Cardiology

Outline• Basic Physiology• Investigations• Hypertension• Angina• Acute Coronary Syndrome• Atrial Fibrillation/Flutter• Heart Block• Heart Failure• DVT/PE• Pericarditis• Infective Endocarditis• Cardiac Tamponade

Basic Physiology

Investigations – Blood TestsBASICS

FBC, U&Es, LIPID PROFILE, GLUCOSE, TFTs

TROPONINRELIABLE 8-12 HOURS POST MI

BRAIN NATRIURETIC PEPTIDERAISED IN HEART FAILURE

Investigations - ECG

Reading an ECG• Rhythm• Rate• Cardiac Axis• P:QRS complex ration• PR interval• Description of the QRS complexes• Description of the ST segements & T waves• THEN offer interpretation

0° - I

-30° - aVL

+60° - II

-90°

+90° - aVF+120° - III

180°

-150° - aVR

Investigations - Other• Blood Pressure• CXR• Holter Monitor• Stress Testing• Tilt Table Test• CT coronary calcium• Echocardiography• Angiography

Scoring Systems• TIMI Risk Score• GRACE scoring• CHA2DS2-VASc• Framingham Risk Score• Wells Clinical Prediction for DVT & PE

Hypertension

A 62-year old male attends your GP surgery with concerns about his blood pressure. His father suffered from heart disease and died at 70-years old from a heart attack. He tries to keep as active as possible taking 30-minute walks every day, but does admit to drinking 3 pints of strong beer a day and smoking 5 cigarettes a day for the past 30 years. He accepts his diet probably isn’t the healthiest eating a full English every day for breakfast and snacking regularly throughout the day on chocolate biscuits and crisps, but he feels he needs the energy otherwise he won’t be able to manage his farm. On examination his blood pressure is 152/95.

BP TARGETS Clinic BP ABPM/HBPM

AGE <80 140/90 135/85

AGE >80 150/90 145/85

Diabetes 130/80 -

A 47-year old female presents to A&E complaining of chest pain. It started two hours ago when she was out on a jog. It felt like a tight band around her chest and she became short of breath. An ambulance quickly arrived and gave her 300mg aspirin as well as a spray underneath her tongue. The pain quickly subsided and she now feels well at rest.

Angina

Assessing Risk

10-29%

30-60%

61-90%

CT calcium scoring

Functional Imaging

Coronary Angiography

1.All patients should receive aspirin, a statin and a short-acting nitrate in the absence of a contraindication

2.Use either a beta-blocker or calcium channel blocker first line3.If poor response to initial treatment increase to maximum

tolerated dose4.After monotherapy use beta-clocker AND calcium channel

blocker5.If neither is tolerated use a long-acting nitrate, ivabradine,

nicorandil or ranolazine

Angina

A 60-year old man with stable angina presents for a routine review. He reports he is still symptomatic despite treatment with verapamil. The pain is starting to come on with minimal activity and his functioning is severely impeded. He has a spray which does still help with the symptoms.

A 56-year old male presents with sharp crushing chest pain that radiates down his left arm. He appears to be cold and clammy and short for breath, although his O2 saturations are stable at 98%. He is tachycardic and hypertensive and reports having a previous diagnosis of Angina. He has been given aspirin and GTN spray but this has not alleviated the symptoms.

Acute Coronary SyndromeUnstable Angina NSTEMI STEMI

1. 300mg aspirin and continue indefinitely2. Offer fondaparinux/unfractionated heparin

Use GRACE scoring system

Low risk (<1.5%)Low risk (1.5-3%)Intermediate risk (3.0-6.0%)High risk (6.0-9.0%)Highest risk (>9.0%)

STEMI• M• O• N• A• R• C• H• S

-orphine-xygen-itrates-spirin and atenolol-eperfusion and ramipril-lopidogrel-eparin/LMWH-imvastatin

Primary Percutaneous Coronary Intervention

Complications• Cardiac arrest• Cardiogenic shock• Chronic heart failure• Tachyarrhythmias• Bradyarrhythmias• Pericarditis• Left ventricular aneurysm• Left ventricular free wall rupture• Ventricular septal defect• Acute mitral regurgitation

Secondary Prevention• ACE inhibitor• Beta-blocker• Aspirin• Statin• Clopidogrel (after appropriate risk assessment if NSTEMI or 4 weeks if

STEMI)

Atrial Fibrillation

A 72-year old female presents complaining of feeling regularly short of breath and feeling dizzy. She reports that she hasn’t lost consciousness at anytime and that the episodes last only 5 minutes at a time. They are very distressing and she is worried she is going to die when the attack comes on.

• What is the extent of the AF?• What lifestyle advice can I give?• What is the stroke risk?• Which drugs do I prescribe?• Does the patient need cardioversion?

Anticoagulation in AFCondition Points

C Congestive heart failure 1

H Hypertension (or treated hypertension) 1

A2 Age >= 75 years 2

D Diabetes 1S2 Prior Stroke or TIA 2

VVascular disease (including ischaemic heart disease and peripheral arterial disease)

1

A Age 65-74 years 1

S Sex (female) 1

Complications of Atrial Fibrillation•STROKE• Heart failure

Atrial Flutter• Atrial rate is around 300/min• Heart rate dependent on conduction• 2:1 block heart rate will be 150

• Management same as AF• Medication may be less effective• More sensitive to cardioversion

• Radiofrequency ablation of tricuspid valve isthmus is curative for most patients

A 45-year old male with a BMI of 56 attended his GP surgery today for a nurses appointment. He regularly drinks 12 units a day and smokes 15 cigarettes per day. His diet is high in red meat and his father died of a myocardial infarction at the age of 53. The nurse is alarmed by the appearance of his ECG as shown below.

Heart BlockFirst degree Heart blockSecond degree Heart block Mobitz type 1Mobitz type 22:1/3:1 conductionComplete Heart block

NEEDS PACEMAKER!!!!!

Bundle Branch Blocks

RBBB

LBBB

V6V1

Wolff-Parkinson-White Syndrome

Aortic Stenosis•Ejection systolic Murmur• Dyspnoea• Displaced apex beat• Slow rising pulse• Narrow pulse pressure• Thrill

OVER 65 = Degenerative calcificationUNDER 65 = Bicuspid aortic valvePost-rheumatic diseaseHOCM

Management

Symptomatic Asymptomatic

Valve replacement Valvular gradient >50 mmHg

Valvular gradient <50 mmHg

Observe

Mitral Regurgitation• Pan-systolic murmur

Mitral Stenosis• Mid diastolic murmur

Aortic Regurgitation• Early diastolic murmur

Heart Failure

A 72-year old male with established Atrial Fibrillation presents to the Emergency Department with increasing shortness of breath. He finds he is unable to perform strenuous activities anymore and can struggle with housework on occasion. He does not have any chest pain but has noticed ankle swelling and needs to be propped up on 4 pillows at night when he sleeps. His GP has seen him previously and started him on Simvastatin, Bisoprolol and Ramipril.

Heart FailureLEFT• Dyspnoea• Orthopnoea• Paroxysmal nocturnal

dyspnoea• Wheezing• Dizziness• Confusion

RIGHT• Oedema• Nocturia• Ascites

LEFT• Displaced apex beat• Gallop rhythm• Heart murmurs

RIGHT• Oedema• Hepatomegaly• Raised JVP• Parasternal Heave

Heart FailureNYHA Class Symptoms

ICardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.

IIMild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.

III

Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).Comfortable only at rest.

IVSevere limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

Heart Failure: DiagnosisPrevious MI?

Echocardiography Serum Natriuretic peptides

ECG and other tests (if not already done)

Treat for heart failure

Other Diagnosis

Investigate other diagnosis

Treatment of Heart FailureLifestyle Advice & Vaccination

Manage co-morbid conditions ACEi + Beta-blocker

ARB if ACEi not tolerated

Aldosterone antagonist/ARB/hydralazine + nitrate

Ivabradine/ Cardiac Resynchronisation Therapy alternatives!!

Drug treatment for all heart failure

Other Interventions

Monitoring

Deep Vein Thrombosis

A 26-year old female presents to her GP with a tender, swollen calf. It came on quite over the previous 3 days. She has recently gotten back from Australia and had a fall from 6ft whilst away. The doctors there reassured her that she was fine and told her to enjoy her holiday. She has been on the combined oral contraceptive pill for 10 years.

Risk FactorsHypercoagulability

Haemodynamic Changes

Endothelial Injury/Dysfunction

Other things to consider…• Musculoskeletal• Cardiovascular• Other conditions

DiagnosisClinical feature Points

Active cancer (treatment within 6 months, or palliation) 1

Paralysis, paresis, or immobilization of lower extremity 1

Bedridden for more than 3 days because of surgery (within 4 weeks)

1

Localized tenderness along distribution of deep veins 1

Entire leg swollen 1

Unilateral calf swelling of greater than 3 cm (below tibial tuberosity)

1

Unilateral pitting edema 1

Collateral superficial veins 1

Alternative diagnosis as likely as or more likely than DVT -2

Total points

Management• ACUTE MANAGEMENT• Warfarin and LMWH• Admit if necessary!!!

• CHRONIC MANAGEMENT• Warfarin• Aim for INR 2.5 (between 2-3)• Below-knee compression stockings• Advice

Pulmonary Embolism

Two months later the same 26-year old collapses suddenly in the supermarket. An ambulance is called and she bought into A&E. She is extremely short of breath and has right sided chest pain on inspiration. The ambulance crew report she had been coughing up some blood. Her temperature is 37.4°, pulse rate is 102, respiratory rate is 34 and O2 saturations are 86%.

Background Information• Lung tissue ventilated but not perfused• Alveolar collapse• Reduction in cross-sectional area of pulmonary arterial bed• Elevation of pulmonary arterial pressure• Reduction in cardiac output• Lung tissue may infarct

• Large/multiple emboli can abruptly increase arterial pressure to an afterload level that can’t be matched by the right ventricle• Sudden death may occur due to acute right ventricular failure

• Annual incidence of 3-4 per 100 000 in the UK• Untreated risk of death is 87%• Treated this falls to 2.3%

• Can lead to CHRONIC THOMBOEMBOLIC PULMONARY HYPERTENSION

Investigating & Managing PEAdmit to Secondary Care*

Confirm PE

Rapid Anticoagulation Oral Anticoagulation

IF MASSIVE

Haemodynamic & Respiratory Support Thrombolysis IVC Filter Insertion Embolectomy

• Points for follow up=• Advice & treatment to prevent DVT• Assess risks and benefits of lifelong anticoagulation• Monitor INR• Evaluate and investigate for cancer if the VTE was

unprovoked• Refer to specialist if pregnant/considering pregnancy

Clinical feature PointsClinical symptoms of DVT 3Other diagnosis less likely than PE 3Heart rate greater than 100 beats per minute

1.5

Immobilization or surgery within past 4 weeks

1.5

Previous DVT or PE 1.5Hemoptysis 1Malignancy 1

Total points

Pericarditis

A 41-year old man is admitted with left-sided pleuritic chest pain. He has a dry cough and reports that the pain is relieved by sitting forward. For the past three days he has been experiencing flu-like symptoms. His temperature is 38°C and you notice oedema in his legs.

ECG findings

Acute• Infective• NSAIDs• Antibiotics if

indicated

Chronic• Radio/

chemotherapy• Autoimmune

disorders• Treatment depends

on underlying cause

Recurring• Addition of

colchicine can help prevent symptoms returning

Infective Endocarditis

A 27-year old male, a known IV drug abuser, presents to A&E with muscle aches, lethargy, and pleuritic chest pain. He reports feeling ‘fluey’ for a long time previously and having drastic weight loss. Examination of his heart reveals a new murmur.

Organisms responsible

• F• R• O• M• J• A• N• E

everoth spotssler nodesurmuraneway lesionsnemiaail haemorrhagemboli

Modified Duke Criteria• Pathological criteria

• Positive histology/microbiology sample obtained at autopsy or cardiac surgery

• Major criteria• Positive blood cultures• Evidence of endocardial involvement

• Minor criteria• Predisposing heart condition or IV drug use• Microbiological evidence does not meet major criteria• Fever >38°C• Vascular phenomena• Immunological phenomena

Cardiac Tamponade• RARE• LETHAL• SYMPTOMS VERY WITH UNDERLYING CAUSE AND SPEED OF ONSET

• Management = ABCs, Referral to Senior Physician for Pericardiocentesis

Cardiac tamponade Constrictive pericarditis

JVP Absent Y descent X + Y present

Pulsus paradoxus Present Absent

Kussmaul's sign Rare Present

Characteristic features Pericardial calcification on CXR