Download Management

Cardiology for Finals
FY1s Poornima Mohan & Ghazal
Saadat
Overview
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Scars
Acute coronary syndromes
Valvular heart disease
Infective Endocarditis
Dextrocardia
Arrhythmias
Midline sternotomy scar
What is this scar?
Which 3 procedures would cause this scar?
What else would you look for?
Grafts
What could this be?
What are the indications?
Where else should you look?
“We have this patient with chest
pain”
66 year old with a background of DM type 2,
hypertension and a 40 pack yr smoking hx. Day 1
post inguinal hernia repair.
Has been having central crushing chest pain for last
15 minutes. No relief from GTN. Hot & sweaty,
vomited twice.
Obs: BP- 120/60 P-75 RR- 24 Sats 98% on RA
What ECG features suggest an STEMI??
ST elevation in 2mm in 2 or more contigous limb leads
ST elevation in 2 or more contigous chest leads
New onset LBBB
Posterior MI
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What features suggest an to NSTEMI ???
ST depression and /or T wave inversion in 2 or more
leads. Risk is assessed using the TIMI score.
What does this ECG show?
Management
What would you do as an F1?
1) Assess haemodynamic stability
2) oxygen(?)
3) Initiate ACS protocol
4) Nitrates
5) Analgesia
STEMI - Primary PCI
NSTEMI – Risk assessment and PCI
Unstable angina – Functional Testing +/- Angiogram
Universal Secondary Prevention and Cardiac Rehabilitation
FUNCTIONAL TESTING
1) EXERCISE TOLLERANCE TEST
2) CT CALCIUM SCORING
4) STRESS ECHO
3) MYOCARDIAL PERFUSION
SCAN
Valvular heart disease
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Common exam question
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Can find lots of patients with valve replacement
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Things to know are
- Which valve
- What the cause could have been
- Clinical signs
- Basic principles of management
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Questions about complications of surgery
Scenario 1
“ A 72 year gentleman man presents with a history of
collapse as he was rushing up a hill to catch a bus.
There was no LOC. He reports no associated
weakness/numbness/tingling in the limbs, visual
disturbance, slurred speech, headache, chest pain, or
palpitaions. This had never occurred before.
He has noticed that he is increasingly SOB of late whilst
gardening/ doing house-work etc.
He has no previous cardiac history. He suffers from
hypertension and gout.”
Aortic Stenosis
Causes
1) Senile calcification
2) Biscuspid Aortic valve
3) strep associated – Rheumatic
fever
Symptoms
Exertional : Dysponea, syncope angina
Features of AS on examination ????
Features on Examination
narrow pulse pressure
slow rising pulse
LV heave
Forcefull apex beat
ESM radiating to the carotid- heard all over the precordium
Features of left ventricular dysfunction
Severe Stenosis → 1) Narrow PP 2) Quite or loss of S2
DDX for an ESM → 1) HOCM 2) VSD 3) Aortic sclerosis.
Management : TAVI vs Open AVR +/- CABG?
Exam tip : Which heart sound is metallic in an AVR??
Mitral Regurgitation
“ A 72 year old lady presents with a history of increasing SOB, orthoponea
and palpitations over a few months. She has a history of Angina,
Hypertension. She is found to be in Atrial fibrillation”
Causes
Valve Annulus
ACUTE
CHRONIC
Leaflets
Papillary
Muscle
Infective
Endocarditis
MyocardiaI
schemia
Function – Chronic
ischemia (post MI)
Prolapse
CCF (LV dilatation)
Connective
tissue
disorders
Amyloidinfiltration
of the
chords.
Mitral Regurgitation
Clinical features
AF
small volume pulse
displace apex beat
loud PSM radiating to the axilla
bibasal crepitations
• MGX: mitral valve clip vs Open MVR
+/- CABG. Discuss indication. Decision
is often based on a TOE.
Mitral Regurgitation
Management
Consider patients pre-morbid state
Medical : Diuresis
Rate control
Anti coagulation
ACE inhibitors and B-blockers.
Surgical : Assessment with an TTE / TOE and angiogram.
Mitral clip or an open Valve Replacement
Mitral Stenosis
Cause: Congenital
Rheumatic Heart disease
Senile Degeneration
Clinical Signs
Malar flush
Irregular pulse
Tapping apex beat – palpable 1st HS
Left parasternal heave / Enlarged LA
Loud 1st heart sound
Opening snap
Mid-diastolic murmur.
On investigation
CXR- Enlarged left atrium,
calcified valves and pulmonary
oedema.
ECG – p-mitrale and AF
Management
Medical : Rate control (digoxin)
Anti-coagulate
Valvuloplasty
Surgical : Valve replacement
Valveotomy (open / closed)
Aortic Regurgitation
Causes : Acute (inf. Endocarditis)
Chronic: Connective tissue disorders
(RA), Rheumatic heart disease, syphilitic heart
disease . Aortitis: Marfans / Anklysing
spondylitis
Clinical features:
Wide PP
collapsing pulse – hyperdynmaic apex beat
Eponymous signs
Early diastolic murmur
Aortic Regurgitation
Other causes of a collapsing pulse?
Anything that causes a high circulating volume:
Pregnancy
Anaemia
PDA
Thyrotoxicosis
Management
Valve replacement vs conservative management
Murmurs Summary
Aortic
Stenosis
Aortic
regurgitation
Mitral
Stenosis
Mitral
regurgitation
Pulse
Slow-rising
Collapsing
Often AF
Apex beat
Forceful, not
displaced
Displaced
Tapping, not
displaced
Murmur
Ejection
systolic
Early diastolic
Rumbling mid- Pansystolic
diastolic
Best heard
Aortic area
Tricuspid area
Mitral area
Radiation
Carotids
Thrusting, +/displaced
Mitral area
Axilla
Complications of Valve replacements
• INFECTION : early vs late.
• FAILURE OF VALVE: early vs late
• DISLODGEMENT
• THROMBUS FORMATION vs HAEMMOHRAGE
Management
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What would you do as an F1?
ECG
CxR
Inform seniors
Echo
Conservative: if AF, rate control. Diuretics
improve symptoms
• Surgical: Valve repair/ replacement
“ A 54 year old lady initially presents with an abscess.
She vascular infarcts on CT and is admitted to the acute
stroke unit. She has no major risk factors for a CVA.
On doing base line bloods she has CRP 300
Urine dip show blood +++
She’s on the stroke ward, she has some left sided
weakness. Obs stable, and apyrexial so far “
What is the diagnosis???
Infective endocarditis
What would you look for ???
What would you look for?
• Signs of sepsis
• New murmur or
change in existing
murmur
• Microscopic
haematuria, ARF,
splenomegaly
• Embolic features e.g.
abscesses
What would you do as an FY1?
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Bloods
Blood cultures
ABG
Urine dip & MCS
CxR
ECG
Echo (TOE)
Inform seniors
Common questions
1. Risk factors?
Lifestyle factors (IVDU), cardiac lesions, aortic or mitral valve
disease, PDA, VSD, coarctation, prosthetic valve
2. Organisms?
• Strep viridans (35-50%), HACEK (Haemophilus, actinobacillus,
cardiobacterium, Eikenella)
• Fungi
• SLE – Libman-Sachs endocarditis
3. Criteria for Diagnosis?
Duke criteria for diagnosis
2 major OR 1 major and 3 minor OR all 5 minor criteria
Major
• +ve blood culture
typical organism in 2 separate cultures or persistently +ve blood
cultures
• Endocardium involved
• Positive echo or new valvular regurgitation
Minor
• Predisposition
• Fever >38C
• Vascular/immunological signs
• +ve blood cultures that do not meet major criteria
• +ve echo that does not meet major criteria
Management
• MDT decision
• Conservative management: Long-term
antibiotics and serial echos
• Surgical management: Valve replacement
Dextrocardia
A congenital defect where the heart is situated on the
right side of the body
2 types:
Isolated dextrocardia – heart placed further to the right
in thorax, associated with other cardiac abnormalities
Dextrocardia situs inversus – heart placed to the right
side as a mirror image
Dextrocardia CxR
Dextrocardia ECG
THANK YOU