Cardiology Revision 2014

Dr P BanerjeeConsultant Cardiologist

University Hospitals Coventry & Warwickshire

Picture slides ECG reading How to examine the CVS Assessment of patient with breathlessness,

chest pain, palpitations, syncope

51 yr old man Admitted with pyrexia, shivering and feeling

unwell Has a heart murmur on examination

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

53 yr old lady Presents to clinic with SOBOE Has Hx of rheumatic fever Cardiac murmur audible on auscultation

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.

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

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

65 yr old Admitted with severe central CP for 2 hrs Sweaty and clammy BP 90/60, Pulse 50/min, SR

Aspirin 300mg + Prasugrel 60 mg loading IV morphine Primary PCI

49 yr old smoker CP for 30 min, improved with IV Morphine Now comfortable, normal BP and pulse Troponin T elevated

Therapeutic clexane Aspirin + clopidpgrel Atorvastatin 80 mg od Beta blocker IV Nitrates and Tirofiban if needed PCI within max 72 hrs

76 yr old man Severe CP 7 days ago for 3 hrs Admitted now with SOB, no CP

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%)

25 yr old lady, non smoker Flu like illness for 7 days Sharp CP on inspiration for 24 hrs, better on

sitting forward

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

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

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

Gentleman suddenly has cardiac arrest again

Emergency DC shock Check all as for VT ICD

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.

Carotid sinus massage, valsalva IV Adenosine, IV Verapamil DC shock-usually not required

74 yr old man Severe central CP for 2 hrs with sweating Stable BP and pulse

Treat as STEMI

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

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

CHA2DS2-VASc score for stroke risk in atrial fibrillation

Feature Score

Congestive Heart Failure 1

Hypertension 1

Age >75 years 2

Age between 65 and 74 years

1

Stroke/ TI A/ TE 2

Vascular disease (previous MI , peripheral arterial disease or aortic plaque)

1

Diabetes mellitus 1

Female 1

Later her ECG changed ? Any change in management

Management same as for atrial flutter New agents for oral anticoagulation in non

valvular AF: Dabigatran, Rivaroxaban

Asymptomatic young and fit man has had these ECGs as part of his employment check

Not indications for pacing

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

Indications for permanent pacing

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

Facies: malar, elfin, moon Corneal arcus, xanthelasma, xanthomas Pulsations Scar marks Prominent veins

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 thrill-

systolic Pulmonary hypertension: RV apex,

Parasternal heave, palpable P2

Heart sounds: S1, S2, Split Murmurs Added sounds; S3, opening snap

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

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

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

This gentleman has rheumatic mitral stenosis

with pulmonary arterial hypertension, tricuspid regurgitation, right heart failure and atrial fibrillation.

Breathlessness Palpitations Chest pain Syncope Oedema Fatigue

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

Orthopnoea PND Exercise tolerance- NYHA CLASS Accompanying symptoms Causes

Heart causes Lung causes Obesity Anaemia Pulmonary hypertension Detraining

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)

COPD, Asthma, Pulmonary fibrosis, obstructive sleep apnoea

Hx of wheeze, smoking, asbestos exposure, Amiodarone, snoring

Concomitant diseases like connective tissue diseases, sarcoidosis

Signs of heart failure, S3, murmurs Reduced breath sounds, obliteration of

liver/cardiac dullness, rhonchi, end- inspiratory crackles at both lung bases

Bloods,ECG, CXR, Echo, ETT,Coronary angio Full PFTs, CT chest, CTPA, V/Q scan Sleep studies

Heart Failure: Diuretics, ACE/ARBs, B-blockers, Digoxin, Spironolactone

COPD: Bronchodilators, steroid inhalers, stop smoking

Sleep apnoea: nasal CPAP, weight reduction

PPH: Nifedipine, Amlodipine, Warfarin, Prostacyclin infusion, Viagra (Sildenafil), Bosentan

A 50 year old gentleman complains of chest pain with associated flu like illness

IHD/ MI Oesophageal pain Musculoskeletal pain Pneumonia/ chest infection Pericarditis PE

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

Bronchial breathing + dullness/ crackles Pericardial rub Chest wall tenderness Epigastric tenderness Signs of DVT

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

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

80 year old man has blacked out twice in 3 months

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

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

HR, ?AF, LS BP, murmurs, Neck movements,

Carotid bruit, full neuro exam Carotid sinus massage

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

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,

Atrial and ventricular ectopics Valve disease: AR, MR Tachyarrhythmias: PAF, SVT, rarely VT Anxiety Hyperthyroidism Excessive caffeine intake

Missed beats or racing heart Syncope, presyncope Sudden onset and sudden termination Paroxysmal or constant Caffeine intake

24 hr tape TFTs Echo

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

HOPE YOU DO VERY WELL