Download Cardiology for Finals

Cardiology for Finals
Andrew C Rankin
Cardiology for Finals
• What do you need for Finals?
• The knowledge and skills
required to be a FY doctor
• History, examination,
investigations, treatments
• Common conditions
Cardiology for Finals OSCE
• Clinical skills
–History
–Examination
• Clinical Skills Website
• ECG
Cardiology for Finals
Heart Failure
Heart Failure
• A 65 yr old man is admitted with heart
failure
• What 5 investigations would you do, and why?
• ECG
• CXR
• Troponin
• Full blood count
• U&E’s
• Echo
Heart Failure
• A 65 yr old man is admitted with heart
failure
• Name 4 drugs which should be prescribed
at discharge from hospital
• For each drug, state:
–
–
–
–
Mechanisms of action?
Why it is prescribed?
Adverse effects?
Drug class?
Drugs for Heart Failure
1. Furosemide (frusemide)
2. Ramipril (and / or candesartan)
3. Carvedilol (or bisoprolol)
4. Spironolactone (or eplerenone)
5. Digoxin
Diuretics
Disease Modifying Therapy
Renin-Angiotensin-Aldosterone System
Sympathetic NS
 Renin
 Noradrenaline
Na retention
K excretion
Fibrosis

 Aldosterone
 AT I
 ACE
AT II

ATII type I receptor
vasoconstriction
 Adrenaline

1-adrenoreceptors
 HR
vasosconstriction
cardiotoxicity
Symptomatic Heart Failure
CONSENSUS I (NEJM 1987)
SOLVD (T) (NEJM 1991)
•
•
•
•
•
•
253 NYHA IV
Enalapril vs placebo
Mean FU : 188 days
1 yr Mortality
Enalapril
Placebo
26%
44%
P=0.002
2569 LVEF 35% + CHF
Enalapril vs placebo
Mean FU : 41.4 months
4 yr Mortality
Enalapril
Placebo
35%
40%
P=0.0036
Carvedilol in severe CHF
2289 patients; NYHA IV Heart failure
100
All-cause mortality
90
Carvedilol
80
% Survival
70
60
Placebo
P=0.00014
50
0
4
8
12
16
Months
20
24
28
Packer et al, NEJM 2001
Beta Blockers in Heart Failure
“Start low, go slow”
• carvedilol 3.125mg bd for 2 weeks
- double every 2 weeks until 25mg/bd
• bisoprolol 1.25mg od for 2 weeks
- double every 2weeks until 10mg
• diuretics may have to be increased
Drug treatment of CHF
SOLVD (1991)
15
CIBIS-II
MERIT-HF
(1999)
10
% death
at 1 year
15.6
12.4
5
0
11.9
7.8
Diuretic
digoxin
Diuretic
digoxin
ACEI
Diuretic Diuretic digoxin
digoxin beta-blocker
ACEI
ACEI
NICE 2010 - Heart Failure
Cardiac Resynchronisation Therapy
RA pacing
LV pacing
(via cardiac vein)
RV pacing
CARE-HF
Cleland et al. N Engl J Med 2005;352:1539-49.
Cardiology for Finals
Cardiomyopathy
Cardiomyopathies
Normal
Hypertrophic
Dilated
From Davidson’s Principles & Practice of Medicine
Cardiology for Finals
Coronary Artery Disease
Coronary Artery Disease
• A 55 yr old man is admitted with severe
central chest pain
• What investigation would you do first, and why?
• ECG
• CXR
• Troponin
• Full blood count
• U&E’s
• Echo
ST elevation
ENHANCED REPERFUSION THERAPY FOR STEMI
Patients presenting to SAS/DGH 2008
STEMI/Posterior MI
Shock
No Shock
Call to balloon
time >90 min
Thrombolysis
contraindicated
Call to balloon
time <90 min*
PCI Centre
Thrombolysis
PCI Centre
Primary PCI
PCI Centre
Primary PCI
Reperfusion
No reperfusion
*Maximum journey
time 40 min*
Cath/PCI within 24hrs
Rescue PCI
Return to local DGH within 24hrs or when stable
ISIS-2.Lancet 1988
Left anterior descending coronary artery
in a patient with STEMI
a
b
c
a. Occluded LAD
b. Post-thrombolysis
c. Post-PCI
Widimsky P Eur Heart J 2010;31:634-636
Thrombolysis vs Angioplasty for STEMI
Danami-2 Study; 1572 patients with STEMI
Busk et al, Eur Heart J 2008
Myocardial infarction redefined
WHO definition: (2 of 3)
• Typical symptoms (chest pain)
• Typical ECG changes (Q waves)
• Enzyme rise
ESC/ACC redefinition 2000
• Troponin rise, with one of:
• Chest pain
• ECG changes (Q waves or ST segment)
• PCI
Acute Coronary Syndrome
Presentation
Working
Diagnosis
ECG
Chest pain
Acute coronary syndrome
ST elevation
No ST elevation
+
+
-
Troponin
Final
diagnosis
STEMI
NSTEMI
Myocardial Infarction
Unstable Angina
Cardiology for Finals
Evidence based medicine
Evidence based Cardiology
• Why do we use a treatment?
• Because it saves lives!
• Evidence of improved outcome
Parachutes: Evidence Base
Smith & Pell 2003
BMJ 327:1459-61
Cardiology for Finals
Arrhythmias
Cardiac Arrhythmias
“Supraventricular”
Atrial
Junctional
Ventricular
Narrow or wide QRS?
Irregular?
AF
Adenosine
P waves?
Terminates AV block
SVT
Atrial
Supraventricular Tachycardia
Accessory
pathway
AV reentry tachycardia
Adenosine and SVT
Accessory
pathway
Termination of AVRT
Adenosine
Carotid Sinus Massage
Atrial Flutter
Atrial Flutter
Adenosine and Atrial Flutter
Adenosine
Radiofrequency ablation
Ablation catheter
Accessory
pathway
Atrial Fibrillation – an new epidemic
• AF affects 1.0-1.5% of the population in
the developed world
• Life-time risk 1-in-4 for >40 year olds
• Increased prevalence with age
– 10% >80 years
• 1% of health care budget in UK
Algorithm for treatment of AF!
Paroxysmal
Persistent Permanent
Peters N, et al. Lancet 2002
Atrial Fibrillation
Risk of embolism Rhythm control
Atrial fibrillation
Rate control
“Natural” time course of AF
ESC AF Guidelines 2010
Rhythm vs Rate control in AFFIRM
All-cause death at Year 5:
23.8 versus 21.3% for rhythm versus rate control
Cumulative mortality (% patients)
30
25
20
Rhythm control
15
Rate control
10
5
(p=0.08; N=4060 )
0
0
1
2
3
4
5
Years
AFFIRM=Atrial Fibrillation Follow-up Investigation of Rhythm Managem
The AFFIRM Investigators. N Engl J Med 2002; 347(23): 1825–33
Amiodarone vs Sotalol for AF
Singh et al (SAFE-T) NEJM 2005;352:1861
Warfarin prevents strokes in AF
• Warfarin prevents 20-30 strokes
per 1000 patient years
• 6 - 8 serious bleeding episodes
per 1000 patient years
CHADS2 Score for Risk Assessment
Cardiac
C
Failure
Hypertension
H
Age
A >75
Diabetes
D
Stroke
S
Score
0
1
2
Risk
Low
Medium
High
1
1
1
1
2
Anticoagulation therapy
Aspirin
Aspirin or Warfarin (INR 2-3)
Warfarin (INR 2-3)
CHA2DS2-VASc and stroke rate
• Previous stroke, TIA
or systemic
embolism
• Age > 75 years
• Heart failure or moderate to
severe LV SD (e.g. EF <40%)
• Hypertension
• Diabetes
• Female sex
• Age 65-74 years
• Vascular disease
ESC AF Guidelines 2010
CHA2DS2-VASc and stroke rate
ESC AF Guidelines 2010
CHA2DS2-VASc and therapy
ESC AF Guidelines 2010
Pulmonary vein isolation for PAF
NICE Guidance – Rate Control for AF
Beta-blocker or CCB
Digoxin added
Management cascade for AF
ESC AF Guidelines 2010
Wide-complex tachycardia
Bundle branch
block
SVT
OR
VT ?
Cardiac Arrhythmia Suppression Trial
Post-MI; LVSD; NSVT
Patients Without Event (%)
100
95
Placebo
(n = 743)
P = 0.001
90
Encainide
or
Flecainide
(n = 755)
85
80
0
91
182
273
364
455
Days After Randomization
Echt et al. NEJM 1991;324:781-788.
Implantable Cardioverter Defibrillator
Transvenous
lead
Pectoral
device
Shocking
coils
Bipolar
endocardial
sensing
ICD for Secondary Prevention
Meta-analysis of the ICD secondary prevention trials
(AVID, CASH, CIDS)
% Mortality
Death
Arrhythmic Death
Amio
ICD
Amio
ICD
Years
Years
Connolly SJ, et al. Eur Heart J 2000;21:2071
Cardiology for Finals
Hypertension
Hypertension – NICE 2006
Hypertension – NICE 2011
NICE CG127 Hypertension 2011
NICE CG127 Hypertension 2011
NICE CG127 Hypertension 2011
Cardiology for Finals
Conclusions
• Cardiology will come up!
• Official Revision Session
• Work hard!
• Do well!