Cardiology for Finals

FY1s Poornima Mohan & Ghazal Saadat

Overview

• Scars• Acute coronary syndromes• Valvular heart disease• Infective Endocarditis• Dextrocardia• Arrhythmias

Midline sternotomy scar

What is this scar?

Which 3 procedures would cause this scar?

What else would you look for?

Grafts

What could this be?What are the indications?

Where else should you look?

“We have this patient with chest pain”

66 year old with a background of DM type 2, hypertension and a 40 pack yr smoking hx. Day 1 post inguinal hernia repair.

Has been having central crushing chest pain for last 15 minutes. No relief from GTN. Hot & sweaty, vomited twice.

Obs: BP- 120/60 P-75 RR- 24 Sats 98% on RA

What ECG features suggest an STEMI??

ST elevation in 2mm in 2 or more contigous limb leads ST elevation in 2 or more contigous chest leads

New onset LBBB Posterior MI

.What features suggest an to NSTEMI ???

ST depression and /or T wave inversion in 2 or more leads. Risk is assessed using the TIMI score.

What does this ECG show?

ManagementWhat would you do as an F1?1) Assess haemodynamic stability2) oxygen(?) 3) Initiate ACS protocol4) Nitrates

5) Analgesia

STEMI - Primary PCI NSTEMI – Risk assessment and PCI Unstable angina – Functional Testing +/- Angiogram

Universal Secondary Prevention and Cardiac Rehabilitation

FUNCTIONAL TESTING

1) EXERCISE TOLLERANCE TEST

2) CT CALCIUM SCORING

4) STRESS ECHO

3) MYOCARDIAL PERFUSION SCAN

Valvular heart disease • Common exam question

• Can find lots of patients with valve replacement • Things to know are - Which valve - What the cause could have been - Clinical signs - Basic principles of management

• Questions about complications of surgery

“ A 72 year gentleman man presents with a history of collapse as he was rushing up a hill to catch a bus.

There was no LOC. He reports no associated weakness/numbness/tingling in the limbs, visual

disturbance, slurred speech, headache, chest pain, or palpitaions. This had never occurred before.

He has noticed that he is increasingly SOB of late whilst gardening/ doing house-work etc.

He has no previous cardiac history. He suffers from hypertension and gout.”

Scenario 1

Aortic Stenosis

1) Senile calcification

2) Biscuspid Aortic valve

3) strep associated – Rheumatic fever

Symptoms Exertional : Dysponea, syncope angina

Features of AS on examination ????

Causes

Features on Examination narrow pulse pressure

slow rising pulse

LV heave

Forcefull apex beat

ESM radiating to the carotid- heard all over the precordium

Features of left ventricular dysfunction

Severe Stenosis → 1) Narrow PP 2) Quite or loss of S2

DDX for an ESM → 1) HOCM 2) VSD 3) Aortic sclerosis.

Management : TAVI vs Open AVR +/- CABG?

Exam tip : Which heart sound is metallic in an AVR??

Mitral Regurgitation

Causes

“ A 72 year old lady presents with a history of increasing SOB, orthoponea and palpitations over a few months. She has a history of Angina, Hypertension. She is found to be in Atrial fibrillation”

Valve Annulus Leaflets Papillary Muscle

ACUTE Infective Endocarditis

MyocardiaIschemia

CHRONIC Function – Chronic ischemia (post MI)

CCF (LV dilatation)

Prolapse

Connective tissue disorders

Amyloid- infiltration of the chords.

Mitral Regurgitation Clinical features

AF

small volume pulse

displace apex beat

loud PSM radiating to the axilla

bibasal crepitations

• MGX: mitral valve clip vs Open MVR +/- CABG. Discuss indication. Decision is often based on a TOE.

Mitral RegurgitationManagementConsider patients pre-morbid state Medical : Diuresis

Rate control

Anti coagulation

ACE inhibitors and B-blockers. Surgical : Assessment with an TTE / TOE and angiogram.

Mitral clip or an open Valve Replacement

Mitral Stenosis Cause: Congenital

Rheumatic Heart disease

Senile Degeneration

Clinical Signs

Malar flush

Irregular pulse

Tapping apex beat – palpable 1st HS

Left parasternal heave / Enlarged LA

Loud 1st heart sound

Opening snap

Mid-diastolic murmur.

On investigation CXR- Enlarged left atrium,

calcified valves and pulmonary

oedema.

ECG – p-mitrale and AF

Management

Medical : Rate control (digoxin)

Anti-coagulate

Valvuloplasty

Surgical : Valve replacement

Valveotomy (open / closed)

Aortic Regurgitation Causes : Acute (inf. Endocarditis)

Chronic: Connective tissue disorders (RA), Rheumatic heart disease, syphilitic heart disease . Aortitis: Marfans / Anklysing spondylitis

Clinical features: Wide PPcollapsing pulse – hyperdynmaic apex beatEponymous signsEarly diastolic murmur

Aortic Regurgitation

Other causes of a collapsing pulse? Anything that causes a high circulating volume:

Pregnancy

Anaemia

PDA

Thyrotoxicosis

Management Valve replacement vs conservative management

Murmurs SummaryAortic Stenosis

Aortic regurgitation

Mitral Stenosis

Mitral regurgitation

Pulse Slow-rising Collapsing Often AF

Apex beat Forceful, not displaced

Displaced Tapping, not displaced

Thrusting, +/- displaced

Murmur Ejection systolic

Early diastolic Rumbling mid-diastolic

Pansystolic

Best heard Aortic area Tricuspid area Mitral area Mitral area

Radiation Carotids Axilla

Complications of Valve replacements

• INFECTION : early vs late.

• FAILURE OF VALVE: early vs late

• DISLODGEMENT

• THROMBUS FORMATION vs HAEMMOHRAGE

Management

• What would you do as an F1?• ECG• CxR• Inform seniors• Echo• Conservative: if AF, rate control. Diuretics

improve symptoms• Surgical: Valve repair/ replacement

“ A 54 year old lady initially presents with an abscess.

She vascular infarcts on CT and is admitted to the acute stroke unit. She has no major risk factors for a CVA.

On doing base line bloods she has CRP 300Urine dip show blood +++

She’s on the stroke ward, she has some left sided weakness. Obs stable, and apyrexial so far “

What is the diagnosis???

Infective endocarditis

What would you look for ???

What would you look for?

• Signs of sepsis• New murmur or

change in existing murmur

• Microscopic haematuria, ARF, splenomegaly

• Embolic features e.g. abscesses

What would you do as an FY1?

• Bloods• Blood cultures• ABG• Urine dip & MCS• CxR• ECG• Echo (TOE)• Inform seniors

Common questions

1. Risk factors?Lifestyle factors (IVDU), cardiac lesions, aortic or mitral valve

disease, PDA, VSD, coarctation, prosthetic valve

2. Organisms?• Strep viridans (35-50%), HACEK (Haemophilus, actinobacillus,

cardiobacterium, Eikenella)• Fungi • SLE – Libman-Sachs endocarditis

3. Criteria for Diagnosis?

Duke criteria for diagnosis

2 major OR 1 major and 3 minor OR all 5 minor criteria

Major• +ve blood culture

typical organism in 2 separate cultures or persistently +ve blood cultures

• Endocardium involved• Positive echo or new valvular regurgitation

Minor • Predisposition• Fever >38C• Vascular/immunological signs• +ve blood cultures that do not meet major criteria• +ve echo that does not meet major criteria

Management

• MDT decision • Conservative management: Long-term

antibiotics and serial echos• Surgical management: Valve replacement

Dextrocardia A congenital defect where the heart is situated on the right side of the body

2 types:

Isolated dextrocardia – heart placed further to the right in thorax, associated with other cardiac abnormalitiesDextrocardia situs inversus – heart placed to the right side as a mirror image

Dextrocardia CxR

Dextrocardia ECG

THANK YOU