Download Cardiology Revision 2014

Dr P Banerjee
Consultant Cardiologist
University Hospitals Coventry &
Warwickshire
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Picture slides
ECG reading
How to examine the CVS
Assessment of patient with breathlessness,
chest pain, palpitations, syncope
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51 yr old man
Admitted with pyrexia, shivering and feeling
unwell
Has a heart murmur on examination
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Murmur with pyrexia
Positive blood cultures
Splinter hge, Roth spot, Oslers nodes,
Janeway lesions, splenomegaly, microscopic
haematuria
Strep Viridans, Staph Aureus, others
IV antibiotics via Hickman line for 6 weeks
Valve surgery
Prosthetic valve endocarditis
Tricuspid valve affected in IVDA
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53 yr old lady
Presents to clinic with SOBOE
Has Hx of rheumatic fever
Cardiac murmur audible on auscultation
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Rheumatic almost always
Loud SI and MDM
Early pulmonary hypertension and secondary
TR
AF common
Remember that all valvular heart disease has
rheumatic fever as a cause except isolated
AS.
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70 yr old lady Presents to clinic
Has been hypertensive for years
SOBOE for 3 years- didn’t see doctors
Orthopnoea and more recently PND
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CCF signs: raised JVP, ankle oedema,
enlarged liver
Left heart failure signs: S3 gallop, basal
crackles, pulsus alternans
Ascites, bilateral pleural effusions in
advanced CCF
Echocardiography, CXR, BNP
Loop diuretic, ACE/ARB, B blocker,
Spironolactone/eplerenone
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65 yr old
Admitted with severe central CP for 2 hrs
Sweaty and clammy
BP 90/60, Pulse 50/min, SR
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Aspirin 300mg + Prasugrel 60 mg loading
IV morphine
Primary PCI
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49 yr old smoker
CP for 30 min, improved with IV Morphine
Now comfortable, normal BP and pulse
Troponin T elevated
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Therapeutic clexane
Aspirin + clopidpgrel
Atorvastatin 80 mg od
Beta blocker
IV Nitrates and Tirofiban if needed
PCI within max 72 hrs
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76 yr old man
Severe CP 7 days ago for 3 hrs
Admitted now with SOB, no CP
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Needs coronary angio but more electively
PCI may not be needed
Discharge on secondary prevention drugs: BB,
aspirin, clopidogrel (1 month if no stent and
missed STEMI), statin, ACE, eplerenone (if
LVEF<40%)
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25 yr old lady, non smoker
Flu like illness for 7 days
Sharp CP on inspiration for 24 hrs, better on
sitting forward
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Usually viral
Check viral titres, inflammatory markers
(CRP), autoimmune profile
Echo to excluse pericardial effusion
Treat with NSAIDS like Ibuprofen, naproxen
etc for 7 days
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75 yr old man collapsed at Tesco
CPR given by Tesco staff
Ambulance arrives in 3 mins
Man breathing spontaneously, BP 110/70,
Pulse 70 min irregular
ECGS X 2 done by ambulance personnel
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If haemdynamic compromise DC shock
If stable IV Metoprolol/Esmolol, IV
Amiodarone via a central line followed by oral
Check for QT prolongation on ECG
Check electrolytes to exclude hypokalaemia,
hypomagnesaemia and hypocalcaemia
Assess LV function by echo
Only Amio and BB safe if LV function poor
Troponin T, Coronary angio even if Trop T
normal
Consider ICD
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Gentleman suddenly has cardiac arrest again
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Emergency DC shock
Check all as for VT
ICD
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28 yr old lady admitted with sudden onset
palpitations
No CP or SOB
Has had such episodes before- usually has
them terminated by IV injection in A&E.
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Carotid sinus massage, valsalva
IV Adenosine, IV Verapamil
DC shock-usually not required
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74 yr old man
Severe central CP for 2 hrs with sweating
Stable BP and pulse
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Treat as STEMI
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63 yr old hypertensive lady
Has had on and off palpitations for months
This morning noticed palpitations
Later developed slurred speech with
weakness on the right side
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Rate control
Anticoagulate (CHADS2 VASC SCORE)
Consider cardioversion
If onset less than 72 hrs direct cardioversion
If onset>72 hrs or unclear TOE+CV or
elective CV after at least 4 weeks of
anticoagulation
Feature
Score
Congestive Heart Failure
1
Hypertension
1
Age >75 years
2
Age between 65 and 74
years
1
Stroke/TIA/TE
2
Vascular disease (previous
MI, peripheral arterial
disease or aortic plaque)
1
Diabetes mellitus
1
Female
1
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Later her ECG changed
? Any change in management
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Management same as for atrial flutter
New agents for oral anticoagulation in non
valvular AF: Dabigatran, Rivaroxaban
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Asymptomatic young and fit man has had
these ECGs as part of his employment check
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Not indications for pacing
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81 yr old gentleman with recurrent cardiac
sounding syncope
Not on any AV blocking drugs
Clinically NAD
Next 2 ECGs are taken as strips from his 4 hr
tape
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Indications for permanent pacing
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JACCO
Hands: splinter haemorrhages, Jane way
lesions, oslers nodes, clubbing
Tongue and eyes; anaemia, cyanosis,
jaundice
Pulse: rate, rhythm, volume, character,
pulse equality, condition of arterial wall
JVP: height, waveforms- a and v waves
Ankle oedema
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Facies: malar, elfin, moon
Corneal arcus, xanthelasma, xanthomas
Pulsations
Scar marks
Prominent veins
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Apical impulse: position, character, thrill
Hyperdynamic, heaving, tapping
Left parasternal heave
Base of the heart palpation: palpable heart
sounds, thrill
Carotid palpation
Apical thrill-diastolic, base of heart thrillsystolic
Pulmonary hypertension: RV apex,
Parasternal heave, palpable P2
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Heart sounds: S1, S2, Split
Murmurs
Added sounds; S3, opening snap
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Comfortable at rest.
The pulse is irregularly irregular
The JVP is elevated at 5 cms above sternal
angle with a prominent V wave.
There is ankle oedema and 2 finger tender
hepatomegaly which is pulsatile
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The apical impulse is located in the left 5th
ICS just inside the MCL. It is tapping in
character and there is an apical diastolic thrill
There is a prominent left parasternal heave
and palpable P2
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The S1 is loud.
P2 is loud. There is a mid-diastolic rumbling
murmur with an opening snap, localised to
the mitral area. Best heard in left lateral and
exp.
PSM at left sternal edge increasing with
inspiration
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This gentleman has rheumatic mitral stenosis
with pulmonary arterial hypertension,
tricuspid regurgitation, right heart failure and
atrial fibrillation.
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Breathlessness
Palpitations
Chest pain
Syncope
Oedema
Fatigue
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65 year old male presents with gradually
increasing breathlessness for 6 months
I am assuming that for all of these you are
assessing the patient by taking a hx,
examining the cvs/resp/gi systems and then
investigating and treating
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Orthopnoea
PND
Exercise tolerance- NYHA CLASS
Accompanying symptoms
Causes
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Heart causes
Lung causes
Obesity
Anaemia
Pulmonary hypertension
Detraining
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Heart failure (Hx of fatigue, PND, ankle
oedema, previous IHD, hyp, valve disease)
Severe valve disease- MR,MS, AS, AR (Hx of
Rheumatic fever, congenital, degenerative)
Atypical angina (angina equivalent)
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COPD, Asthma, Pulmonary fibrosis,
obstructive sleep apnoea
Hx of wheeze, smoking, asbestos exposure,
Amiodarone, snoring
Concomitant diseases like connective tissue
diseases, sarcoidosis
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Signs of heart failure, S3, murmurs
Reduced breath sounds, obliteration of
liver/cardiac dullness, rhonchi, endinspiratory crackles at both lung bases
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Bloods,ECG, CXR, Echo, ETT,Coronary angio
Full PFTs, CT chest, CTPA, V/Q scan
Sleep studies
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Heart Failure: Diuretics, ACE/ARBs, Bblockers, Digoxin, Spironolactone
COPD: Bronchodilators, steroid inhalers, stop
smoking
Sleep apnoea: nasal CPAP, weight reduction
PPH: Nifedipine, Amlodipine, Warfarin,
Prostacyclin infusion, Viagra (Sildenafil),
Bosentan
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A 50 year old gentleman complains of chest
pain with associated flu like illness
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IHD/ MI
Oesophageal pain
Musculoskeletal pain
Pneumonia/ chest infection
Pericarditis
PE
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Classical Hx of effort angina (chest heaviness or
tightness), > 30 min constant pain =MI, RF for
CAD,
Sputum, SOB, wheeze, pleuritic CP
GE reflux
CP worse on postural changes, constant pain,
chest tenderness
Pleuritic CP which improves on sitting forward +
fever + raised ESR/CRP
SOB + pleuritic pain, DVT, long flight, prev Hx
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Bronchial breathing + dullness/ crackles
Pericardial rub
Chest wall tenderness
Epigastric tenderness
Signs of DVT
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Bloods : wbc, ESR, CRP, viral titres
CXR: pneumonia, pleural effusion, elevated
hemidiaphragm, pulmonary infarcts, loss of
pul vascularity
ECG: ACS, MI, Pericarditis, PE
Blood gases,V/Q scan, CTPA
Gastroscopy
ETT, Myocardial perfusion scan, stress
echo, coronary angiography
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IHD: B Blocker, Ca blocker, oral nitrate, nicorandil,
aspirin, statin
ACS/MI: Above plus LMW heparin, clopidogrel, Gp
2b-3a receptor antibodies, IV GTN, Coronary angio,
Thrombolysis for STEMI, Primary PTCA
Pneumonia: antibiotics, bronchodilators, chest
physio
PE: warfarin, thrombolysis
GORD: PPI.
NSAIDS for pericarditis
Muscular: simple pain killers
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80 year old man has blacked out twice in 3
months
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Cardiac syncope: Sick sinus syndrome,
hypersensitive carotid sinus syndrome,
intermittent AV block, VT, bifacsicular or
trifascicular block, obstructing cardiac
tumours, HOCM, severe AS, PAF causes
dizziness only.
Neurogenic syncope: TIAs, strokes,
epilepsy
Massive PE
Vasovagal/ neurocardiogenic syncope
Cough and micturition syncope
Postural hypotension
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Sudden, transient, rapid recovery, pale, no
warning: Stokes-Adam attack eg. known
previous MI with poor LV
Aura, seizure, prolonged LOC, slow
recovery: epilepsy
limb weaknesses, speech problems, Cx
spine problems: TIA, strokes
? Postural, chest pain or palpitations,
drugs, following fright or heat etc
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HR, ?AF, LS BP, murmurs, Neck movements,
Carotid bruit, full neuro exam
Carotid sinus massage
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24 hr Holter monitor, cardiomemo or event
recorder
Echo
Tilt table test
Reveal device implant
Postural hypotension: short synacthen test,
drugs, 24 hr urinary catecholamines
EEG, CT head
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Permanent pacemaker for 2nd and 3rd degree
AV block, HCSS, SSS, bi or trifascicular block
with symptoms
VT with good LV function- b blockers,
amiodarone. VT with poor LV- ICD.
Ischaemic VT: revascularisation
AS: surgery, HOCM : Amiodarone, ICD,
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Atrial and ventricular ectopics
Valve disease: AR, MR
Tachyarrhythmias: PAF, SVT, rarely VT
Anxiety
Hyperthyroidism
Excessive caffeine intake
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Missed beats or racing heart
Syncope, presyncope
Sudden onset and sudden termination
Paroxysmal or constant
Caffeine intake
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24 hr tape
TFTs
Echo
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No Rx for ectopics
PAF: B-blocker, flecainide, disopyramide,
propafenone, amiodarone, warfarin, ablate
and pace
SVT: Verapamil and all of the above, slow
pathway ablation
Valve disease: surgery if severe. Otherwise
ACE for MR, Hydrallazine or Nifedipine for
AR
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HOPE YOU DO VERY WELL