Cardiology Cases Dr Aqib Chaudry - PowerPoint Presentation

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Cardiology Cases

Dr Aqib Chaudry

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Disclaimer

This lecture series has been designed and produced by doctors and students. We have made every effort to ensure that the information contained is accurate and in line with Learning Objectives featured on SOFIA, however this guide should not be used to replace formal ICSM teaching and educational materials.

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Cardiology Schedule

Chest Pain – STEMI, NSTEMI, Angina

Shortness of Breath – Heart Failure

Atrial Fibrillation

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A 72 year old gentleman attends the Emergency Department complaining of chest pain…

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What could it be?

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Chest Pain Differentials

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Understand the Pain

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Understand the Pain

S

– central/sided

O – sudden/very sudden/gradual

C

– pressure/stabbing/tearing

R

- left arm/jaw/shoulders

A

– nausea/vomiting/sweating/fear

T

– last longer than 30

mins

E

– exertion/position/GTN/morphine

S

– out of 10

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Presenting Complaint

72 year old gentleman

Sudden onset, 1 hour ago at rest

CentralCrushingNausea, no vomiting

Sweatiness

Worse when trying to walk towards his front door

Improved with GTN spray

Sometimes gets chest pain on climbing stairs

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Past Medical History

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Past Medical History

Hypertension

Type 2 Diabetes

Raised cholesterolPsoriasis

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Drug History

Amlodipine 5mg

Atorvastatin 20mg

GTN sprayAllergies - Penicillin

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Family History

Mother had a head attack aged 62

Nil other

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Social History

Lives with wife

Accountant

30 pack year smoking historyOccasional alcohol

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Examination

Looks distressed, sweaty, clammy

BP 150/75, HR 110 + regular,

Sats 94% on airHS I+II+0Lungs clearVomits during examination

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Investigations

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Investigations

Full set of observations

ECG

Routine Bloods – FBC, U&Es, LFTs, CRP, Lipids, HbA1c, BNP, TroponinChest X-Ray

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Stable Angina

Chest pain resulting from myocardial

ischaemia

that is precipitated by exertion and relieved by rest.CAUSES:MOST COMMON – Atherosclerosis

RARE TYPES OF ANGINGA –

Decubitus Angina – symptoms occur when lying down

Prinzmetal

Angina – symptoms caused by coronary vasospasm

Coronary Syndrome X – symptoms of angina with normal exercise tolerance and normal coronary angiograms

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Stable Angina - Management

Conservative

Medical

Surgical

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Stable Angina - Management

Conservative

Diet Modification

ExerciseStop smokingMedical Symptomatic Relief – GTN Spray

Beta Blockers / Calcium Channel Blockers

Risk Factor Modification – Statins

Surgical

Coronary Stent, Bypass

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Acute Coronary Syndrome

Cardiac symptoms caused by a sudden reduced blood flow to the heart muscle.

Unstable Angina NSTEMISTEMI

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Key Investigations

ECG

STEMI

ST elevationNew onset LBBB

Hyper acute T waves

NSTEMI/UA

ST depression,

T wave inversion

Troponin

STEMI or NSTEMI

A raised troponin suggests myocardial infarction

Unstable Angina

Does not have an elevated troponin

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ST Elevation

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ST Depression

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Where is the infarct?

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Where is the infarct?

Inferior (right coronary artery): II, III,

aVF

Anterior (left anterior descending): V1-V4Lateral (left circumflex): I, aVL, V5/6

Posterior (posterior descending): tall R wave + ST depression in V1-3

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STEMI Management

Immediately:

M

orphine & Metoclopramide

O

xygen

N

itrates

A

spirin 300mg STAT

C

lopiodgrel

300mg STAT or

Ticagrelor

180mg STAT

AIM OF STEMI TREATMENT

: Coronary reperfusion either by PCI or fibrinolysis

Patient presenting < 12 hours from onset of symptoms

Send to

cathlab

for PCI if it can happen within 120

mins

of the time that fibrinolysis could have been administered

Patient presenting > 12 hours from onset of symptoms

Coronary angiography followed by PCI if indicated

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Acute Coronary Syndrome

Long term management of STEMI

A – ACE Inhibitor

B – Beta blocker

C – Cholesterol lowering agent

D – Dual antiplatelet therapy

E – Echo to assess heart function

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NSTEMI/UA Management

Immediately:

M

orphine & MetoclopramideOxygen

N

itrates

A

spirin 300mg STAT

C

lopiodgrel

300mg STAT or

Ticagrelor

180mg STAT

PLUS

Fondaparinux

2.5mg daily – if low bleeding risk unless coronary angiography planned

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NSTEMI/UA Management

Risk stratify using GRACE score

High Risk

Coronary angiography within 72 hoursLow RiskConservative management and outpatient investigations (e.g. angiography, echo, exercise ECG)

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Complications of ACS

Sudden Death on PRAED Street

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Complications of ACS

Sudden Death on PRAED Street

P – Pump Failure

R – Rupture of papillary muscle or septumA – Aneurysm and arrhythmiasE – EmbolismD – Dressler’s Syndrome

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OSCE Station: Midline

Sternotomy

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OSCE Station: Midline

Sternotomy

Valve Replacement (Tissue or Metallic)

Valve RepairCoronary Artery Bypass GraftRepair of a congenital defectHeart transplant

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A 72 year old lady attends the Emergency Department complaining of breathlessness…

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Presenting Complaint

2 day history of shortness of breath

Wheezy

Has had to sleep in her armchair Woke up in middle of night feeling breathlessReduced exercise tolerance

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Past Medical

Hx

Hypertension

T2DMRaised cholesterolMI 2015 – stent insertedMI 2018 – coronary artery bypass graft

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Drug Hx

Aspirin 75mg

Atorvastatin 20mg

Bisoprolol 5mgAmlodipine 10mg

Furosemide 20mg recently started by GP

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Family Hx

Unremarkable

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Social History

Lives with her son’s family

Stair lift

No carersNo smoking, no alcohol

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Examination

Raised JVP (5cm)

Third heart sound

Peripheral oedema to the mid shinBilateral crackles to the midzone

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Heart Failure

Failure of the heart to adequately meet the cardiac output required to meet the body’s physiological requirements

Acute v Chronic

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Causes of LHF

Heart Muscle

Ischemic heart disease

Myocardial infarctionCardiomyopathyHeart Valves

AS, AR, MS, MR

Arrhythmias

Systemic – e.g. HTN

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Causes of RHF

Secondary to left Heart Failure

Lungs

Pulmonary HTNPulmonary EmbolusPulmonary valve disease

Chronic lung disease

Heart Muscle

Heart Valves

PS, PR, TS, TR

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LHF – Signs & Symptoms

RESPIRATORY SYMPTOMS

Dyspnoea

OrthopnoeaParoxysmal Nocturnal Dyspnoea

Cough +/- pink sputum

Wheeze

Fatigue

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LHF – Signs & Symptoms

Heart

Inc

HR/RR3rd heart soundMurmur

Displaced apex beat

Lungs

Bilateral crackles

Wheeze

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RHF – Signs & Symptoms

Swelling – ankles, abdomen, face

Weight gain

FatigueDecreased mobility

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RHF – Signs & Symptoms

Heart

Inc

HR/RRMurmur Head and NeckRaised JVP

Facial

oedema

Abdomen

Distension – ascites / hepatomegaly

Peripheries

Pitting

oedema

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Investigations

Bloods

FBC, U&E, LFT, Lipids, Glucose

BNPTroponinECG

Chest X-Ray

Echocardiogram

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Heart Failure CXR

A – Alveolar Shadowing

B –

Kerley B LinesC – CardiomegalyD – Upper lobe diversionE – Pleural effusions

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Management of Heart Failure

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Acute Heart Failure

Sit patient up

High flow oxygen 15L/min via non-rebreathe mask

IV Diuretics - Furosemide 40mg IV

If systolic > 90mmHg consider IV vasodilators such as GTN

If systolic < 90mmHg consider inotropes

Analgesia if required (e.g. small dose opiates)

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Chronic Heart Failure

Optimise

CV risk

Statin, anti-HTN, DM, anti-plateletSpecific1st

–

ACEi

, Beta Blocker, Loop Diuretic

2

nd

– Add Spironolactone

3

rd

– Consider Digoxin

4

th

Consider cardiac

resynchronisation

therapy

Annual influenza vaccine + one off pneumococcal vaccine

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Thanks for coming along