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CARDIOLOGY UNIT PRESENTATION

Nwalozie J.C. 17/03/2014. CARDIOLOGY UNIT PRESENTATION. Question. A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.

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CARDIOLOGY UNIT PRESENTATION

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  1. Nwalozie J.C. 17/03/2014 CARDIOLOGY UNIT PRESENTATION

  2. Question • A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom. • Discuss 3 differential diagnoses & describe the management of Acute Left Ventricular Failure.

  3. Answers • 3 differential diagnoses: 1. Acute Severe asthma 2. Pulmonary Embolism 3.Acute exacerbation of COPD

  4. MANAGEMENT OF ACUTE LEFT VENTRICULAR FAILURE

  5. Outline • Introduction Precipitating factors Pathophysiology Clinical features Investigations • Management Treatment Prognosis & Monitoring Follow-up • Conclusion

  6. Introduction • Inability of the left ventricle to effectively handle its pulmonary venous return with leakage of fluid from the pulmonary capillaries & venules into the alveolar space (secondary to increased hydrostatic pressure) leading to rapid onset of breathlessness. • It is a medical emergency . • It can arise de novo or on a background of chronic left ventricular failure.

  7. PRECIPITATING FACTORS • Dietary indiscretion • Uncontrolled hypertension • Non adherence to drugs • Myocardial ischaemia or infarction • Arrhythmias • Thyrotoxicosis • Fluid overload • Anaemia • Pulmonary & other infections • Inappropriate medications- -ve inotropes, NSAIDS • Acute valvular insufficiency

  8. PATHOPHYSIOLOGY ↓ CARDIAC OUTPUT INCREASED PCWP ACTIVATIONOF RENIN ANGIOTENSIN SYSTEM ACTIVATION OF S/S SYSTEM SYMPTOMATIC DECOMPENSATION CARDIAC ISCHAEMIA ↓ LEFT VENTRICULAR FUNCTION INCREASED HEART RATE INCREASED SYSTEMIC VASCULAR RESISTANCE INCREASED PRELOAD

  9. CLINICAL FEATURES • Extreme SOB with use of accessory muscles of respiration • Sensation of drowning, chest pain, palpitations • Cough(with pink , frothy sputum) • Previous history: Of cardiac disease • Restlessness, Profuse sweating

  10. CLINICAL FEATURES Orthopnoea(patient noticed to be sitting up in bed) - sensitivity 5% - specificity 77% • PND • Pulse(Tachycardia, Pulsus Alternans) •  BP • S3 • Wheezing (Cardiac ‘asthma’) – sensitivity 22% - specificity 58% • Crepitations - sensitivity 6% - specificity 78%

  11. Other features: -Cyanosis -Cold skin -Features of underlying heart disease/precipitating factor -Features of right heart failure

  12. INVESTIGATIONS • 1.Pulse oximetry • 2. Blood • 3. Electrocardiography • 4. Radiologic • 5.Others- eg. Pulmonary arterial catheterisation

  13. BLOOD INVESTIGATIONS • ABG • FBC – anaemia, infection • U & Es • CARDIAC MARKERS

  14. CARDIAC MARKERS • CARDIAC ENZYMES • OTHER CARDIAC MARKERS

  15. IMPORTANCE OF BNP IN HF • 1. Useful in Diagnosis • 2. Assessing Severity • 3. Predicting short & long-term CVS mortality

  16. WHAT LEVELS ? • NO HEART FAILURE -BNP< 100pg / dl -NT PRO-BNP< 300pg / dl • HEART FAILURE -BNP >500pg / dl -NT PRO-BNP > 1000pg / dl *80% Sensitivity for heart failure

  17. ELECTROCARDIOGRAM • Ischaemia / infarction • Arrhythmia – A fib • LVH • Prolonged QRS

  18. CHEST RADIOGRAPH • FINDINGS IN HEART FAILURE • Cardiomegaly – 74% sensitive, 78% specific • Vascular redistribution • Interstitial oedema • Alveolar oedema • Pleural effusions (right sided/bilateral)

  19. Others • Echocardiography 1.Identify reversible cause eg MI, valvular insufficiency ,tamponade 2.Distinguish between systolic and diastolic dysfunction • Monitor urine output

  20. Treatment • A medical emergency • Begin treatment before investigations • ABC of resuscitation , Patient to sit up • Treatment can be medical, radiological/surgical

  21. TREATMENT • AIMS OF IMMEDIATE MANAGEMENT Overall aim- Redistribute fluid out of lungs! -Decrease Preload (right-sided filling) eg loop diuretics,morphine,tolvaptan -Increase left-sided emptying eg ACE-I,NTG,nitroprusside ↓ Afterload,  Cardiac output -± improve LV contractility – inotropes eg dopamine,dobutamine,milrinone,levosimendan

  22. Other measures-diet , fluid restriction , ultrafiltration , treat precipitating cause eg infection • Radiological-IABP,LV assist device , CRT • Surgical-Valve repairs , transplantation

  23. Prognosis & monitoring • Poor prognostic factors include: -Underlying heart disease/precipitating factor -BNP>500 pg/dl -K <3mmol/l -Na < 133mmol/l -Frequent ventricular extrasystoles Monitoring for vital signs, other signs , symptoms ,urine output ,renal function ,electrolytes.

  24. Follow Up

  25. Conclusion • ALVF is a life-threatening medical emergency that is as a result of LV compromise leading to accumulation of fluid in the lungs with resultant acute onset of symptoms. • It is essential to make a diagnosis( ie differentiate it from similar conditions) so that necessary interventions can be instituted as soon as possible • Management is multidisciplinary and should be individualised according to how each patient presents.

  26. THANK YOU FOR LISTENING !

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