Cardiology Finals Revision

Andrew DegnanPALI

Wednesday 12th September 2012

Why Cardiology?

Why Cardiology?• 2005

– Paper 1-Heart failure– Paper 2-Unstable angina– Resit 1-Aortic stenosis– Resit 2-Infective endocarditis

and pericarditis• 2006

– Paper 1-Heart failure– Paper 2-Primary prevention

• 2007– Paper 1-Heart failure and

pericarditis– Paper 2-None

• 2010– Paper 1-None– Paper 2-Postural hypotension– Resit 1-Aortic stenosis– Resit 2-Infective endocarditis

• 2011– Mock-Heart failure– Paper 1-None– Paper 2-Infective endocarditis and heart

failure– Resit 1-Acute MI– Resit 2-Postural hypotension

• 2012– Paper 1-None– Paper 2-Unstable angina and postural

hypotension

2012 Mock Paper

Unstable Angina

MEQ 1.8• A 39 year old Asian man was admitted to the medical

admissions unit with pains in his chest and neck. He admitted to smoking 20 cigarettes per day and a blood cholesterol had been measured at 7.2mmol/L (reference range 3.5-5.0mmol/L). His average HR on admission was 90 bpm and his blood pressure was 170/100mmHg. An initial diagnosis of unstable angina was made.

(a) What are his risk factors for coronary artery disease? (2 marks)

MEQ 1.8

• A 39 year old Asian man was admitted to the medical admissions unit with pains in his chest and neck. He admitted to smoking 20 cigarettes per day and a blood cholesterol had been measured at 7.2mmol/L (reference range 3.5-5.0mmol/L). His average HR on admission was 90 bpm and his blood pressure was 170/100mmHg. An initial diagnosis of unstable angina was made.

Risk Factors for CVD

Unmodifiable Factors• Male• Increasing age• Asian decent• Post-menopause• Family History

Modifiable Risk Factors• Smoking• Hyperlipidaemia• Obesity (diet and exercise)• Diabetes• Hypertension• Stress

(b) You decide to admit him to hospital. What drug therapy could he be

started on? List 4 potentially beneficial drugs (2 marks) and give a reason for prescribing each (2 marks).

Immediate Treatment of NSTEMI and UA

• Anti-ischaemic therapy (decrease myocardial oxygen demand)– Nitrates (GTNIV), venodilation, decrease venous return– Beta-blockers, decrease sympathetic drive and so decrease

O2 demand• Anti-thrombotic therapy (prevent further development of

partially occluded thrombus)– Aspirin, prevents platelet aggregation and activation– Clopidogrel, alternative action on platelets. Can be used in

combitaion with or in place of aspirin– Heparin, usually LMWH, breaks down any clots

• Results of blood tests revealed a Troponin T of 0.35ng/ml (normal=unrecordable), peak CK was 180iu/ml (reference range: 25-200iu/ml) on day 2

(c) List the 2 cardinal ECG features of an acute full thickness anterior

myocardial infarction and outline their electrophysiological cause (4 marks)

The Easy Bit

http://en.wikipedia.org/wiki/File:12_Lead_EKG_ST_Elevation_tracing_color_coded.jpg

The Hard Bit

Is it enough to answer with “It just does”?

• ST Elevation– Changes in the action potentials produced by necrotic tissue– Abnormal firing of action potentials leads to early

repolarisation secondary to ischaemia, causing this abnormal wave

• Pathological Q Waves– Any initial downward movement of the QRS is a Q wave.– Pathological Q waves are Q waves developing after MI

which have a width of ≥ 1 small box and a depth > 25% of the total QRS height

– Develop from living tissue behind the infarct which is picked up by the ECG as a downward movement as impulses move away from the anterior leads

Cardiac Enzymes

http://en.wikipedia.org/wiki/File:AMI_bloodtests_engl.png

Discussion Points?

2005 Paper 1

Left Ventricular Failure

MEQ 1.2• A 78 year old man had a large anterior myocardial infarction

three years ago. Initially he made a good recovery, but has had to take a diuretic for ankle swelling since. In the last 2 months he has become short of breath on exertion. You suspect that he has developed left ventricular failure

(a) Give 2 additional symptoms that would support this diagnosis (2

marks)

MEQ 1.2• A 78 year old man had a large anterior myocardial infarction

three years ago. Initially he made a good recovery, but has had to take a diuretic for ankle swelling since. In the last 2 months he has become short of breath on exertion. You suspect that he has developed left ventricular failure

(a) Give 2 additional symptoms that would support this diagnosis (2

marks)

Left Heart Failure

• Exertional dyspnoea• Orthopnoea• Paraxysmal nocturnal

dyspnoea• Fatigue and weakness• Poor exercise tolerance• Cardiac wheeze• Nocturnal cough with frothy

pink sputum• Impaired urine output during

the day and nocturia at night• Impaired metal status• Cold peripheries

Right Heart Failure

• Peripheral oedema• Abdominal discomfort• Weight gain• Anorexia and nausea

Left Heart Failure

• Exertional dyspnoea• Orthopnoea• Paraxysmal nocturnal

dyspnoea• Fatigue and weakness• Poor exercise tolerance• Cardiac wheeze• Nocturnal cough with frothy

pink sputum• Impaired urine output during

the day and nocturia at night• Impaired mental status• Cold peripheries

Right Heart Failure

• Peripheral oedema• Abdominal discomfort• Weight gain• Anorexia and nausea

Left Heart Failure

• Cachexia• Cyanosis• Sweating• Tachopnoea

• Tachycardia• Pulses alternans• Bilateral basal crackles• Displaced apex beat• Extra heart sounds and

murmurs (depends on cause)

Right Heart Failure

• Cachexia• Oedema

• Increased JVP with positive hepatojugular reflex

• RV heave• Hepatomegaly• Ankle oedema• Sacral oedema• Ascities

(b) You arrange for a chest X-ray. Give four features that would support

the diagnosis of left ventricular failure (4 marks)

Adapted from http://www.e-radiography.net/technique/chest/chest_eval.htm

Adapted from http://www.learningradiology.com/archives2007/COW%20267-Pulmonary%20edema-CHF/caseoftheweek267page.html

Adapted from http://en.wikipedia.org/wiki/Kerley_lines

Adapted from http://www.radiologysingapore.com/lectures/plain-films-with-diagnosis-6/

(c) Give 2 neurohormonal mechanisms which may be

activated in heart failure (2 marks)

4 Neurohormonal Mechanisms 1. Sympathetic Nervous System Activity

– Fall in CO detected by baroreceptors, sympathetic drive increases, ↑ HR and BP

2. RAAS– Decreasing renal perfusion activates RAAS which ↑ PVR (angiotensin II)

and blood volume (aldosterone) which both play a role in ↑ BP3. ADH

– Released in response to low BP and release of angiotensin II. ↑ blood volume and hence BP

4. Natriuretic Peptides– Both ANP and BNP. Both inhibit RAAS and so ↓ blood volume and BP.

Beneficial effect, but not released in sufficient enough quantities. BNP=prognostic marker

These all have an effect on…?• Frank Starling Mechanism• Improved venous return improves LV contraction • Preload vs. afterload

And this combination leads to• Symptoms of LV HF• Hypertrophy

(d) If starting this patient on an ACE inhibitor, what precautions would

you take? (3 marks)

Side-effects

• First dose hypotension• Persistent cough• Hyperkalaemia• Renal impairment

• Headache• Dizziness• Fatigue• Nausea

Contra-indications and Cautions

• Hypersensitivity• Bilateral renal artery

stenosis• Pregnancy

• Impaired renal function• Aortic stenosis• Cardiac outflow obstruction• Hypovolaemia• Haemodialysis

Other Precautions

• Check baseline BP (first dose hypotension) and Us+Es (hyperkalaemia, renal dysfunction)

• Start low, tritrate dose up• Continue to monitor Us+Es• Drug interactions

Discussion Points?

2011 Paper 2 (also 2005 Resit 1 and 2010 Paper 2)

Infective Endocarditis

MEQ 2.6A 32 year old woman, who is a known alcoholic and abuser of intravenous drugs, presents to A+E complaining of gradual onset malaise, fever, weight loss and night sweats. She is pyrexial (38.5°). She has a pansystolic murmur which is thought to be a new finding and you suspect she has a diagnosis of infective endocarditis

(a) Name 4 additional clinical signs that may be found on examination in

this patient (2 marks)

MEQ 2.6A 32 year old woman, who is a known alcoholic and abuser of intravenous drugs, presents to A+E complaining of gradual onset malaise, fever, weight loss and night sweats. She is pyrexial (38.5°). She has a pansystolic murmur which is thought to be a new finding and you suspect she has a diagnosis of infective endocarditis

(a) Name 4 additional clinical signs that may be found on examination in

this patient (2 marks)

http://en.wikipedia.org/wiki/File:Acopaquia.jpg

http://en.wikipedia.org/wiki/File:Splinter_hemorrhage.jpg

http://en.wikipedia.org/wiki/File:Osler_Nodules_Hand.jpg

http://medicalpicturesinfo.com/janeway-lesion/

Signs of Infective Endocarditis

• Hands– Splinter haemorrhages– Janeway lesions – Osler’s nodes– Clubbing

Signs of Infective Endocarditis

• Hands– Splinter haemorrhages– Janeway lesions – Osler’s nodes– Clubbing

• Eyes– Roth Spots

http://www.aao.org/theeyeshaveit/optic-fundus/roth-spot.cfm

Signs of Infective Endocarditis• Hands

– Splinter haemorrhages– Janeway lesions – Osler’s nodes– Clubbing

• Eyes– Roth Spots

• Heart– New murmur– Signs of HF

• Others– Abscess– Splenomegaly– Petechia

Agent Route

Strep. Viridans Dental procedures

Staph. aureus IVDU/Thoracotomy/Peripheral lines

Enterococci UTI

Candida Peripheral lines/catheters

Strep. Bovis Colorectal carcinoma

(b)Name the 2 most likely organisms likely to be implicated in infective endocarditis (2 marks)

• Blood (microhaematuria)• Pathology

– Micro-emboli from vegetation on heart valve– Can block vessels in the glomerulus, causing

glomerularnephritis and ARF.– Micro-emboli cause other clinical signs

(c)Your FY2 asks you to dip the urine. What would you expect to find and what is the pathology behind this abnormality? (2 marks)

(d) Name two investigations that are mandatory to confirm your diagnosis

(1 mark)

• Blood Cultures– 3 sets– Different times– Different places

Major Criteria (x2)• Positive blood culture

– Typical organism in 2 separate cultures

– Persistently +’ve over time• Echo evidence of valvular

involvement• New valvular regurgitation

(murmur)

• Echo– Trans-oesophageal more

sensitive– >2mm for trans-thoracic

Minor Criteria (x5)• Risk factors • Fever• Vascular phenomenon• Immunological phenomenon• Positive blood cultures not

meeting requirement for major criteria

• Echo evidence not meeting requirement for major requirement

Dukes Criteria

1 Major + 3 Minor

Environment favourable to Infection

• IVDU• Dental surgery• Thoracotomy• Catheterisation• Peripheral/central lines• Immunosuppression

Allow Implantations and Growth of Organism

• Prosthetic heart valve• Pre-existing valvular disease

– Rheumatic– Acquired– Congenital

(e)Other than IVDU, name 4 risk factors for this condition (2 marks)

On further examination you can also hear the pansystolic murmur. This is loudest at the left sternal edge and you demonstrate the JVP is elevated with giant “v” waves. In addition she also has tender pulsatile hepatomegaly.

(f) What is the most likely cardiac lesion to be responsible for this, given

the above history and examination? (1 mark)

On further examination you can also hear the pansystolic murmur. This is loudest at the left sternal edge and you demonstrate the JVP is elevated with giant “v” waves. In addition she also has tender pulsatile hepatomegaly.

(f) What is the most likely cardiac lesion to be responsible for this, given the

above history and examination? (1 mark)

Tricuspid Regurgitation

Murmurs Systolic

• Loud• Radiate• Ejection Systolic

– Aortic Stenosis• Pansystolic

– Mitral Regurge

Diastolic• Quiet• Accentuated by

manoeuvres• Early-mid diastolic

– Aortic regurge• Late diastolic

– Mitral stenosis• Remember DARMS

Discussion Points?

Thank You!