Dr. Bahaa Kasem

20/03/2025

Implantable cardiac defibrillators

Implantable cardiac defibrillators (ICDs) are crucial in managing patients at high risk for life-threatening arrhythmias. Here are the key indications:

Long QT Syndrome: Patients with congenital long QT syndrome (e.g., LQT1, LQT2) who have experienced syncope or documented ventricular tachycardia (VT) should be considered for ICD placement to prevent sudden cardiac death.
Hypertrophic Obstructive Cardiomyopathy (HOCM): ICDs are indicated in patients with HOCM who have a history of cardiac arrest, family history of sudden death, or significant risk factors such as maximal wall thickness >30mm and unexplained syncope.
Previous Cardiac Arrest due to VT/VF: Survivors of cardiac arrest due to ventricular fibrillation (VF) or sustained VT require an ICD for secondary prevention, as they are at high risk for recurrence.
Previous Myocardial Infarction: In patients with a history of myocardial infarction, non-sustained VT on 24-hour monitoring, inducible VT during electrophysiology testing, and an ejection fraction

20/03/2025

Patent foramen ovale

A patent foramen ovale (PFO) is an interatrial shunt resulting from the incomplete closure of the foramen ovale after birth, present in approximately 20% of the population. This anatomical variant can facilitate a paradoxical embolism, where venous thrombi (e.g., from deep vein thrombosis) bypass the pulmonary circulation and enter systemic circulation, potentially leading to ischaemic stroke.

There is emerging evidence suggesting a correlation between PFO and migraine, particularly migraine with aura. Studies indicate that closure of PFO may lead to a reduction in migraine frequency and severity, possibly due to decreased right-to-left shunting during episodes.

The management of patients with PFO who have experienced a stroke remains contentious. Current guidelines suggest:

Antiplatelet therapy: Aspirin or clopidogrel may be considered for secondary prevention.
Anticoagulant therapy: Warfarin or direct oral anticoagulants may be indicated based on individual risk factors.
PFO closure: Percutaneous closure is recommended in select cases, particularly if there is a strong suspicion of paradoxical embolism as the stroke mechanism.
Decisions should be tailored to individual patient risk profiles and preferences, considering the potential benefits and risks associated with each treatment modality.

20/03/2025

Torsades de pointes

Torsades de pointes (TdP) is a specific type of polymorphic ventricular tachycardia characterised by a distinctive "twisting" pattern on the ECG. It typically occurs in the setting of a prolonged QT interval, which can be congenital or acquired.

Common causes of acquired long QT include:

Medications: Certain drugs such as antiarrhythmics (e.g., sotalol), antipsychotics (e.g., haloperidol), and some antibiotics (e.g., erythromycin) can prolong the QT interval.
Electrolyte disturbances: Hypomagnesaemia, hypokalaemia, and hypocalcaemia are significant contributors.
Ischaemic heart disease: Myocardial ischaemia can also lead to TdP.
The acute management of TdP involves:

Intravenous magnesium sulfate: Administering magnesium stabilises myocardial membranes and can rapidly terminate TdP.
Cardiac monitoring: Continuous ECG monitoring is essential due to the risk of recurrence.
Correction of electrolyte imbalances: Address any underlying hypokalaemia or hypomagnesaemia.
If TdP persists despite magnesium administration, further interventions may include overdrive pacing or antiarrhythmic agents like isoproterenol. Long-term management focuses on identifying and addressing the underlying cause of the prolonged QT interval.

16/03/2025

15/03/2025

UK guidelines advise against using biochemical markers, imaging, or neurophysiological studies for prognostication in the acute phase following cardiac arrest.

15/03/2025

Warfarin: management of high INR

Management of high INR levels in patients on warfarin is crucial to prevent complications. The approach varies based on the presence and severity of bleeding.

Major Bleeding (e.g., variceal haemorrhage, intracranial haemorrhage):
Immediately stop warfarin.
Administer intravenous vitamin K 5 mg.
Use prothrombin complex concentrate (PCC) for rapid reversal; if unavailable, administer fresh frozen plasma (FFP).

INR > 8.0 with Minor Bleeding:
Stop warfarin.
Give intravenous vitamin K 1-3 mg.
If INR remains elevated after 24 hours, repeat vitamin K dose.
Restart warfarin when INR is < 5.0.
No Bleeding with INR > 8.0:
Stop warfarin.
Administer oral vitamin K 1-5 mg (using IV preparation orally).
Repeat if INR still high after 24 hours.
Restart when INR is < 5.0.

Minor Bleeding with INR 5.0-8.0:
Stop warfarin and give intravenous vitamin K 1-3 mg.
Restart when INR is < 5.0.

No Bleeding with INR 5.0-8.0:
Withhold one or two doses of warfarin.
Consider dose adjustment based on INR trends and patient factors.

This structured approach ensures timely management of high INR levels while minimising the risk of thromboembolic events upon resuming anticoagulation therapy.

15/03/2025

CABG is preferred in patients over 65, with diabetes, or triple vessel disease due to better long-term outcomes.

14/03/2025

HELLP syndrome is a severe form of pre-eclampsia characterised by the following triad:

Haemolysis: This is indicated by elevated lactate dehydrogenase (LDH) and low haptoglobin levels. Peripheral blood smears may show schistocytes.
Elevated liver enzymes: Typically, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are markedly increased, reflecting hepatic dysfunction.
Low platelets: Thrombocytopenia is defined as a platelet count

14/03/2025

"لو انت دكتور وبتجهز ل MRCP، فـ انت عارف إنها مش مجرد امتحان، دي خطوة كبيرة لمستقبل أفضل! 🩺💡
ابدأ بمصدر قوي زي Passmedicine أو Pastest، وخلي Nice guidelines و Oxford Handbook أصحابك في الرحلة.
ذاكر Smart، حل MCQs كل يوم،
والأهم: حافظ على حماسك، وخليك وسط مجموعة بتحفّزك!

14/03/2025

Amniotic fluid embolism

Amniotic fluid embolism (AFE) is a rare but serious obstetric emergency characterised by the entry of amniotic fluid into the maternal circulation, leading to acute cardiovascular collapse and coagulopathy. The classic triad includes:

Respiratory distress
Cardiovascular instability
Coagulopathy, often manifesting as disseminated intravascular coagulation (DIC)
In AFE, pulmonary embolism may present similarly with respiratory distress; however, it typically does not cause DIC. The presence of DIC in AFE is due to the release of tissue factors from fetal tissues and amniotic fluid components, triggering a hypercoagulable state that can lead to bleeding complications.

Septic shock can mimic AFE, presenting with hypotension and respiratory failure. However, in septic shock, there is usually an identifiable source of infection, which is absent in AFE. Diagnosis is primarily clinical, supported by exclusion of other causes such as pulmonary embolism or sepsis.

Management involves supportive care: oxygenation, fluid resuscitation, and addressing coagulopathy. Early recognition and intervention are critical for improving maternal and neonatal outcomes.

13/03/2025

HELLP syndrome is a severe form of pre-eclampsia characterised by the following triad:

Haemolysis: This is indicated by elevated lactate dehydrogenase (LDH) and low haptoglobin levels. Peripheral blood smears may show schistocytes.
Elevated liver enzymes: Typically, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are markedly increased, reflecting hepatic dysfunction.
Low platelets: Thrombocytopenia is defined as a platelet count

13/03/2025

In the context of a suspected pulmonary embolism (PE), the initial investigation involves a structured approach to exclude other conditions. A chest X-ray (CXR) is typically performed first for several reasons:

Exclusion of Differential Diagnoses: The CXR can help identify alternative pathologies such as pneumonia, pneumothorax, or pleural effusion that may mimic PE symptoms.
Signs of PE: While a normal CXR does not rule out PE, certain indirect signs may be present, such as Westermark's sign (regional oligemia) or Hampton's hump (wedge-shaped opacity).
Urgency of CT Pulmonary Angiogram (CTPA): If PE is strongly suspected based on clinical assessment and D-dimer results, a CTPA should be arranged urgently. This imaging modality provides definitive diagnosis by visualising occlusions in the pulmonary arteries.
D-dimer Testing: In cases with low pre-test probability, a negative D-dimer can effectively rule out PE, reducing unnecessary imaging.
Overall, the combination of clinical assessment, CXR, and timely CTPA forms a comprehensive strategy for diagnosing PE while ensuring other serious conditions are not overlooked.