Cardiology in a Heartbeat

Cardiology in a heartbeatYour hosts: Malik ‘heart throb’ Fleet and Thomas ‘heart ache’ McLeod

Objectives

Be able to perform in a cardio related osce.

Describe the key features and management of: Atrial Fibrillation Acute Coronary Syndrome

Answer SBAs related to this week’s teaching

Outline of session

20 minutes OSCE and debrief

40 minutes tutorial

20 minutes SBAs

Answer any questions

Notes from the OSCE scenario

DR ABCDE: (Before ‘D’!)

Ask examiner for observations

Does patient meet PERT criteria? They always do so call for help!

(PERT criteria=


D - anger R - esponse A -irway B- reathing C - irculation D - isability (AVPU) E - xposure

LOOK

FEEL

LISTEN

MEASURE

TREAT


A - irway: Look Feel Listen Measure Treat

Often patient is breathing so able to say airway is patent. If not, suggest ensuring airway e.g Guedel airway


B- reathing Look: cyanosed? Trachea central? Chest expansion? Feel: symmetrical chest movement? Percussion? Listen: auscultate chest (ask examiner for findings) Measure:

a. Resp rate B. O2 sats on air

Treat: Give oxygen: high flow (e.g. 15L/min) - non

rebreathe mask (unless C/I e.g COPD)


C- irculation Look: cyanosed? General appearance? JVP? Pain? Feel: Peripheries- cool? Clammy?; Pulse Listen: heart sounds Measure:

Heart rate Blood pressure Cap refill Urine output Temp. ECG

Treat: IV access (“two wide bore cannulae”) Bloods (FBC/ U and E) Fluid Challenge (MONA if acute coronary syndrome)


D- isability: AVPU + BM Patient responds to:

A - lert V - oice P - ain U - nresponsive

Ask examiner for BM


E- xposure: Expose patient from head to toe looking for

any other clue for deterioration.

+ “ending exam”: write notes, hand over to team etc.

Notes from the OSCE scenario:

8 Reversible causes of VT: The 4 ‘H’s and 4 T’s.

4 T’s:

T-hrombosis (coronary or pulmonary)

T-amponade

T-oxins

T-ension pneumothorax

4 H’s:

H-ypoxia

H-ypovolaemia

H-ypo/er kalaemia (metabolic)

H-ypothermia


2 shockable rhythms: Pulseless Ventricular Tachycardia Ventricular Fibrillation

2 non shock: -Pulseless electrical activity -Asystole


Tutorial: Atrial Fibrillation

AF: Objectives

By the end of this session you should be able to:

Identify how AF presents and establish an appropriate differential

Suggest sensible investigations as relating to your differential

Recognise and describe the classic ECG findings and the pathophysiology of AF.

Classify AF as according to its pattern and amenability to cardioversion (‘the 3 P’s)

Describe the management options in terms of Rate and Rhythm control and list suitable examples of patients and medications accordingly.

Case: “Jo-Jo”

“Joe” Joe is a 45 year old professional clown.

He has recently returned from a boozy working holiday in Magaluf.

He has the biggest performance of his career at the Brent Cross circus tomorrow. He feels terribly unprepared and begins to sweat when talking about it.

He presents to you in A and E complaining of being aware that his heart is doing ‘funny things’ and feels short of breath.

Differential Diagnosis at this stage?

Anxiety induced palpitations (panic attack)

Atrial Fibrillation

(hyperthyroidism)

Examination

“irregularly irregular”* *NICE recognise as very ‘sensitive’ sign for dx of AF. Regular radial pulse= 96% negative predictive value.

Investigations:

ECG: (Please present)Joseph Jackson D.O.B: 16/3/ 1967

AF: ECG findings and pathophysiology ECG findings:

Absent p waves ~ no identifiable p waves throughout trace. Narrow QRS (AV conduction in tact)

AF: ECG findings and pathophysiology Pathophysiology:

Diagnosis= AF. What are you worried about?

AF: Risk of: EMBOLISM STROKE

Haemodynamic compromise

Other investigations:

+/-

Case development

History: diagnosed with hypertension 10 years ago. Stopped taking ‘useless tablets’ after 6 months. Father died at 60 from hypertensive heart disease/failure.

Ix: No echo done Bloods: TFTs: negative

Troponin: negative

Joe begins to feel worse, his heart rate increases to 150 bpm and he has slight pain. No ST elevation on ECG.

AF: Management: “The Blender”

“Rate” or “Rhythm” Control

AF: Management: Acute Onset

If HAEMODYNAMIC INSTABILITY:

Non Life threatening:

-RATE (if major contributor to haemodynamic instability):

-Beta Blocker / Ca Channel Blocker

-Amiodarone

-RHYTHM:

-PCV* (or ECV if available)

*Pharmacological Cardioversion:

I.V Amiodarone

-ANTICOAGULATION:

-start heparin

- commence oral warfarin depending on outcome of CV/ onset of AF.

Life threatening:

-RHYTHM:

Emergency electrical cardioversion

-(Anticoagulation should not delay intervention).

AF: Rhythm Control: Cardioversion

Pharmacological Electrical

< 48 hours > 48 hours

AF: Rhythm: Cardioversion: WARNING!

AF = clot generator

Normal rhythm (cardiac output restored)

clots disseminated to brain etc.

CARDIOVERSION

AF: Rhythm: Cardioversion: VTE prophylaxis

<48 hours

-Heparin

-PCV (or ECV)

-Confirm onset of AF:

-If definitely <48hours: no need for further anticoagulation.

-If unsure: warfarin for 4 weeks

>48hours

a. ANTI COAGULATE (3 weeks)

or

b. TRANS OESOPHAGEAL ECHO (TOE)

-detects whether a thrombus is present or not.

-If not: heparin + cardioversion

-If present: warfarin for 3 weeks and repeat TOE.

* Continue warfarin for 4 weeks post cardioversion

AF: Rhythm: Cardioversion: VTE prophylaxis

AF: Rhythm: Cardioversion: PHARMACOLOGICAL

<48 hours

Flecainide Amiodarone NO structural heart disease* YES structural heart disease*

(<8 hours) (>8 hours)

*Structural heart disease defined as: “coronary artery disease or LV dysfunction”

AF: Rhythm: Cardioversion: ELECTRICAL

>48 hours

ECV (= low grade shock to heart): 1st line: > 48 hours

If doubts over success (e.g. previous failure to cardiovert; early recurrence of AF): Give AMIODARONE or SOTALOL for 4 weeks prior to ECV.

Improves rates of cardioversion

Atrial fibrillation: “3 p’s” Classification

Paroxysmal: Spontaneous self termination <7 days (often <48hours)

Persistent: Lasts > 7 days NOT self terminating

Permanent Does not terminate Not amenable to cardioversion (NOTE: can return to sinus rhythm if cure underlying pathology e.g.

hyperthyroidism)

AF: Management: Paroxysmal

Classified as…

Therapeutic objective: SUPPRESSION OF PAROXYSMS

Paroxysm defined as…

From the Greek…


Classified as… Spontaneous self termination <7 days (often <48hours)

Paroxysm defined as…"sudden attack, outburst"

From the Greek… (παροξυσμός paroxusmos), "irritation, exasperation".[

http://en.wikipedia.org/wiki/Paroxysmal_attack


Suppression of paroxysms:

CONSERVATIVE:

1.there is a known precipitant of paroxysm E.g. Alcohol; caffeine.

2. the patient asymptomatic/few symptoms

3. No history of left ventricular dysfunction/ ischaemic heart disease

Rx: -drug free / “pill in the pocket” strategy:Pill in a pocket= “Flecainide” (or other Class 1c agent)


Suppression of paroxysms:

MEDICAL/ PHARMACOLOGICAL:

-If patient is symptomatic-Frequent paroxysms-No known precipitant

1st Line: Beta Blocker

2nd line (symptoms not controlled): Sotalol

3rd line/ if poor left ventricular function: Amiodarone

AF: Management: Persistent

Classified as…

Therapeutic objective: think blender: control the rate or rhythm.

AF: Management: Persistent

RHYTHM vs RATE

AF: Management: Persistent: RATE

RATE control strategy should be preferred 1st line option in:

Over 65s

Coronary artery disease

C/I to antiarrhthymic drugs

Not suitable for cardioversion

No heart failure

AF: Management: Persistent: RATE

RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker

Monotherapy: Beta blocker Ca Channel Blocker (Digoxin ~ if sedentary)

If require more than monotherapy: Beta blocker/ Ca channel blocker + Digoxin

AF: Management: Persistent: RHYTHM

RHYTHM control strategy should be preferred 1st line option in:

Younger patients

Symptomatic

AF secondary to treated/ corrected precipitant (e.g. chest infection)

With heart failure

AF: Management: Persistent: RHYTHM

RHYTHM control strategy 1st line option is:

Cardioversion + Anticoagulation

If recurrence/ unsuccessful/ requires drug to maintain sinus rhythm:

1st line: Beta Blocker

2nd Line (I.e. not effective/ contraindicated):+ structural heart disease :AMIODARONE - NO structural heart disease: FLECAINIDE (or Sotalol)

AF: Management: Permanent

Classified as…

Therapeutic objective: think blender: control rate as rhythm functions are broken!

AF: Management: Permanent

RATE only!

AF: Management: Permanent: RATE

RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker

Monotherapy: Beta blocker Ca Channel Blocker (Digoxin ~ if sedentary)

If require more than monotherapy: Beta blocker/ Ca channel blocker + Digoxin

AF: Management: ANTICOAGULATION Acute:

Commence heparin until full risk assessment of emboli has been performed. >48 hours- 3 weeks of oral anticoagulation (warfarin) prior to cardioversion

NO anticoagulation if: Stable sinus rhythm has been restored <48 hours No risk factors for emboli

Chronic:

Discuss with patient risks and benefits of anticoagulation.

CHADS 2 = predictor of stroke.

C= congestive cardiac failure (1)

H= hypertension (1)

A = age (>75) (1)

D= Diabetes (1)

S= stroke/ previous TIA (2)

Warfarin : aim for therapeutic INR 2 -3 (If warfarin C/I : Aspirin 300 mg/day)

CHADS 2 score of: % risk of stroke

0: 1.9%

6: 18.2%

AF: Summary

You should now be able to:

Identify how AF presents and establish an appropriate differential

Suggest sensible investigations as relating to your differential

Recognise and describe the classic ECG findings and the pathophysiology of AF.

Classify AF as according to its pattern and amenability to cardioversion (‘the 3 P’s)

Describe the management options in terms of Rate and Rhythm control and list suitable examples of patients and medications accordingly.

Tutorial: Acute Coronary Syndrome

Case

57 year old Gavin stumbles into A&E complaining of severe chest pain. He’s grey and very sweaty.

Objectives

Pathophysiology Definitions Presentation Investigations Management of STEMI

What causes ischaemic heart disease?

Fatty streak > Simple plaque > Complicated

Risk Factors

Non-modifiable

Age Gender (males are at greater risk) family history of IHD

Modifiable

Definitions

Acute Coronary Syndrome

Unstable Angina NSTEMI STEMI

Ischaemia Reduced perfusion. Purely symptomatic. No cell

death

InfarctionReduced perfusion exceeding tolerance of cells. Cell

death

Ischaemia Reduced perfusion. Purely symptomatic. No cell

death• Stable Angina• Unstable Angina

InfarctionReduced perfusion exceeding tolerance of cells. Cell

Death• NSTEMI• STEMI

Clinical Application

Acute Coronary Syndrome

Unstable Angina NSTEMI STEMI

Differentiate?

ECG

Troponin

0Hrs 12Hrs

Unstable angina

ST elevation

Troponin +ve

NSTEMI

Troponin +ve

STEMI

ST elevation

Troponin +ve

Back to the case

What next?

History and Examination

Investigation.

ECG & Troponin

Anatomy

ST: Elevation: Localisation

Right Left

ST: Elevation: Localisation

ST: Elevation

Mechanism behind ECG changes:

Complete occlusion of coronary vessel leads to ischaemia/infarction which is seen as ST elevation.

The mechanism is, however, poorly understood.

Injury wave hypothesis= abnormal currents are generated between normal and infarcted tissue and detected as an ‘injury wave’.

Localisation: Right Coronary Artery (Post. Descending/ Marginal): Inferior STEMI: Leads II, III, avF Left Anterior Descending: Anterior STEMI: V1-V4 Left circumflex: Lateral STEMI: I, aVL, V5, V6

Gavin’s ECG

Initial Treatment

Morphine – 5-10mg IV (+ metoclopramide) Oxygen – aim for SaO2 > 95% Nitrate – 2 puffs or 1 tablet Aspirin – 300mg PO

Restore coronary perfusion

Restore Coronary Perfusion

Primary PCI Rx of choice if within 12h

Thrombolysis Contraindicated beyond 24hr Streptokinase, Alteplase

Gavin has Primary PCI at the London Heart Hospital. He survives and is very grateful.

What is the next stage of his management?

Subsequent Management

Modifiable risk factors

Antiplatelet – Aspirin, Clopidogrel B-blockers Statin ACE

Summary

Pathophysiology Definitions Presentation Investigations Management of STEMI

A 45 year old man suffers sudden central chest pain while at rest. It spreads across his chest and up to his neck. After 20 mins, the pain has not eased and he is increasingly sweaty and short of breath. This is the third such episode in the last 3 months

12hr Troponin I <0.05 ug/L

What is the single most accurate classification of this event?

A. Acute Coronary SyndromeB. Non-ST elevation myocardial infarctionC. ST elevation myocardial infarctionD. Stable anginaE. Unstable angina

What is the single most accurate classification of this event?

A. Acute Coronary SyndromeB. Non-ST elevation myocardial infarctionC. ST elevation myocardial infarctionD. Stable anginaE. Unstable angina

A 55 year-old woman has noticed her heart beating fast. It happens infrequently and is not assosciated with any other symptoms. She is anxious about the cause of these attacks as she has no other medical problems.

HR 80bpm, BP 115/75mmHg

After a normal ECG, a 24hr tape is performed

Which is the single most appropriate treatment?

A. Amiodarone 100mg PO once dailyB. Digoxin 62.5mcg PO once dailyC. Flecainide 150mg PO as requiredD. Metoprolol 25mg PO twice dailyE. Sotalol 40mg PO twice daily

Which is the single most appropriate treatment?

A. Amiodarone 100mg PO once dailyB. Digoxin 62.5mcg PO once dailyC. Flecainide 150mg PO as requiredD. Metoprolol 25mg PO twice dailyE. Sotalol 40mg PO twice daily

SBAs:

Which of the following is not a reversible cause of cardiac arrest?

Hypoxia Hypo/Hyperkalaemia Tension Pneumothorax Hyperthyroidism Tamponade

SBAs:

Which of the following is not a reversible cause of cardiac arrest?

Hypoxia Hypo/Hyperkalaemia Tension Pneumothorax Hyperthyroidism Tamponade

SBAs:

A 67 year old lady has just been diagnosed with persistent AF. Cardioversion has previously failed. She is symptomatic, has coronary artery disease but no heart failure. What1st line treatment would you prescribe?

Paracetamol Beta Blocker Flecainide Sotalol Amiodarone

SBAs:

A 67 year old lady has just been diagnosed with persistent AF. Cardioversion has previously failed. She is symptomatic, has coronary artery disease but no heart failure. What1st line treatment would you prescribe?

Paracetamol Beta Blocker Flecainide Sotalol Amiodarone

A 48-year old patient gives a 5 day history of dyspnoea. He is found to be in atrial fibrillation. Which is the most appropriate management plan?

A. Chemical cardioversion with IV amiodaroneB. Chemical cardioversion with IV flecainideC. Anticoagulation with warfarin and rate controlD. Transthoracic echocardiogram to exclude thrombus

followed by DC cardioversionE. Anticoagulation with warfarin then initiation of oral

amiodarone

A 48-year old patient gives a 5 day history of dyspnoea. He is found to be in atrial fibrillation. Which is the most appropriate management plan?

A. Chemical cardioversion with IV amiodaroneB. Chemical cardioversion with IV flecainideC. Anticoagulation with warfarin and rate controlD. Transthoracic echocardiogram to exclude thrombus

followed by DC cardioversionE. Anticoagulation with warfarin then initiation of oral

amiodarone

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Cardiology in a Heartbeat