Play the game How do you do a cardiovascular examination Case 1 Examination Mild SOB at rest HR 65 regular BP 15090 Added third HS Bibasal course crackles Pitting oedema to midshins Differential ID: 774700
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Slide1
Cardiology in Finals
Daniel Belete
Slide2Play the game!
Slide3How do you do a cardiovascular examination?
Slide4Case 1
Slide5Examination
Mild SOB at restHR 65 regularBP 150/90Added third HSBibasal course cracklesPitting oedema to mid-shins
Slide6Differential
Slide7Investigations
Bedside
ECG
Bloods
FBC, U+Es, TFTs, HbA1c, lipids, LFTs, TFTs,
BNP
Imaging
CXR, Echo, cardiac MRI
Slide8Chronic HF Management
Conservative
Patient education
Diet and fluid intake advice
Cardiac rehab
Community heart failure team
Annual influenza vaccine and a pneumococcal vaccination
Medical
Titrate loop diuretic
Reduced EF
β
-blocker and
ACEi
/ARB
Consider long term CV risk
Think
antiplatelets
and statins
Slide9How would you grade the severity?
What are the causes of Heart Failure?
Slide10New York Heart Association (NYHA)
Class I — no limitation of physical activity
Class II — slight limitation of physical activity on exertion
Class III — marked limitation of physical activity on exertion
Class IV — unable to carry out any physical activity without discomfort, symptoms at rest can be present
Slide11Most common
IDH
HTN
Other cardiac causes
Valvular
pathology (AS), pericardial disease, arrhythmias (AF)
High output states
Drugs
Alcohol, NSAIDs, CCBs, some
antiarrhythmics
Slide12Case 2
Slide13Examination
Gentleman – late middle agePulse 80 bpm irregularBP 160/80
Slide14Slide15No heaves or thrills
HS present, nil added
Slide16Slide17Slide18What is your diagnosis?
Slide19This patient presents with chest pain. How would you investigate this patient?
Bedside
Serial ECGs – ischaemic changes, arrhythmias, old infarcts
Bloods
Risk factors – HbA1c, cholesterol
Troponin
Imaging
CXR - Cardiomegaly
Echocardiogram – ventricular function,
valvular
function
Further Ix depend on risk of having CAD (complex, NICE 2010)
Low risk – CT calcium scoring
Medium risk – functional, e.g. myocardial perfusion scan (MIBI), stress echo, cardiac MRI
High risk – coronary angiogram
Slide20How would you manage patients with chronic IHD?
Conservative
Education, exercise, weight loss
Smoking cessation
Medical
Aspirin, beta-blockers, Ca ant, GTN, etc,
AF – warfarin, rate control
Control risk factors – optimise T2DM, statins
Surgical
PCA – percutaneous coronary angioplasty
CABG
Slide21Case 3
Slide22Comfortable at rest. SOB on exertionHR 72bpm, regular Slow rising. No stigmata of endocarditisBP = 110/90JVP + 2 cm above sternal notchApex beat not displaced.
Examination
Slide23No heaves or thrills,
HS I + II + ejection systolic murmur, loudest in the aortic area in expiration, radiating to the carotids.
Clear lung fields, no pedal
oedema
Slide24Differentials
Slide25Bedside – ECG (LVH, possibly LBBB or complete heart block)
Imaging:
CXR – LVH, calcified aortic valve, post stenotic dilatation of aorta
Echo –
Diagnostic
Severity – severe = valve gradient >50 mmHg and valve area <0.5 cm
2
Invasive – cardiac catheter – assess gradient, LV function, CAD
Slide26Conservative
Follow up clinics (‘I would arrange…..’)
Patient education
Medical
Essentially treatment of heart failure/angina
Surgical
Valve replacement
Valvuloplasty
Slide27What are the causes of aortic stenosis?
Slide28Case 4
Slide29Pulse 92BP 130/80JVP elevated +6 cm above sternal notchCrackles at lung bases
Examination
Slide30Apex laterally displaced in anterior axillary line, 5
th
ICS, with palpable thrill
Heart sounds soft S1, normal S2
Pan-systolic murmur, 4/6, loudest in expiration radiating into axilla
Slide31Slide32Would you like to present your findings?
Heart failure – oedema, raised JVP, crackles
Infective endocarditis
Murmur
Slide33What is your differential diagnosis of a pan-systolic murmur?
MR
TR
VSD
Slide34How would you investigate this patient?
Bedside
ECGs (MR
AF, p mitrale, LVH; IE
arrhythmias
)
Urine dip (haematuria)
Bloods
Biochemistry – CRP, U&E, LFTs
Haematology - WCC
Blood cultures
Imaging
CXR – pulmonary oedema, mitral valve calcification, LAH, LVH
Echo - assess LV function; TOE to assess severity and suitability for repair rather than replacement; Doppler echo to assess size and site of regurg
Other
Cardiac catheterisation - confirm diagnosis, exclude other valve disease, assess CAD
Slide35Management of MR
Conservative
Regular follow up, educate patient
Medical
AF – rate control, anticoagulate
Diuretics improve symptoms
Surgical
Mitral valve repair
Mitral valve replacement
Slide36What are the causes of mitral regurgitation?
Abnormal leaflets/cusps
Rh fever
Endocarditis
Myxomatous
degeneration (= mitral valve prolapse)
Abnormalities of tensor apparatus
Papillary muscle rupture (due to MI) or rupture of chordae
tendinae
Abnormal LV cavity
Functional
regurg
secondary to dilatation
lateral migration of papillary muscles
Slide37What does this picture show?
Slide38How would you diagnose infective endocarditis?
Modified Duke’s criteria:2 major OR 1 major + 3 minor OR 5 minorMajorBlood cultures with typical organism, multiple bottlesEndocardial involvement (Positive echo – vegetation, abscess, etc)
Minor
Predisposition (cardiac lesion, IVDU,
etc
)
Fever >38C
Vascular/immunological signs
Blood culture not met by major criteria
Echo that does not meet criteria
Slide39Case 5
Slide40Young man, comfortable at rest.
Capillary pulsations in the nailbeds.Pulse 60bpm, regular and collapsing.
Examination
Slide41BP 130/60
Visible carotid pulsations
JVP not elevated.
Thrusting apex beat displaced to the mid axillary line.
Early diastolic murmur (2/4) loudest in aortic area in expiration.
Lungs clear, no pedal
oedema
Slide42What is your differential diagnosis?
Aortic
Reguritation
What if there is a low pitched late diastolic murmur at the apex?
- This is the classic Austin Flint murmur of AR caused by the
regurgitant
jet hitting the anterior leaflet of the mitral valve.
Slide43What are the markers of severity of AR?
Wide pulse pressure
Long duration of the diastolic murmur
Austin Flint murmur
Pulmonary hypertension
Signs of decompensation (i.e. cardiac failure)
S3
Slide44What are the causes of AR?
ACUTE
Infective endocarditisAortic dissectionFailure of a synthetic valve
CHRONIC
Congenital bicuspid valve
Hypertension
Rheumatic fever
Rheumatological
disease – RA, SLE,
Ank
Spond
, Psoriatic arthritis
Connective tissue disease –
Marfan’s
, Ehlers
Danlos
,
Osteogenesis
imperfecta
Slide45How would you manage this patient?
Conservative
- patient education
- dietary advice and exercise
Medical
- Diuretics for heart failure
Surgical
Valve replacement is the only definitive management.
Slide46