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Phase2 Karl Wild and Rowena Speak The Peer Teaching Society is not liable for false or misleading information… Stable Angina • Stable Angina - A retrosternal chest tightness or heaviness which is brought on by exertion and relieved by rest. • Symptoms – constricting discomfort in the front of the chest, arms, neck and jaw, Provoked by physical exertion, especially after meals and in cold, windy weather or excessive emotion Relieved (within minutes) with rest or glyceryl trinitrite. • Causes – Mostly Atheroma. Anaemia, Aortic Stenosis, Tachyarrhythmia, Hypertrophic Cardiomyopathy Arteritis. Unstable Angina – Angina of recent onset (<24hr) or a deterioration in stable angina with symptoms occurring at rest. Refractory Angina – Refers to patients with severe coronary artery disease in whom revascularization is not possible and whose angina is not controlled by medical therapy. Angina Examination Signs – Anaemia Thyrotoxicosis Hyperlipidaemia Aortic Stenosis (Ejection Systolic murmur radiating to neck) Check blood pressure Angina Investigation • 12 lead ECG -During an attack – Transient ST depression & T wave inversion. • Cardiac Catheterization, CT Coronary Angiography • Exclude anaemia, diabetes, hyperlipidaemia, thyrotoxicosis and arteritis Angina Management • Address risk factors • Aspirin 75mg daily • B-blocker/ Ca2+ – Atenolol/Amlodipine Both if uncontrolled on one • Nitrates – GTN, Isosorbide Mononitrate bd • Ivabradine/Nicorandil Revascularisation • PCI – Single vessel CAD and normal LV function • CABG – Triple vessel disease and abnormal LV function Acute Coronary Syndromes • ST Elevation Myocardial Infarction (STEMI) • Non ST Elevation Myocardial Infarction (NSTEMI) • Unstable Angina • Causes – Plaque rupture Thrombosis Emboli Coronary Spasm Vasculitis NSTEMI ECG changes ST depression T Wave inversion Could be normal STEMI • ECG changes – Tall T waves ST elevation New LBBB Later – T wave inversion Pathological Q waves ACS symptoms • • • • • • Acute central chest pain Radiates neck and arm Lasting >20 minutes Nausea Dyspnoea Palpitations ACS Signs • • • • • • Distress, anxiety, pallor, sweatiness Tachy/bradycardia Hyper/hypotension 4th heart sound Signs of HF and murmur Later - Pericardial friction rub & peripheral oedema ACS Investigations • ECG • Bloods • Cardiac Enzymes – Cardiac Troponin (T & I) ^ 3 hours after onset and peak at 24-48hr Creatine Kinase (CK-MB) ^ 3 hours after onset, peak within 24hr ACS Management NSTEMI Oxygen Morphine GTN Aspirin 300mg PO Clopidogrel 300mg PO Atenolol PO / Verapamil PO Enoxaparin More Nitrate if in pain. High risk – GPIIb/Iia antagonist (tirofiban) Low risk – Discharge if 12hr Trop -ve STEMI Oxygen Aspirin 300mg PO Morphine GTN PRIMARY PCI / Thrombolysis Atenolol ACS Pathology (Stable angina) Cause ECG changes Cardiac enzymes (Narrowing lumen) Unstable angina Ischaemia Nonocclusive thrombus No ST elevation -ve troponin NSTEMI Ischaemia/Infa Nonrction occlusive thrombus No ST elevation +ve troponin STEMI Transmural infarction ST elevation +ve troponin Occlusive thrombus The Peer Teaching Society is not liable for false or misleading information… Hypertension (HTN) • Essential (primary) HTN = idiopathic • Secondary HTN = something is causing it The Peer Teaching Society is not liable for false or misleading information… HTN: causes of secondary • Renal disease: intrinsic, renovascular • Endocrine: Cushing’s, Conn’s, Phaeochromocytoma, Acromegaly, Hyperparathyroidism • Coarctation of the aorta • Pre-eclampsia and HTN in pregnancy • Drugs and toxins: alcohol, cocaine, ciclosporin, decongestants, adrenergic medications, oral contraceptives, corticosteroids, liquorice The Peer Teaching Society is not liable for false or misleading information… HTN: symptoms • Usually asymptomatic • Headaches, paroxysmal sweats or palpitations = think phaeochromocytoma (tumour of the adrenal medulla) The Peer Teaching Society is not liable for false or misleading information… HTN: diagnosis • GP surgery BP measurements of adults at least every 5 years White coat syndrome = patients have elevated BP in a clinical setting but not in other settings due to anxiety experienced during a clinic visit. • • • • • • • ABPM = ambulatory blood pressure monitoring HBPM = home blood pressure monitoring Cardiovascular risk assessment HTN retinopathy screening ECG to look for LVH Bloods: electrolytes, creatinine, eGFR, fasting glucose, lipids Urinalysis: albuminuria, proteinuria or haematuria ± albumin:creatinine ratio. The Peer Teaching Society is not liable for false or misleading information… HTN: stages • Stage 1 - BP in surgery/clinic is ≥140/90 mm Hg and ABPM or HBPM is ≥135/85 mm Hg. • Stage 2 - BP in surgery/clinic is ≥160/100 mm Hg and ABPM or HBPM is ≥150/95 mm Hg. • Severe - BP in surgery/clinic is ≥180/110 mm Hg or higher. The Peer Teaching Society is not liable for false or misleading information… HTN: lifestyle interventions • • • • • Lower salt intake Reduce alcohol consumption Stop smoking Do more exercise Be less stressed The Peer Teaching Society is not liable for false or misleading information… HTN: initiation of treatment • Offer step 1 treatment to people aged under 80 with stage 1 hypertension and one or more of: a) target organ damage b) established cardiovascular disease c) renal disease d) diabetes e) 10-year cardiovascular risk equivalent to 20% • Offer step 1 treatment to people of any age with stage 2 hypertension The Peer Teaching Society is not liable for false or misleading information… HTN: treatment The Peer Teaching Society is not liable for false or misleading information… Heart failure • A complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation. The Peer Teaching Society is not liable for false or misleading information… HF: aetiology • • • • Ischaemic heart disease Cardiomyopathy HTN Diseases of the heart valves • Pericardial disease • Arrhythmias • • • • • • Alcohol Cocaine Chemo Severe anaemia Thyroid disease Idiopathic The Peer Teaching Society is not liable for false or misleading information… HF: symptoms Left • Exertional dyspnoea • Orthopnoea • Paroxysmal nocturnal dyspnoea (PND) • Fatigue Right • Swollen ankles • Fatigue • Anorexia The Peer Teaching Society is not liable for false or misleading information… HF: signs Left • Cardiomegaly • Third and fourth heart sounds • Tachycardia • Crepitations in lung bases Right • Raised JVP • Hepatomegaly • Pitting oedema • Ascites The Peer Teaching Society is not liable for false or misleading information… The Peer Teaching Society is not liable for false or misleading information… HF Investigations • • • • • Chest X ray Bloods B-type Natriuretic Peptide ECG Transthoracic echocardiogram Chronic HF Management • • • • • • Diuretics – Furosemide ACE-I – Ramipril / ARB – Candesartan B-Blocker – Atenolol Spironolactone Digoxin Vasodilators – Hydralazine & Isosorbide Dinitrate Acute HF Management • • • • • Oxygen Diamorphine IV Furosemide IV GTN spray If systolic BP >100mmHg IV nitrate HF Question A 75 year-old woman is brought to the Emergency Department by ambulance following an emergency call at 4 am. She is pain-free but very breathless. She has previously been diagnosed with congestive cardiac failure and is receiving drug treatment from her General Practitioner. GOOD LUCK!!!