cardiology for finals fy1s poornima mohan & ghazal saadat
TRANSCRIPT
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?
“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.
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 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