020216 acs and heart failure.pptx

7/25/2019 020216 ACS and heart failure.pptx

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C2F- ACS and HF

FY1 Grace McKay



Pre lecture quiz

You are the FY1 on general medical on call You are !lee"edto re&ie' Mr #hite( a )% year old male in !ed $ com"lainin"ain

the nur+e hand+ o&er the *ollo'ing in*ormation



S- )% yo "t Mr #hite +udden on+et o* che+t "ain ,1% min+

B- day $ "o+t o" K. +econdary to /A

A- 0e'+ % increa+ed ..( H. and +lightly hy"erten+i&e( ta

"aracetamol !ut no im"ro&ement

R- Plea+e come and re&ie' him3



You go to +ee the "atient

He i+ com"laining o* a +e&ere che+t tightne++and a "ain in hi+ throat( he ee"+ hiccu"ingand !elching during the con&er+ation andrelay+ that he *eel+ quite +ic Mr #hite loo+

!reathle++ and "ale 'ith a +'eaty *orehead he nur+e in*orm+ you that Mr #hite ha+ 24M diet controlled( hy"erchole+terolemiaand u+ually +moe+ 15 cigarette+ a day



Medication+

Sim&a+tatin 65mg P/ /4

.ami"ril 2%mg P/ /4

Paracetamol 1g P/ 74S4ihydrocodeine $5mg 88

Senna 1%ml P/ /4

inza"arin 6%55 unit+ SC /4



71 #here i+ the in*arct8



72

1#hich "art o* the heart i+ re"re+ented !y 9CG lead+ :1

a. anterior

b. lateralc. inferior

d. septal

e. high lateral



7$

#hich +erum !iochemical marer 'ill mo+t a

in the diagno+i+ *or thi+ "atient8

a. Calcium

b. D-dimer

c. Troponin

d. Creatinine kinase

e. Lactate



76

Sugge+t 2 alternati&e diagno+e+ *or thi+ "atiacute che+t "ain- other than ACS



7%

#hat i+ the a""ro"riate ultimate managemethi+ "atient8

a. Aspirin 300mg

b. Primary PC

c. Thrombolysis

d. ! unfractionated heparin

e. "C lo# molecular #eight heparin



7)<=

#hat com"licationha+ occurred inthi+ "atient8

Ho' 'ould youmanage it8



7>

?ucily your attendance at thi+ lecture mean+ that you manage to "atient He i+ +cheduled to !e di+charged home 2 'ee+ a*ter all t#hat $ additional medication+ 'ould !e most im"ortant to contindi+charging the "atient8

a a+"irin( clo"idogrel( !eta-!locer

! clo"idogrel( met*ormin and ator&a+tatin

c i+o+or!ide monotitrate( !endro@umathiazide and !eta-!locer

d a+"irin( 'ar*arin and *ru+omide

e a+"irin( tinza"arin and G0



7

Fa+t *or'ard 2 year+( you ha""en to !e on a GP rotation 'hmeet Mr #hite again3 He ha+ come to the "racti+e com"lainocturnal cough( reduced eBerci+e tolerance and anle +'e#hat "o+t M com"lication ha+ Mr #hite mo+t liely de&elo

a Pulmonary em!oli+m

! Pericardial eDu+ion

c Heart *ailure

d .educed re+"on+e to ACS medication

e :entral +e"tal de*ect



715

You request an Xray toinvestigate thesesymptoms further, whichfeatures of this imagesupport your initialdiagnosis?

( points availa!le"



Ho' did you do8



71 #here i+ the in*arct8

$ "T ele%ation in Leads &' 3 and A

inferior infarct. )b also reciprocal



72

1#hich "art o* the heart i+ re"re+ented !y 9CG lead+ :1

$ "eptum



7$

#hich !iochemical marer 'ill aid you in the

diagno+i+ *or thi+ "atient8

$ "erum troponin- *& hours



76

Sugge+t 2 alternati&e diagno+e+ *or thi+ "atiacute che+t "ain- other than ACS

*. Pericarditis

&. Dissecting aortic aneurysm3. Pulmonary embolism

+. ,esphageal reflu' spasm or rupture

. /iliary tract disease

. Perforated peptic ulcer

1. Pancreatitis



7%

#hat i+ the a""ro"riate ultimate managemethi+ "atient8

$ Percutaneous coronary inter%ention



7)<=

#hat com"licationha+ occurred inthi+ "atient8 :F

Ho' 'ould youmanage it8 "ut out a

cra+h call( +tart CP.( a+"er A?S "rotocol



7>

?ucily your attendance at thi+ lecture mean+ that you ma+a&e thi+ "atient He i+ +cheduled to !e di+charged home 2a*ter all the drama #hat $ additional medication+ might ycon+ider continuing !e*ore di+charging thi+ "atient8 E0 h

already on a +tatin and an AC9

a a+"irin( clo"idogrel( !eta-!locer



7

Fa+t *or'ard 2 year+( you ha""en to !e on a GP rotation 'hmeet Mr #hite again3 He ha+ come to the "racti+e com"lanocturnal cough( reduced eBerci+e tolerance and anle +'e#hat "o+t M com"lication ha+ Mr #hite mo+t liely de&elo

c Heart *ailure



715

You reque+t an ray to in&e+tigatethe+e +ym"tom+ *urther( 'hich*eature+ o* thi+ image +u""ort yourinitial diagno+i+8

#$Al&eolar oedema E!at 'ing+

%$B line+ -Kerley

&$'ardiomegaly

$)ilated "rominent I? &e++el+

$*Du+ion+-"leural



A'S



#hat i+ ACS- acute coronary+yndrome8

he cla++icL



he cla++ic"re+entation

Hx: Central chest pain or discomfort #ith a tightness or ac

to throat' arm' back and epigastrium. Can be accompanied

and indigestion.

O/E: (rom the end of the bed2 Pale' ",/' s#eating' ani

eneral- #hy bother4



he great mimic+ o* A

*. Pericarditis

&. Dissecting aortic aneurysm

3. Pulmonary embolism

+. ,esphageal reflu' spasm or rupture

. /iliary tract disease. Perforated peptic ulcer

1. Pancreatitis



Some 9M7+- match the "ain

1Aortic di++ection

2Pericarditi+

$.e@uB

6Myocarditi+

a. Patient presents #ith chest pain de%eloping o%er a fe# d

include pyreia' dyspnoea' fatigue and tachycardia.

b. Patient presents #ith continuous abdominal pain #hich back5 there are asymmetric pulses in the upper limbs an

hypotensi%e.

c. Patient presents #ith a sharp chest pain' slightly relie%e

,n auscultation' a rubbing noise is audible.

d. Patient presents #ith a burning retrosternal chest pain'

stooping do#n or straining. other symptoms include #at



n&e+tigation+ -9CG

eBam"le+ B $

6hat



S9M

,2mm in che+t

,1mm in lim!+

n e+tigation+ -iochemical



n&e+tigation+ -iochemicalmarer+

Myocardial necro+i+ relea+e o* tro"onin



ro"onin

#hat other "athologie+ can cau+ri+e in tro"onin8



n&e+tigation+-9cho < C.

SG0 guideline"orta!le C. to a++cardiac +ize and oe



Cla++i*ying ACS

)"T789A



treatment

M orphine :diamorphine &.-*0mg ; 8etoclopramid

O ygen <if hypoic= aim >+->?@ sats

N itroglycerine- & puffs T)

A spirin 300mg

C lopidogrel 300mg

L m#h therapeutic dose



S9M treatment

#$+-A' (."/gi&en in catheter la!

2 Primary Percutaneou+ Coronarynter&ention

$ Fi!rinoly+i+

Contraindication+ to



Contraindication+ toO!rinoly+i+

Absolute

*. Pre% haemorrhagic stroke

&. schaemic stroke mo

3. C)" damage:neoplasm

+. 8aBor surgery' head inBury or maBor

trauma 3 #eeks

. Acti%e internal: bleeding *mo

<not mense=

. no#n:suspected aortic dissection

1. no#n bleeding disorder

elati%e

*. efractory hypertensio

&. TA mo

3. P, anticoags

+. Pregnant: * #eek post

. Li%er or renal dysfnc

. LP *mo

1. E*0 mins cpr

?. )on compressible %asc

>. Acti%e peptic ulcer dise

*0.Ad%anced li%er disease



ACS

!( and sudden death

HF

Cardiogenic shock

!"D

8

Arrhythmia

Pericarditis

Pseudo-anyeursm and f

rupture

Pericardial effusion

,ngoing chest pain and



Heart Failure

Ma++i&e to"ic *or $5 minute+3



9++entially

#hat - inadequate cardiac out"ut to "er*u+e !ody

#hy

Pre+entation

4iagno+i+

Se&erity

Progno+i+

Management



9++entially

#hat

#hy

Pre+entation

4iagno+i+

Se&erity

Progno+i+

Management

Pre pump Pump Post

Too much bloodeg thyrotoicosis

8Cardiomyopathy!al%ular diseaseDrugs

Arrhythmia8yocarditisCongenital structuralChemo agents

Fyperten AtherosclCoarctati



9++entially

#hat

#hy

Pre+entation

4iagno+i+

Se&erity

Progno+i+

Management



9++entially

#hat

#hy

Pre+entation

4iagno+i+

Se&erity

Progno+i+ 01 mortality within years

Management



9++entially

#hat

#hy

Pre+entation

4iagno+i+

Se&erity

Progno+i+

Management

A t H t * il P l



Acute Heart *ailure- Pulmonaryoedema

You are the FY1 on cardiology You ha&e Qu+t !een !lee"ed Mr+ Pott+ a )6 year old *emale 'ho had "rimary PC thi+ a*a S9M he nur+e hand+ o&er that Mr+ Pott+ i+ !reathle++u" a "in *rothy +"utum and tachy"noeic 0e'+ %



The patient is sat up in

bed leaning for#ards'

she is pale and s#eaty

#ith tachypnoea and she

seems distressed.

Fer chest has fine lung

crackles on auscultation.

G!P is raised.



#hat do you do8



P/4MA0 -hel"

2- o+itionJ u"right i* not already 'ith "illo'+

- BygenJ 155R i* no "re eBi+ting lung di+ea+e

)- iuretic+J Furo+emide 65mg : +lo'ly

+- or"hineNdiamor"hine 2%-%mg : +lo'ly

A- ntiemetic

-- itrate+ G0 +"ray to nitrate in*u+ion i+o+or!ide nitrate



Hel" ho"e*ully'ill ha&e come!y then mayneed an 0:

deci+ion



HF

1 riad to diagno+e ACS

2 reatment acronym M/0A?C- PCNhrom!

$ Com"lication+ o* M -including Heart *ailu6 Acute Heart *ailure - "ulmonary oedema

emergency



Fin

020216 acs and heart failure.pptx

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