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Cardiology Cases

Topic Page Ischaemic Heart Disease 2 Valvular Heart Disease 10 Infective Endocarditis 15 Cardiac Rhythm Disorders 18 Hypertension 21 Heart Failure 24 Cardiomyopathies 27 Aortic Dissection 29 Pericardial Disease 31 Appendices 33-34

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ISCHAEMIC HEART DISEASE KEY AREAS TO BE COVERED

The atherosclerotic plaque Plaque rupture and thrombosis in the setting of acute myocardial infarction and

unstable angina Clinical features of stable angina, unstable angina and acute myocardial infarction Drug therapy of angina Management of acute myocardial infarction, including the use of thrombolytic

drugs Complications of acute myocardial infarction, including ventricular fibrillation Resuscitation including defibrillation of ventricular fibrillation Cardiac investigations - ECG, exercise stress test, echocardiography, angiography Interventional cardiology - PTCA / stent implantation Coronary artery bypass grafting

LEARNING OBJECTIVES

On completion of the attachment the student should be able to: List the recognised risk factors for the development of coronary atherosclerosis

and explain the pathological processes involved in plaque progression and the development of unstable angina / acute myocardial infarction

Describe the anatomy and physiology of the coronary circulation and its relevance to acute myocardial infarction

Explain the physiological basis of the regulation of cardiac output and blood pressure in both the normal and the diseased heart

Describe the typical clinical symptoms of a patient presenting with angina / acute myocardial infarction, the potential complications associated with acute myocardial infarction, and the management of these conditions.

List the major classes of drugs available for the treatment of ischaemic heart disease and discuss the indications for and potential side-effects of these drugs [β-blockers, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, nitrates, potassium channel activators, anti-platelet agents (aspirin, clopidogrel), fibrinolytic drugs (streptokinase, t-PA), heparins (unfractionated, low molecular weight), oral anticoagulants (warfarin), and statins].

The student should have observed and / or be able to describe the following procedures:

Recording of 12 lead electrocardiogram Exercise stress test (where possible, with radionuclide perfusion imaging) Cardiac catheterisation (and where possible PTCA) {for those students attached

to hospitals other than the Royal Victoria Hospital and Belfast City Hospital a visit to the Cardiac Catheterisation laboratories can be arranged after discussion with your Supervising Consultant}

The student should be able to interpret the following investigations:

Common / basic ECG abnormalities: acute myocardial infarction presenting with ST elevation

Common CXR abnormalities: cardiomegaly, pulmonary oedema Results of cardiac enzyme/marker estimations: CK, CK-MB, AST, LDH,

Troponins

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CASE 1 A 52 year old man is referred by his family doctor to the Cardiac Outpatient Department complaining of recurrent chest discomfort on exertion over the preceding six months. His father died age 58 years of a myocardial infarction. He works as a Taxi Driver and smokes 20 cigarettes per day. He is married with four children. There is no other medical history of note. He is not on any regular medication although his family doctor has prescribed GTN for sublingual use as required. 1. What additional information would you wish to obtain from the patient? 2. Which investigations would you wish to perform on this patient? Should this patient

have an exercise stress test performed or should the severity of his disease be judged by clinical history and response to therapy?

3. What general advice would you give him? 4. What are the therapeutic options for the management of this patient? Discuss the

different pharmacological therapies and their potential side-effects.

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5. Are there any implications for this gentleman’s employment? The gentleman has an exercise stress test performed using a standard Bruce protocol. He exercises for only 5 minutes ( 4 METS) and stops because of chest pain. At peak exercise there is 4mm ST depression noted on the ECG in leads V4 – V6, I and aVL, which normalises ten minutes into the recovery period. 6. What is meant by the term MET? 7. Should this gentleman have any further investigations performed and, if so, which

investigations would you recommend?

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CASE 2 A 61 year old gentleman presents to the Accident and Emergency Department with a two hour history of severe central chest pain unrelieved by his usual sublingual GTN therapy. He gives a two year history of infrequent chest discomfort and states that his family doctor had been treating him for mild angina. He has been a heavy smoker for many years and was diagnosed as suffering from diabetes mellitus six months earlier (commenced on diet). In his past history he had had appendectomy as a child. On examination he appears pale and sweaty and is in obvious distress with pain. His pulse rate is 110/min, BP is 130/80, the heart sounds are unremarkable and there are a few bibasal crepitations on chest examination. An ECG was performed and is shown as Figure 1. 1. What is the diagnosis? 2. What is the appropriate management of this condition? Are there any additional

specific questions which you would like to ask the patient before administering treatment?

3. What are the potential adverse effects of these therapies?

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Figure 1

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Shortly after admission to the Cardiac Unit the patient becomes suddenly unresponsive and pulseless. A monitor strip is shown below.

4. What is the diagnosis and how would you manage the situation? 5. The gentleman suffers from maturity onset diabetes which is normally controlled by

diet. What will happen to his blood sugar control in the immediate post-infarction period?

Over the next 36 hours the patient complains of mild dyspnoea and his CXR shows pulmonary congestion? At this time he does not have any further chest pain. 6. How should heart failure be managed in this situation?

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On the morning of the third day after admission he complains of further chest pain. He states that the pain is different from that at the time of presentation and is worse when he breathes. 7. What is the most likely diagnosis and how would you manage the situation? List other complications which can commonly or occasionally occur after acute myocardial infarction? His condition improves over the next few days and he is fit for discharge on the eighth day following admission. 8. Are there any other investigations which you would like to perform pre discharge? Which treatments have been shown to improve prognosis after myocardial infarction? 9. What advice will you give him pre discharge? Is there any evidence to support a role for cardiac rehabilitation in this situation? 10. The patient’s wife wishes to discuss her husband’s condition with you pre-discharge.

What information will you impart to the wife?

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Additional Reading

Relevant pharmacological texts on thrombolytic therapy.

Landmark articles on the role of thrombolytic therapy in the management of acute myocardial infarction – there is a huge number of studies published (ranging from ASSET through GISSI, GUSTO, and ISIS to TAMI and TIMI). Three important studies are listed below. Details of further studies can be accessed via Medline.

o ISIS II (Second International Study of Infarct Survival) Collaborative

Group: Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction. Lancet 1988;2:349-360.

o ISIS III (Third International Study of Infarct Survival) Collaborative

Group: A randomised comparison of streptokinase vs tissue plasminogen activator vs anistreplase and of aspirin plus heparin vs aspirin alone among 41,299 cases of suspected acute myocardial infarction. Lancet 1992;339:753-770.

o The GUSTO Investigators: An international randomised trial comparing

four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329:673.-682.

Recent publications on primary coronary intervention for myocardial infarction.

o Andersen HR et al. A comparison of coronary angioplasty with

fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003;349:733-742.

o Jacobs AJ. Primary angioplasty for acute myocardial infarction – is it worth the wait? N Engl J Med 2003;349:798-800.

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VALVULAR HEART DISEASE KEY AREAS TO BE COVERED

Aetiology of valvular heart disease Symptoms in patients with valvular heart disease Cardiac response to pressure / volume overload Clinical examination in the following situations:

o Aortic stenosis / aortic incompetence o Mitral stenosis / mitral incompetence o Tricuspid incompetence

Echocardiography (transthoracic / transoesophageal) - its role in assessment of valvular disease

Clinical management Surgical therapy - prosthetic valves Antibiotic prophylaxis

LEARNING OBJECTIVES

On completion of the attachment the student should be able to: Summarise the characteristic clinical findings in patients with aortic stenosis /

aortic incompetence / mitral stenosis / mitral incompetence / tricuspid incompetence, the common aetiologies of these conditions, the investigations used in assessing the severity of the valvular disease, and the surgical procedures available for management of valvular disease

List the major classes of drugs available for the treatment of valvular heart disease and discuss the indications for and potential side-effects of these drugs [diuretics, β-blockers, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, nitrates, anti-platelet agents (aspirin, clopidogrel), heparins (unfractionated, low molecular weight), oral anticoagulants (warfarin)].

The student should have observed and / or be able to describe the following procedures:

Echocardiogram The student should be able to interpret the following investigations:

Common CXR abnormalities: ‘mitral’ heart

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CASE 3 You are called in the Cardiac Ambulance to see a 75 year old lady who has collapsed while shopping in town. For several years she has been treated by her family doctor for angina. She states that she felt unwell while carrying her shopping. She took two puffs of her GTN spray and then felt dizzy before collapsing to the ground. She did not sustain any injuries and by the time you see her she feels well again. She takes 100 μg L-thyroxine daily for hypothyroidism and has been on aspirin 75mg daily following one episode of amaurosis fugax eight months earlier. On examination of the praecordium you note a loud systolic murmur radiating to the neck. 1. What are the potential diagnoses in this situation? 2. Which investigations should be carried out? The patient is admitted to hospital for further investigations. The ECG shows sinus rhythm and there is evidence of left ventricular hypertrophy. An echocardiogram is performed and shows thickening and reduced movement of the aortic valve with a peak gradient across the aortic valve of 90mmHg and moderate concentric left ventricular hypertrophy. 3. What are the potential mechanisms responsible for this lady’s collapse and which is

the most likely in light of the clinical information available? 4. What is the appropriate management for this lady?

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5. List the aetiological causes of aortic stenosis and which is the most likely in this age group. 6. This lady has been complaining of angina-like symptoms. Discuss the potential causes of such symptoms in this situation.

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CASE 4 A 52 year old lady is admitted to the Medical Unit with a history of increasing dyspnoea over the previous two months. She is a non-smoker and does not complain of any chest pain. As a child she had been off school for several months because of ‘growing pains’. She had required a heart operation at the age of 20 years. She has since remained well and did not experience any difficulties during her three pregnancies (26, 24, 21 years earlier). On examination her pulse is irregular and the radial rate is 90 beats/min. Praecordial examination shows a left thoracotomy scar and auscultation reveals both a systolic murmur radiating to the axilla and a mid-diastolic murmur audible just internal to the apex. 1. What is the likely diagnosis? 2. How would you investigate this lady? The ECG confirms the clinical impression of atrial fibrillation. The ventricular rate at rest is 100/min. 3. What are the potential complications associated with atrial fibrillation? 4. Discuss the therapeutic options for management of atrial fibrillation.

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The echocardiogram confirms mitral valve disease with moderate mitral regurgitation and moderate mitral stenosis (estimated valve area 1.3 cm2). The pulmonary arterial pressure is estimated at 40mmHg. 5. Why should this lady have evidence of pulmonary hypertension? What are the

mechanisms involved? 6. What is the appropriate long term management for this lady?

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INFECTIVE ENDOCARDITIS KEY AREAS TO BE COVERED

Symptoms and clinical findings in patients with endocarditis Common aetiological organisms Investigations, including the role of echocardiography Management - antibiotic therapy, the role of surgery Prevention - antibiotic prophylaxis, dental hygiene

LEARNING OBJECTIVES

On completion of the attachment the student should be able to: Summarise the clinical features of infective endocarditis, list the common

microbiological organisms involved in this disease process, and discuss appropriate management of this condition, including its prevention

List the major classes of antibiotics available for the treatment of infective endocarditis disease and discuss the indications for and potential side-effects of these drugs [ref section 5 of British National Formulary].

The student should have observed and / or be able to describe the following procedures:

Echocardiogram, showing a valvular vegetation

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CASE 5 A 47 year old farmer is referred for admission complaining of lethargy, sweats, shivering episodes and mild dyspnoea over the previous four weeks. He had previously been fit and healthy although he states that he had been told at a routine medical examination some years earlier that he had a soft murmur. He has not been on any recent foreign trips. On examination his temperature is recorded at 38.4 0C, a few splinter haemorrhages are present and a loud early diastolic murmur is audible. 1. What is the most likely diagnosis here? Give a list also of potential differential

diagnoses. 2. How would you proceed to investigate and manage this patient? The day following admission you receive a call from the bacteriologist who says that an organism has been grown from several blood culture bottles. 3. List the most common organisms associated with infective endocarditis. 4. Discuss appropriate pharmacological therapy of the condition.

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The patient initially progresses well but two weeks following admission he develops recurrent pyrexia. 5. Discuss potential mechanisms for this pyrexia. 6. What are the indications for surgical intervention in the setting of infective

endocarditis? Additional Reading 1. British National Formulary: Section 5, Table 1: Antibacterial Therapy – Cardiovascular System Section 5, Table 2: Antibacterial Prophylaxis - Endocarditis

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CARDIAC RHYTHM DISORDERS

KEY AREAS TO BE COVERED

Anatomy of the cardiac conduction system Bradycardias / heart block Atrial tachycardia, including atrial fibrillation and atrial flutter - aetiological

factors, complications and management Atrioventricular tachycardia - nodal / accessory pathways, Wolff-Parkinson-

White syndrome Ventricular tachycardia Anti-arrhythmic drugs Pacemakers Electrophysiological Studies

LEARNING OBJECTIVES

On completion of the attachment the student should be able to: List the common causes of and discuss the management of atrial and ventricular

rhythm disorders, including both bradycardias and tachycardias List the major classes of drugs available for the treatment of valvular heart

disease cardiac arrhythmias [β-blockers, calcium channel blockers, digoxin, amiodarone, adenosine, lidocaine].

The student should have observed and / or be able to describe the following procedures:

Ambulatory monitoring Cardiopulmonary resuscitation, including defibrillation DC cardioversion Pacemaker implantation / Electrophysiological Studies

The student should be able to interpret the following investigations:

ECG abnormalities: atrial fibrillation / ventricular fibrillation / heart block / Wolff-Parkinson-White syndrome

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CASE 6 A 77 year old lady is referred following a collapse in which she sustained a fractured wrist and facial bruising. She has been in good health throughout her life and apart from pregnancy has not previously been in hospital. She is a widow who lives alone approximately two miles from the local village. She normally drives her car to do the shopping and usually plays golf one to two times per week. She is not on any regular medication. The admitting physician is concerned as her pulse rate is rather low at 30 beats / min. Examination of the praecordium reveals only a soft systolic murmur. An ECG confirms the presence of complete heart block. The fractured wrist is undisplaced and is treated with a standard plaster cast. 1. How would you manage the lady in this acute setting? What are the causes of

conduction system disease? A permanent pacemaker is implanted and the patient mobilises well. 2. How does an artificial pacemaker work? What follow-up is required for a patient with

a permanent pacemaker? 3. When will she be able to drive again? 4. How would you arrange the discharge of this lady from the hospital and what

additional services could be mobilised to ensure that she could safely return home?

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CASE 7 A 20 year old girl presents to the Emergency Department complaining of palpitations for the past hour. She has had recurrent palpitations over the past three years but the attacks normally last up to 10 minutes and have previously abated spontaneously. On this occasion she also complains of mild shortness of breath. On examination she has a pulse rate of 180 beats per minute and her blood pressure is normal at 110/84. The remainder of the examination is unremarkable. An ECG is recorded and confirms a heart rate of 180 / min with a regular narrow complex rhythm. 1. What is the most likely diagnosis? 2. How would you manage the tachyarrhythmia in the acute situation? 3. What are the long term management options for this problem?

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HYPERTENSION

KEY AREAS TO BE COVERED

Definition of hypertension and epidemiological features Causes of hypertension Investigation of hypertension Non-pharmacological therapy Drug therapy

LEARNING OBJECTIVES

On completion of the attachment the student should be able to: Summarise the causes of hypertension and discuss the investigation and

management of patients with hypertension List the major classes of drugs available for the treatment of hypertension and

discuss the indications for and potential side-effects of these drugs [diuretics, β-blockers, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, nitrates, α-blockers].

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CASE 8 A 37 year old gentleman is referred as his family doctor has had difficulty in achieving optimal control of the patient’s hypertension. The patient had been noted to be hypertensive during a routine medical examination for insurance purposes six months earlier. He had been tried on several medications, including a β-blocker and calcium antagonist but these had either proved ineffective or the patient had stopped taking them because of adverse effects. 1. Discuss the normal mechanisms involved in regulation of blood pressure. 2. What is hypertension? 3. List the common causes of hypertension and the appropriate methods of investigation. 4. Describe how you would investigate and manage this patient?

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5. Discuss non-pharmacological therapy of hypertension. 6. What are the potential complications of uncontrolled hypertension? Additional reading

European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertension 2003;21:1011-1054

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003;289:2560-2571.

1999 World Health Organization – International Society of Hypertension Gudelines for the Management of Hypertension. J Hypertension 1999;17:151-183.

British Hypertension Society guidelines for hypertension management 1999: summary. BMJ 1999;319:630-5.

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HEART FAILURE

KEY AREAS TO BE COVERED

What is heart failure? Congestive heart failure / left ventricular failure / pulmonary oedema Acute and chronic heart failure Epidemiological features Appropriate Investigation Neurohormonal responses Management of heart failure – diuresis versus vasodilatation Prognosis

LEARNING OBJECTIVES

On completion of the attachment the student should be able to: Describe the typical clinical features and management of both acute and chronic

heart failure List the major classes of drugs available for the treatment of heart failure and

discuss the indications for and potential side-effects of these drugs [diuretics, β-blockers, ACE inhibitors, angiotensin receptor blockers, nitrates, digoxin, inotropic agents].

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CASE 9 A 67 year old man is admitted to the Emergency Department at 3am in acute respiratory distress. He is unable to speak but appears very ill, cold and clammy. His wife, who has accompanied the patient, states that her husband had woken complaining of feeling short of breath and that his condition had deteriorated over the subsequent 30 minutes. She had called an ambulance and the ambulance men had administered oxygen during the transfer to the hospital. She also stated that her husband had not complained of chest pain but that he had had a myocardial infarction four years earlier from which he had appeared to have made a good recovery, although she had been told at that time that he had sustained a moderate amount of heart muscle damage. 1. What is the likely diagnosis? Give a list of potential differential diagnoses. 2. Which emergency investigations would you like to perform? 3. What is your emergency management of the situation? The patient responds well to your therapy in the Emergency Department and is admitted to the Cardiology Unit. 4. Which investigations would you like to perform? What is your long term treatment

plan for this gentleman?

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The patient has an echocardiogram performed and the report states that his left ventricular ejection fraction is 30%. In addition, moderate mitral regurgitation is also noted. 5. What is meant by the term ejection fraction? What is the normal left ventricular

ejection fraction? 6. Why should this gentleman have associated mitral regurgitation?

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CARDIOMYOPATHIES

KEY AREAS TO BE COVERED

Classification of the cardiomyopathies - hypertrophic / dilated / restrictive The sarcomere Aetiology / Mendelian inheritance in some forms of cardiomyopathy Investigation and Management

LEARNING OBJECTIVES

On completion of the attachment the student should be able to: List the different types of cardiomyopathies

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CASE 10 You are asked to see the parents and sibs of an 18 year old university student who had died suddenly while playing football some weeks earlier. The student had had no past medical history of note. A post-mortem examination had been carried out and the relatives were told that he had died of a cardiomyopathy and that this condition was inherited in some cases. 1. List the types of cardiomyopathies 2. Which inheritance patterns have been described for cardiomyopathies? 3. How would you investigate the surviving family members?

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AORTIC DISSECTION

KEY AREAS TO BE COVERED

Clinical presentation and differentiation from acute myocardial infarction Aetiology, including discussion on Marfan Syndrome Investigation: transoesophageal echocardiography vs CT scan vs MRI Management: surgical vs medical Control of blood pressure Complications and prognosis

LEARNING OBJECTIVES

On completion of the attachment the student should be able to: Summarise the aetiology, clinical features and management of aortic dissection

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CASE 11 A 38 year old man presents with a sudden onset of severe chest and interscapular pain. He has not experienced any similar pain in the past. He has been diagnosed as suffering from Marfan syndrome but is not on any regular medication. On examination he is in obvious distress with pain. His BP is recorded at 142/90. His peripheral pulses are all present. Auscultation of the praecordium reveals a soft early diastolic murmur audible at the left sternal edge. 1. What are the diagnostic features of Marfan syndrome? How is this syndrome

inherited and what is the responsible gene? 2. Which investigations would you use to confirm or refute your clinical diagnosis of

aortic dissection? 3. Is a blood pressure of 142/90 acceptable in this situation? 4. Why does this gentleman have an early diastolic murmur audible? 5. How would you manage this situation?

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PERICARDIAL DISEASE

KEY AREAS TO BE COVERED

Aetiology and clinical presentation of acute pericarditis Aetiology and clinical presentation of pericardial effusion Clinical signs: pulsus paradoxus, Kussmaul’s sign Constrictive pericarditis

LEARNING OBJECTIVES

On completion of the attachment the student should be able to: List the clinical features of acute pericarditis / pericardial effusion / constrictive

pericarditis

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CASE 12 A 56 year old lady presents with malaise and increasing shortness of breath over the preceding two to three weeks. In her past medical history she had had surgical removal of a breast lump three months earlier. The Casualty Officer arranged for a chest X-ray to be performed This shows cardiomegaly and you are asked to see the patient as a possible diagnosis of pericardial effusion. 1. What are the specific physical signs which you must look for on clinical examination? 2. Which investigations would you use to confirm or refute your clinical diagnosis of

pericardial effusion resulting in tamponade? 3. Pericardiocentesis is performed by the Consultant Cardiologist and you are asked to

send the appropriate samples to the laboratory. Which tests will you request?

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APPENDIX 1

CASE HISTORY - CARDIOLOGY

Notes for Teachers and Students

The student should submit one Case History during the Cardiology attachment. The Case History should contain the following: History and Examination:

- as is standard for all cases (DO NOT LIST PATIENT’S NAME / ADDRESS) - where part of the examination is not performed or not feasible (for example, full neurological examination during the early days after myocardial infarction) then please simply state that the examination was not carried out and state the reason - drugs should be listed (in CAPITAL LETTERS) according to their generic name and the indication for the drug should be listed

Problem List and Differential Diagnosis: - list all the patient’s problems (for example: 1. Chest pain – possible myocardial infarction; 2. Diabetes mellitus; 3. Smoker; 4. Urinary frequency – possible urinary tract infection; 5. Painful left knee – possible osteoarthrosis; 6. Poor housing; 7. Lives alone etc) - state the likely differential diagnoses (usually 3 to 6) for the main medical problems in your patient rather than simply listing all the possible causes

List Appropriate Investigations

- also give the results of these investigations in your patient (with the appropriate reference range for the laboratory results) and offer interpretation of the results

Management

- discuss the way in which your patient was managed Discussion

- you should centre this on your patient and relate the presentation / clinical findings / investigations / management to the standard descriptions of the condition and also to your additional background reading – remember that the most up-to-date information will be available in journals rather than older textbooks (please supply details of references).

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APPENDIX 2 Assessment of the Case History

CRITERION REFERENCE MARKING SCHEME

MARK RANGE CRITERIA

8 – 10

7

6

5

1 - 4

HISTORY – all aspects covered in an accurate, focussed and structured layout, with relevant, positive and negative features included and irrelevant material omitted. EXAMINATION – FOCUSSED To include all relevant features and evidence that all possible clinical abnormalities were CONSIDERED. CLINICAL ACUMEN Ability to interpret clinical findings. KNOWLEDGE High level of knowledge of disease, pathophysiology, therapeutics and pharmacology related to the patients’ conditions. Most of above but with minor deficiencies in history, examination or other features. Occasional significant deficiencies. eg. (part of history omitted, long or irrelevant material included). Significant Omissions, missed or incorrect clinical signs. No application of commentary to patient. Presentation of adequate standing only. Major deficiencies in 1 or 2 areas. Significant deficiencies in many aspects. Poor knowledge of disease or management issues including pharmacology and therapeutics.