular disease) and an anticoagul
Atropine — Atropine is an antagonist of the muscarinic acetylcholine receptor

Clinical Examination & ECG

ECG: Coronary Territories — Anteroseptal (V1-V4): left anterior descending · inferior (II, III, aVF): right coronary
Heart Sounds: S2 — S2 = closure of the aortic valve (A2) closely followed by the pulmonary valve (P2)
Jugular Venous Pulse — 'a' wave = atrial contraction — large with high atrial pressure (tricuspid stenosis, pulmonary stenosis, pulmonary hyper
ECG: PR Interval — Prolonged PR interval: idiopathic · ischaemic heart disease · digoxin toxicity · hypokalaemia · rheumatic fever
Murmurs — Ejection systolic: aortic stenosis · pulmonary stenosis · HOCM · ASD · Fallot's.
Pulses — Pulsus paradoxus: >10 mmHg inspiratory fall in systolic BP → faint/absent pulse in inspiration — severe asthma, cardiac
Heart Sounds — S1 (mitral + tricuspid closure): soft if long PR or MR; loud in mitral stenosis.
JVP: Cannon Waves — Cannon waves: right atrium contracts against a closed tricuspid valve.
ECG: Digoxin — Digoxin effect on ECG: down-sloping ST depression ('reverse tick').
ECG: Hypothermia — Hypothermia ECG: bradycardia.
ECG: Hypokalaemia — Hypokalaemia ECG: U waves.
Valsalva Manoeuvre — Forced expiration against a closed glottis → ↑ intrathoracic pressure → ↑ venous/right atrial pressure → ↓ venous return
ECG: Normal Variants — Normal variants in an athlete: sinus bradycardia · junctional rhythm · first degree heart block · Wenckebach phenomenon.
ECG: ST Depression — Causes of ST depression: secondary to abnormal QRS (LVH, LBBB, RBBB).
ECG: Left Bundle Branch Block — Mnemonic WiLLiaM MaRRoW: LBBB = 'W' in V1, 'M' in V6; RBBB = 'M' in V1, 'W' in V6.
ECG: Axis Deviation — Left axis deviation: left anterior hemiblock · left bundle branch block · Wolff-Parkinson-White syndrome with a right-si

Cardiac Investigations & Imaging

Exercise Tolerance Tests — Uses: suspected angina (2010 NICE guidelines do not support ETT for all patients) · risk stratification after MI · asses
Cardiac Catheterisation and Oxygen Saturation Levels — Basics: deoxygenated blood returns via SVC/IVC at ~70% · RA, RV and PA normally ~70% · lungs oxygenate to 98-100% · LA,
Pulmonary Capillary Wedge Pressure — PCWP measured with balloon-tipped Swan-Ganz catheter in the pulmonary artery.
Cardiac Imaging: Non-Invasive Techniques Excluding Echocardiography — NICE CG95 (2016 update): CT CORONARY ANGIOGRAPHY is first-line for stable chest pain where angina cannot be excluded cli
Exercise Tolerance Tests: Further Notes — Indications: suspected angina (2010 NICE guidelines do NOT support ETT for all patients) · risk stratification post-MI ·
Exercise: Physiological Changes — Blood pressure: systolic increases, diastolic decreases → increased pulse pressure; MABP rise is slight in healthy young

Special Situations & Emergencies

DVLA: Cardiovascular Disorders — Hypertension: drive unless treatment side-effects; no need to notify DVLA; Group 2 disqualified if resting BP consistent
Pre-Eclampsia — PROPHYLAXIS is the highest-yield point: advise aspirin 75-150 mg daily from 12 weeks until birth for any woman with ONE
Scoring Systems — Cardiovascular: CHA₂DS₂-VASc (need to anticoagulate in AF) · NYHA (heart failure severity) · Wells score (DVT risk estim
Anaphylaxis — Adrenaline IM into the anterolateral mid-thigh is the single most important treatment — give it immediately and REPEAT e
Eclampsia — Eclampsia = development of seizures in association with pre-eclampsia (condition seen after 20 weeks gestation: pregnanc