Act as Internalist 👨🏻‍⚕️🫀🩺

🔹Prevention Of ARF 📍1. Primary Prevention ➡️ Give Antibiotics During Symptoms Of GAS Pharyngitis (Before Day 9 Of The Symptoms Onset) 📍2. Secondary Prevention (Prevents Recurrence Of ARF) : ▪︎Phenoxy-Methyl-Penicillin (250mg 2x Daily Oral) Or Benzathine Penicillin (Single Dose 1.2M IM Monthly) ▪︎Erythromycin Or Sulfadiazine (Alternative To Penicillin) ▪︎Duration Of Prophylaxis : I. Healthy Person ➡️ Until Age Of 21 Or 5 Years After The Last Episode II. Residual Heart Disease ➡️ Continue Prophylaxis 10 Years After Last Episode Or Until Age Of 40 Years 🔹Complications Of ARF 📍1. Heart Failure 📍2. Recurrent Attacks Of ARF 📍3. Chronic RF (Valvular Heart Damage) : ▪︎More in Women ▪︎Mitral Valve (Most Commonly Affected As MS Or Mixed MS/MR) ▪︎Then Aortic Then Tricuspid Then Pulmonary.

🔴Acute Rheumatic Fever (ARF) ▪︎Rheumatic Fever is Multi-Systemic Disorder Results From Autoimmune Response Attacks The Body Organs In Reaction To GA Streptococcal Pharyngitis Or Skin Infection ▪︎More in Children At 5-15 Years Age in The Developing Countries البلدان الفقيرة ▪︎The GA Streptococcal Antigens Cross Reacts With Cardiac Proteins That Result in Cardiac Inflammation That Produces Heart Valve Damage in The Future 🔹Dx Of ARF (Jones Criteria) ▪︎(Two Major) Or (One Major + Two Minors) + Evidence Of Preceding Streptococcal Infection ➡️ Confirm Dx ▪︎Only Chorea Or Only PancCarditis (All Cardiac Layers Inflammation) Or Recurrent Acute Rheumatic Fever in Highly Risk Patients ➡️ Confirm Dx (No Need To Other Criteria) 📍1. Major Features : ▪︎Carditis ▪︎PolyArthritis ▪︎Chorea ▪︎Erythema Marginatum ▪︎Subcutaneous Nodules 📍2. Minor Features : ▪︎Fever ▪︎Arthralgia (Joint Pain) ▪︎Elevated ESR Or CRP ▪︎Leukocytosis ▪︎Previous Rheumatic Fever ▪︎1st Degree AV Block 📍3. Evidence Of Proceeding Streptococcal Infection : ▪︎+Ve Throat Culture (+Ve Only in 10-25%) ▪︎Recent Scarlet Fever حمى قرمزية ▪︎+Ve Streptozyme Test Or Anti-DNaseB Or Anti-Hyaluronidase ▪︎Elevated ASOT (>200U in Adults Or >300U in Children But Anti Streptococcal Antibody Titer Normal in ⅕ Of The Cases) 🔹Clinical Features Of ARF 📍1. Fever With Anorexia & Lethargy & Joint Pain 2-3w After Episode Of GA Streptococcal Pharyngitis 📍2. Arthritis (75% Most Common & Occurs Early) : ▪︎Acute Painful Asymmetric Migratory PolyArthritis Of Large Joints (Affect One Joint Then Move To The Other) ▪︎No Risk Of Deformity ▪︎Good Response To Aspirin 📍3. Carditis (90% At Age Of 3 Years & 30% At Adolescent) : ▪︎Chest Pain & Friction Rub & Tenderness (Due To Pericarditis Or PanCarditis) ▪︎SOB (Due To HF Or Pericardial Effusion) ▪︎Palpitation & Tachycardia ▪︎Cardiac Enlargement (On Xray) ▪︎New Or Changes Murmurs (Due To MR/AR/Valvulitis) ▪︎ECG Changes (ST & T Wave Changes/Accelerated Junctional Rhythm) 📍4. Skin Lesions : ▪︎Erythema Marginatum (5%) ➡️ Red Macules Faded in The Centre & Seen On Trunk & Proximal Limbs ▪︎Subcutaneous Nodules (5-7%) ➡️ Small Painless Firm Nodules Over The Extensor Surfaces Of Bones Or Tendons Seen 3w After The Onset Of Other ARF Features 📍5. Sydenham's Chorea (St Vitus Dance) : ▪︎Emotional Liability With Purposeless Involuntary ChoreiForm Movements (Of The Hands Or Feet Or Face) & Explosive Halting Speech كأنها مخبلة او بيها جني ▪︎Seen More in Females 3m After The Episode Of ARF (Late Neurological Complication When All Other Features Of ARF Disappeared) ▪︎Usually Spontaneous Recovery in Few Months (But Risk Of Developing Chronic RF) 📍6. Pleural Effusion/Pleurisy/Pneumonia 🔹Mx Of ARF 📍1. Bed Rest 📍2. Antibiotics : ▪︎Benzathine Penicillin (Single Dose 1.2M IM) ▪︎Phenoxy-Methyl-Penicillin (250mg 4x Daily For 10 Days Oral) ▪︎Erythromycin Or CephaloSporins (Alternative To Penicillin) 📍3. Cardiac Support (Mx Of HF) : ▪︎Fluid Restriction ▪︎Diuretics ▪︎ACEI 📍4. Aspirin (60-100mg/Kg/Day [Maximum 8g/Day]) : ▪︎Relive The Arthritis Rapidly (in 24-72h) ▪︎Given Continuously Until ESR Decreases Then Gradually Tapered 📍5. Steroids (Oral Prednisolone 1-2mg/Kg/Day) : ▪︎For Carditis Or Severe Arthritis ▪︎Given Continuously Until ESR Decreases Then Gradually Tapered

ايش هو ال faget sing ؟

بالمختصر عندنا قاعدة تقول : " كل ارتفاع بمقدار 1°C في درجة حرارة الجسم يؤدي إلى زيادة معدل النبض بحوالي 10 نبضات في الدقيقة .." يعني اذا درجة حرارة المريض 37 ونبضه 80/بالدقيقة .. بعدين ارتفعت درجة حرارته لـ 40 فمن المتوقع نبضه يرتفع لـ 110/بالدقيقة .. لكن بالـ Faget sign يحدث بطء نسبي .. يعني ترتفع حرارته لـ 40 ونبضه اقل من المتوقع يعني مثلًا 95/بالدقيقة .. فهذا اصبح عكس المتوقع له, هنا نقول المريض " Relative bradycardia " (Faget sign)

طيب ايش السبب؟

في معك عدة اسباب .. حسب المرض المتصل فيبه : 1/ بسبب زيادة نشاط العصب المبهم Increased vagal tone فيأثر على الـ SA node.. 2/ بسبب تأثير السموم البكتيرية او الفيروسية برضو على الـ SA node.. 3/ في بعض امراض الكبد و اليرقان يكون بسبب   Bile salt retention يأثر على الـ SA node .. -------------------------------------------------------

محاضرات الدكتور المتألق #أيمن_السياغي

Topic of tonight is #valvular_HD@Clinicalinternalmedicine

🔰Aortic Stenosis (AS) ▪︎Most Common Valve Disease in Old Ages (Usually Seen At 65-85 Years) ▪︎Usually Due To Rheumatic Heart Disease (in Developing World) 🔹Pathological Changes During AS 📍1. LV Try To Pumps Blood To Body Against Partially Closed Aortic Valve 📍2. Results in : ▪︎LV Hypertrophy & Dilatation ▪︎Aortic Root Dilatation ▪︎Pulmonary Congestion ▪︎Low Cardiac Output 🔹Clinical Features Of AS 📍1. Asymptomatic in Mild-Moderate Stenosis 📍2. Poor Effort Tolerance Due To Fixed Cardiac Output (Exertional Dyspnea/Syncope/Angina/Sudden Death) 📍3. Acute Pulmonary Edema Due To LV Failure 📍4. Slow Raising Carotid Pusle 📍5. Narrow Pulse Pressure (Difference Between Systolic & Diastolic Pressure is Small) 📍6. LBBB 📍7. Asucilataion : ▪︎Harsh Ejection Systolic Murmur (Radiates To Neck [Carotid] & Sternal & SupraSternal Notch) ▪︎Thrusting Apex Beat (LV Pressure Overload) 🔰Aortic Regurgitation (AR) 🔹Pathological Changes During AR 📍1. When The LV Pumping Blood To Body, Part Of This Blood Will Re-Enter The LV Again From The Aorta Due To Incomplete Aortic Valve Closure 📍2. in Next Cycle The Amount Of Blood Pushed To Body Will Be Doubled 📍3. Results in : ▪︎LV Hypertrophy & Dilatation ▪︎Aortic Root Dilatation ▪︎Increase Cardiac Output 🔹Clinical Features Of AR 📍1. Mild-Moderate AR : ▪︎Asymptomatic ▪︎Palpitation When Lying On Left Side (High Cardiac Output) 📍2. Severe AR (Features Of LHF) : ▪︎Dyspnea & Paroxysmal Nocturnal Dyspnea (PND) ▪︎Angina ▪︎Peripheral & Pulmonary Edema 📍3. Pulse Changes : ▪︎Collapsing Pulse (WaterHammer) ▪︎Large Volume & High Pressure Pulse ▪︎Bounding Peripheral Pulses قوي ▪︎Nail Bed Capillary Pulsation (Quincke's Sign) ▪︎Femoral Bruit (Pistol Shot/Duroziez's Sign) ▪︎Head Nodding With Pulse (De Musset's Sign) ▪︎Pulsus BisFeriens تحس نبضتين 📍4. Asucilataion : ▪︎Early Diastolic Murmur (Best Heard At Left Sternum & By Held Breath in Expiration) ▪︎Displaced Heaving Apex Beat (LV Volume Overload)

🔴Valvular Heart Diseases 🔹Basics ▪︎Mitral Valve ➡️ Between LA & LV ▪︎Tricuspid Valve ➡️ Between RA & RV ▪︎Aortic Valve ➡️ Inside The Aorta (Opens To Push Oxygenated Blood To The Body) ▪︎Pulmonary Valve ➡️ Inside Pulmonary Artery (Opens To Push DeOxygenated Blood To The Lungs) ▪︎Valve Stenosis (Difficulty Pushing Blood To Next Chamber) ➡️ Causes Hypertrophy Of The Chamber Above ▪︎Valve Regurgitation (Blood Returns To Its Original Chamber) ➡️ Causes Hypertrophy Of The Above & Below Chamber Due To Volume Overload 🔹Causes Of Valve Disease (in General) 🔸A. Acute Valve Failure 📍1. Aortic Regurgitation (AR) Due To : ▪︎Aortic Dissection ▪︎Infective Endocarditis 📍2. Mitral Regurgitation (MR) Due To : ▪︎Papillary Muscle Rupture After Acute MI ▪︎Infective Endocarditis ▪︎Chordae Rupture Due To Myxomatous Degeneration 📍3. Prosthetic Valves : ▪︎Valve Fracture ▪︎Valve Thrombosis ▪︎Valve Dehiscence ▪︎Valve Jamming  ▪︎Valve Degeneration 🔸B. Chronic Valve Failure 📍1. Rheumatic Heart Disease (Most Common) 📍2. Infective Endocarditis 📍3. Chronic Syphilis Infection 📍4. Congenital Abnormality 📍5. Senile Valve Degeneration يكبر بالعمر 🔹General Mx Of Heart Valve Diseases 📍1. Anticoagulation (If Risk Of AF Present) 📍2. Symptomatic Mx (Of HF Or Pulmonary Edema) 📍4. Valve Repair Or Replacement 🔰Mitral Stenosis (MS) ▪︎Always Due To Rheumatic Heart Disease ▪︎More in Women At 40-50 Years 🔹Pathological Changes Due To MS 📍1. There's High Resistance Facing The Blood Pumping During Diastole From The LA To LV 📍2. Results in High Amount Of Blood Stay in LA While Low Amount Of Blood Reach LV 📍3. Then Results in : ▪︎LA Hypertrophy & Dilatation ▪︎Pulmonary Congestion ▪︎Low Cardiac Output 🔹Clinical Features Of MS 📍1. Pulmonary Congestion (Pulmonary Edema/Pleural Effusion) 📍2. Exertional Dyspnea With Effort & Exercise Intolerance & Cough 📍3. Atrial Fibrillation (AF) With Palpitation & Thromboembolic Events 📍4. Pulmonary HT Leads To RV Hypertrophy & TR Then RHF (Chest Pain/Peripheral Edema & Ascites) 📍5. Haemoptysis (Due To Acute Pulmonary Edema/Pulmonary HT/Pulmonary Embolism) 📍6. Fatigue (Due To Low Cardiac Output) 📍7. Auscultation : ▪︎Loud S1 ▪︎Palpable Tapping Apex Beat (Due To High LA Pressure) ▪︎Opening Snap ▪︎Low Pitched Mid Diastolic Murmur & Thrill (Best Heard By Bell At Apex & By Rolling The Patient To Left Side & Murmur Decrease By Exercise) 🔰Mitral Regurgitation (MR) ▪︎Mostly Due To Mitral Valve Prolapse (in Developed World الاغنياء) Or Rheumatic Heart Disease (in Developing World الفقرة) 🔹Pathological Changes During MR 📍1. When The LV Pumping Blood To The Body, Part Of This Blood Will Re-Enter The LA Again Due To incomplete Closure Of MV (LA Hypertrophy) 📍2. In Next Cycle The Amount Of Blood Entering The LV Will Be Doubled (LV Hypertrophy) 📍3. Results in : ▪︎LA & LV Dilatation & Hypertrophy ▪︎Pulmonary Congestion ▪︎LV Volume OverLoad 🔹Clinical Features Of MR 📍1. Chronic MR : ▪︎Compensatory Hypertrophy & Dilatation Protects From Development Of Pulmonary Edema ▪︎Asymptomatic if Mild To Moderate ▪︎Symptoms Of LHF If Severe ▪︎Risk Of AF 📍2. Acute MR (No Compensatory Mechanisms) ➡️ Features Of Pulmonary Edema 📍3. Asucilataion : ▪︎Pan Systolic Murmur & Thrill (Best Heard At Apex & L.Sternum & Radiate To Axilla) ▪︎S3 Heart Sound ▪︎Active Rocking Displaced Apex Beat (LV Volume Overload) 🔰Mitral Valve Prolapse (MVP/Barlow Syndrome) ▪︎Projection Of One Or Two Of The Valve Leaflets Backwards into The LA ▪︎Most Common Valvular Heart Disease ▪︎Usually Due To Myxomatous Degeneration Or Unknown Ateiology 🔹Clinical Features Of MVP 📍1. Usually Asymptomatic 📍2. Or Only Atypical Chest Pain & Palpitation 📍3. Auscultation ➡️ Mid Systolic Click 🔹Mx Of MVP 📍1. Reduce Caffeine Intake 📍2. Beta Blockers (BB) For Symptomatic Patients

Topic of tonight is #Infective_endocarditis@Clinicalinternalmedicine

▪︎Abscess Formation

🔴Infective Endocarditis (IE) ▪︎It's A Microbial Infection Of The Heart EndoCardium (Heart Valves & Chordae Tendinaes) 🔷Risk Factors For IE 📍1. Old Age & Male Gender 📍2. Prosthetic Heart Valve 📍3. Structural Heart Disease 📍4. Rheumatic Heart Disease 📍5. Dental Surgery & IV Drug Users 📍6. Immunocompromised 🔹Causes (Organisms) Of IE ▪︎Most Common Cause At All ➡️ Staph.Aureus ▪︎Most Common Cause Of SubAcute IE ➡️ Strept.Viridans 📍1. Most Common Organisms : 🔻I. High Virulence Staph.Aureus : ▪︎Affect Normal Valves ▪︎Present With Acute Endocarditis ▪︎Common With IV Drug Users 🔻II. Low Virulence Streptococcus (Viridans/Mitis/Sanguis/Gallolyticus) & Enterococcus (Faecalis/Faecium) : ▪︎Affect Abnormal Valves ▪︎Present With SubAcute Endocarditis ▪︎Strept.Gallolyticus (Bovis) Associated With Large Bowel Malignancy 📍2. Other Organisms : ▪︎Postoperative Endocarditis ➡️ Mostly Due To Coagulase -Ve Staphylococci (Epidermidis/Lugdenensis) ▪︎Q Fever Endocarditis : •By Coxiella Burnetii •Hx Of Contact With Farm Animals •Present With Hepatitis/Pneumonia/Purpura/Affect Aortic Valve ▪︎Brucella Endocarditis ➡️ Hx Of Contact With Goats & Cattle/Affect Aortic Valve ▪︎Endocarditis in Immunocompromised ➡️ Caused By Yeats & Fungi (Candida/Aspergillus) ▪︎Endocarditis By Gram -Ve HACEK Group (Haemophilus/Aggregatibacter/Cardiobacterium/Eikenella/Kingella) 📍3. Endocarditis Due To Autoimmunity (SLE Risk Of Libman-Sacks Endocarditis) & Malignancy 🔷Clinical Features Of IE 🔸A. SubAcute Endocarditis 📍1. Hx Of Congenital Or Valvular Heart Disease 📍2. Persistent Fever/Tiredness/Night Sweat/Rigor/Weight Loss 📍3. Development Of New Or Changed Murmur 📍4. Specific Features For IE : ▪︎Osler's Nodes (Painful Fingers & Toes) ▪︎Janeway Lesions (Painless Palms & Soles) ▪︎Roth Retinal Spots ▪︎Splinter Hemorrhage & Late Digital Clubbing 📍5. Purpura/Petechia/Subconjunctival Hemorrhage/Hematuria 📍6. Embolic Stroke/Peripheral Embolism/SplenoMegaly 🔸B. Acute Endocarditis ➡️ Acute Onset Of Fever/Petechiae/Change Murmur/Heart Or Renal Failure/Embolic Events 🔸C. Postoperative Endocarditis ➡️ Unexplained Fever in Patient Had Recent Heart Valve Surgery 🔷Dx Of IE (Duke Criteria) 📍1. Obtain 3-6 Sets Of Blood For Culture (≥6h Apart Between Each Set & Before Giving Antibiotics) 📍2. Transesophageal Echo (TOE) ➡️ See Oscillating Irregular Mass (Vegetation) inside The Heart 📍3. High ESR/Normochromic Normocytic Anemia/Leucocytosis 📍4. ProteinUria/Non Visible Hematuria 📍5. AV Block On ECG 📍6. Cardiomegaly On Xray 📍7. Duke Criteria (Confirm Dx) : ▪︎[2 Major] Or [1 Major + 3 Minor] Or [5 Minors] 🪀Major Criteria : 🔺I. Blood Culture : ▪︎[≥2 +Ve Blood Culture With Typical Organisms (Staph.Aureus/Strept.Viridand)] ▪︎Or [2 +Ve Blood Cultures >12h Apart] ▪︎Or [3 +Ve Blood Cultures ] ▪︎Or [≥4 +Ve Blood Cultures ≥1h Apart] 🔻II. Serology ➡️ [Single +Ve Blood Culture For C.Burnetii Or IgG Titer ≥1/800] 🔻III. Echocardiography ➡️ [+Ve For Mass Or Abscess Or Dehiscence Of Prosthetic Valve Or New Valve Regurgitation] 🪀Minor Criteria : 🔻I. Suggestive Blood Culture & Echo Findings (Not Met Major Criteria) 🔻II. Hx Of Embolic (Stroke) Or Vasculitis Events (Glomerulonephritis/Osler Nodes) 🔻III. Hx Of Heart Or Valve Disease 🔻IV. Hx Of Pyrexia ≥38°C 🔻V. Hx Of IV Drug Users 🔷Complications Of IE 📍1. Heart Failure Due To Valve Damage 📍2. Heart Block Due To Aortic Root Abscess 📍3. Embolic Events Lead To Organ Infarction & Abscess 📍4. Glomerulonephritis 🔷Mx Of IE ▪︎Empirical Antibiotics (For 2-4w in Native Valve & 6w in Prosthetic Valve) 📍1. SubAcute Endocarditis ➡️ Amoxicillin ± Gentamycin 📍2. Acute Endocarditis ➡️ Vancomycin + Gentamycin 📍3. Prosthetic Valve ➡️ Vancomycin + Gentamycin + Rifampicin 📍4. Fungal Endocarditis ➡️ IV Flucytosine + Oral Fluconazole 📍5. Indications For Valve Surgery : ▪︎Fungal/Staph.Aureus (MRSA)/Prosthetic Valve Infection ▪︎No Response To AB ▪︎HF/Heart Block/Acute MR Or AR ▪︎Recurrent Emboli ▪︎Large Left Side Vegetation

❤️ If pregnancy occurs, urgent counselling by a specialist Pregnancy Heart Team is essential; termination should be discussed where appropriate. ━━━━━━━━━━━━━━━━━━

💜 6. VALVULAR HEART DISEASE

🚨 Severe mitral stenosis and severe aortic stenosis can make pregnancy extremely hazardous and may be considered contraindications depending on severity, symptoms and haemodynamic status. 🩺 Balloon valvuloplasty or transcatheter intervention may be considered in carefully selected refractory cases. 💗 Bioprosthetic valves may be preferred for women planning pregnancy (Class I, Level B). ⚠️ Mechanical valves carry substantial maternal and fetal risks; ROPAC data cited in the supplied summary report approximately 54% event-free pregnancy with live birth. 💊 Mechanical valves require meticulous, individualised anticoagulation planning. ━━━━━━━━━━━━━━━━━━

🔵 7. ANTICOAGULATION IN PREGNANCY — MECHANICAL VALVES

💊 First trimester: The supplied 2025 ESC/EACTS summary describes a dose-based approach: warfarin at ≤5 mg/day may favour continued VKA treatment; higher doses may prompt consideration of dose-adjusted, twice-daily LMWH with anti-Xa monitoring. 📅 Around week 36: Plan transition to UFH/LMWH before delivery under specialist supervision. 🧪 Anti-Xa monitoring: Individualise targets for mechanical valves; the supplied ESC pregnancy summary cites a peak target around 1.0–1.2 IU/mL. 💉 Enoxaparin dosing must be adjusted to anti-Xa results rather than relying on a fixed mg/kg dose alone.

🚫 DOACs are contraindicated for mechanical heart valves during pregnancy.

⚠️ Anticoagulation changes can cause catastrophic valve thrombosis or bleeding. Management must be coordinated by a Pregnancy Heart Team and anticoagulation specialists. ━━━━━━━━━━━━━━━━━━

🩷 8. HYPERTENSION IN PREGNANCY

🎯 Blood pressure target: Below 140/90 mmHg, according to the supplied guideline summary. 💊 Acute severe hypertension may require IV labetalol, urapidil or nicardipine; oral nifedipine or methyldopa may also be used according to the clinical setting and local guidance. 🚫 Avoid ACE inhibitors, ARBs and ARNIs during pregnancy. ━━━━━━━━━━━━━━━━━━

❤️ 9. ACQUIRED HEART DISEASE

🫀 Acute coronary syndrome: Do not delay necessary assessment and treatment because of pregnancy; individualise management with a multidisciplinary team. 💊 DAPT: Tailor antiplatelet selection and duration to ischaemic and bleeding risks. 🧪 Statins: May be considered in selected women with established ASCVD following specialist risk–benefit assessment. 🚑 Cardiac arrest: Manual left uterine displacement during CPR is recommended when the uterus is large enough to cause aortocaval compression, commonly around 20 weeks or later. 🩺 Heart transplantation: Pregnancy is generally discouraged during the first year after transplantation; immunosuppression and graft function require close monitoring. ━━━━━━━━━━━━━━━━━━

🌺 10. ADVERSE PREGNANCY OUTCOMES (APOs)

⚠️ Preeclampsia, preterm birth and intrauterine growth restriction are associated with increased future cardiovascular risk. ❤️ Women with these pregnancy complications should receive cardiovascular risk assessment, counselling and appropriate long-term follow-up. ━━━━━━━━━━━━━━━━━━

🌷 11. CONTRACEPTION & ASSISTED REPRODUCTION

💗 Options often suitable for women with cardiovascular disease: levonorgestrel IUD, copper IUD and progestin implant, depending on individual circumstances. 🚫 Combined oral contraceptives may be unsuitable in high-risk groups, including some women with thrombosis risk, Fontan circulation or mechanical valves. ✅ Emergency contraception is generally available to women with cardiovascular disease; select the method according to clinical circumstances. 👶 Assisted reproduction: Single-embryo transfer is recommended to reduce multiple-pregnancy risk (Class I, Level C). ━━━━━━━━━━━━━━━━

2026

🫀🌸 CARDIOVASCULAR DISEASE & PREGNANCY 🌈 KEY GUIDELINES & PRACTICAL CLINICAL PEARLS | 2025–2026

━━━━━━━━━━━━━━━━━━

🔴 1. ARRHYTHMIAS

❤️ Long QT Syndrome (LQTS)

💊 β-blockers (nadolol or propranolol) are recommended during pregnancy and lactation (Class I, Level B); continue the pre-pregnancy dose postpartum.

➡️ LQT2 carries the highest postpartum risk, extending up to 12 months — maintain treatment and vigilance throughout this period.

🍼 Lactation caution: Nadolol has greater breast-milk excretion (relative infant dose approximately 4–7%); monitor infants for bradycardia, particularly with high maternal doses. Consider any switch to propranolol before pregnancy rather than changing treatment during pregnancy or postpartum. 💗 Consider left cardiac sympathetic denervation before pregnancy if arrhythmias remain uncontrolled.

🌸 Catecholaminergic Polymorphic VT (CPVT) 💊 β-blockers (nadolol/propranolol), with flecainide added if arrhythmic events occur (Class I, Level C).

➡️ Continue established treatment during pregnancy and postpartum; consider sympathetic denervation in refractory cases.

💙 Brugada Syndrome

💊 Quinidine may be considered if arrhythmic events occur during pregnancy (Class IIa, Level C).

💜 Short QT Syndrome (SQTS)

💊 Continue quinidine throughout pregnancy and postpartum when indicated (Class IIa, Level C).

🚨 General antiarrhythmic caution Amiodarone is not recommended routinely during pregnancy; reserve it for refractory, life-threatening ventricular arrhythmias, with fetal monitoring for bradycardia and intrauterine growth restriction.

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💗 2. PERIPARTUM CARDIOMYOPATHY (PPCM)

✅ Counsel every woman about recurrence risk, even after ejection fraction (EF) recovery (Class I, Level C).

💊 Consider bromocriptine with prophylactic LMWH in selected patients (Class IIa, Level C). 🧬 Genetic counselling and testing may be considered.

❤️ Treat according to heart-failure guidance and generally continue therapy for at least 12 months after EF recovery, with individualised reassessment. ⚠️ Important clinical nuance: The 2025 SMFM Consult Series #73 advises against β-blockers in acute decompensated LV failure, favouring hydralazine/nitrates and furosemide for acute management; ACE inhibitors, ARBs and ARNIs are reserved for postpartum use. Individualise treatment according to haemodynamic status and specialist advice. ━━━━━━━━━━━━━━━━━━

🟢 3. AORTOPATHIES

🧬 Assess inherited aortic disease, including Marfan syndrome, Loeys–Dietz syndrome, bicuspid aortic valve (BAV), Turner syndrome and vascular Ehlers–Danlos syndrome. 📏 High-risk aortic thresholds highlighted in the supplied summary:

Marfan syndrome: aortic diameter greater than 45 mm

BAV: aortic diameter greater than 50 mm

Turner syndrome: aortic size index (ASI) greater than 25 mm/m²

Vascular EDS: pregnancy may carry extreme risk and may be contraindicated. ❤️ Pre-pregnancy counselling is essential after aortic dissection or surgery.

💊 β-blockers during pregnancy and postpartum are recommended for Marfan syndrome/heritable thoracic aortic disease when indicated (Class I, Level C).

━━━━━━━━━━━━━━━━━━

🟣 4. CONGENITAL HEART DISEASE (CHD)

🔹 Fontan circulation: Pregnancy is strongly discouraged in many patients because of substantial maternal and fetal risks. 🔹 Systemic right ventricle: Following Mustard/Senning repair or in congenitally corrected TGA, pregnancy requires specialist risk assessment and counselling. 🔹 Eisenmenger syndrome: Pregnancy is contraindicated because of extremely high maternal risk. 🔹 Simple repaired ASD/VSD/PDA: Often lower risk when there are no significant residual lesions or complications. ━━━━━━━━━━━━━━━━━━

🟠 5. PULMONARY ARTERIAL HYPERTENSION (PAH)

🚨 Pregnancy is contraindicated in PAH because of potentially life-threatening maternal risk.

#Diseases_of_pericarditis@Clinicalinternalmedicine

🔴Diseases Of Pericardium

🔰Acute Pericarditis

▪︎Acute Inflammation Of Pericardium Due To Infectious Or Inflammatory Or Malignant Conditions

🔹Clinical Features

1. Retrosternal Chest Pain That Aggravated By Deep Breathing/Movement/Change Position/Exercise/Swallowing 2. Low Grade Fever 3. Pericardial Effusion 4. Pericardial Friction Rub (Diagnostic)

🔹Dx ➡️ Clinical Features + ECG (Diffuse ST Elevation/PR Interval Depression [Most Specific]/T Inversion)

🔹Mx

1. Pain Relief By Aspirin/Indomethacin 2. Colchicine/Steroids (Reduce Inflammation) 3. AB & PeriCardioCentesis For Purulent Pericarditis

🔰Pericardial Effusion

▪︎Fluid Accumulation Inside The Pericardium Mostly After Pericarditis

🔹Presentation

1. Muffled Heart Sounds 2. Muffled Friction Rub 3. Sensation Of Retrosternal Oppression 4. Large Effusion Causing Cardiac Tamponade

🔹Dx

1. Echo (Confirm Dx) 2. ECG (Decrease QRS Voltage/Electrical Alternans) 3. Chest Xray (Increase Cardiac Silhouette/Globular Heart) 4. Aspiration

🔹Mx ➡️ Aspiration & Pericardial Drain/Surgical Drainage For Viscous/Loculated/Recurrent Effusion

🔰Cardiac Tamponade

▪︎Large Pericardial Effusion Causing Acute HF Due To Cardiac Compression ▪︎Occurs After Pericarditis/Truma/Malignancy/Heart Wall Rupture After Mi

🔹Presentation

1. Hypotension/Tachycardia/Raised JVP 2. Dyspnea & Collapse 3. Muffled (Soft) Heart Sounds 4. Pulsus Paradoxus (Large Fall in BP During Inspiration) 5. Kussmal Sign (Rise JVP During Inspiration)

🔹Dx ➡️ By Echo

🔹Mx ➡️ Emergent Pericardiocentesis

Topic of the day is #Cardiomyopathy@Clinicalinternalmedicine

🔰Takotsubo Cardiomyopathy (Broken Heart Syndrome) ▪︎It's A Disorder Characterized By Features Of Acute Myocardial Infarction But With Normal Coronary Arteries (Coronary VasoConstriction With Acute LV Dysfunction & Dilatation in Response To Hormonal Stimuli) ▪︎More In Women ▪︎Usually Results After Acute Environmental Or Emotional Stress ▪︎Self Limited But Has Risk Of Death Due To Arrhythmia Or Ventricular Wall Rupture 🔹Clinical Features & Dx Of Takotsubo Cardiomyopathy 📍1. LV Dysfunction & Dilatation (Heart Failure) 📍2. Features Of MI (Chest Pain/SOB/ST Elevation On ECG) 📍3. Normal Coronary Arteries On Angiography 📍4. Echo ➡️ Apical Ballooning Of LV (Dilated Apex Beat & Narrow LV Outflow) 🔹Mx Of Takotsubo Cardiomyopathy 📍1. Spontaneous Resolution Of LV Dysfunction Within 4-5 Days 📍2. BB ➡️ To Prevent Arrhythmia 📍3. ACEI ➡️ To Tx LV Dysfunction

🔰Arrhythmogenic Ventricular Cardiomyopathy (AVC) ▪︎Autosomal Dominant Disorder Causing Fibrous & Fatty Tissue Deposition inside The MyoCardium Of The RV That Results in RV Dysfunction 🔹Features & Dx Of AVC 📍1. Right Side HF 📍2. Ventricular Arrhythmia 📍3. Sudden Death 📍4. ECG ➡️ Broad QRS (Epsilon Wave) & Inverted T Wave in Right Limb Leads 🔹Mx Of AVC ➡️ Tx Of HF & Arrhythmia

🔰Myocarditis ▪︎Acute Inflammation Of Myocardium (Heart Muscle) Due To Infection Or Toxins Or Autoimmunity ▪︎Mostly Due To Viral Infection (Coxsackie/Influenza A-B) ▪︎Self Limited & Good Prognosis (But Risk For Development Of Dilated Cardiomyopathy) 🔹Risk Factors For Myocarditis 1. Infections 2. Steroids & Immunosuppression & Radiation Exposure 3. Exercise 4. Previous Myocardial Damage 5. Alcohol Consumption 6. Drugs (Cocaine/Lithium/Doxorubicin/Penicillin/SulphonAmides) 7. Poisons (Lead/Carbon Monoxide) 🔹Clinical Features Of Myocarditis 📍1. Fulminant Myocarditis (Develops Over Short Time) ➡️ Severe HF Or Cardiogenic Shock Usually After Viral Infection Or Influenza Like Symptoms 📍2. Acute Myocarditis (Develops Over Loner Time) ➡️ Causing HF & Dilated Cardiomyopathy 📍3. Chronic Active Myocarditis (Chronic Myocardial Inflammation) 📍4. Chronic Persistent Myocarditis ➡️ Focal Myocardial Infiltration Causing Chest Pain & Arrhythmia 🔹Causes Of Death in Myocarditis 1. Ventricular Arrhythmia 2. Acute HF 3. Sudden Death in Young Athletes 🔹Dx Of Myocarditis 📍1. Echo ➡️ Focal LV Dysfunction 📍2. Cardiac MRI 📍3. Elevated Cardiac Enzymes (Troponin) 📍4. Abnormal ECG Changes 📍5. EndoMyocardial Biopsy ➡️ Confirm Dx 🔹Mx Of Myocarditis (Supportive) 📍1. HF & Arrhythmia Mx 📍2. Avoid Intense Physical Activity 📍3. Antibiotics (If Bacterial Infection Suspected) 📍4. Ventricular Assist Device (Temporary While Recovery) 📍5. Herat Transplantation (in Severe Cases With No Improvement)