Cardiology Revision 2014

1. Cardiology Revision 2014 Dr P Banerjee Consultant Cardiologist University Hospitals Coventry & Warwickshire

2. Format of the revision • Picture slides • ECG reading • How to examine the CVS • Assessment of patient with breathlessness, chest pain, palpitations, syncope

3. Clinical scenario • 51 yr old man • Admitted with pyrexia, shivering and feeling unwell • Has a heart murmur on examination

6. Infective Endocarditis • 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

7. Clinical scenario • 53 yr old lady • Presents to clinic with SOBOE • Has Hx of rheumatic fever • Cardiac murmur audible on auscultation

9. Malar Flush- Mitral Stenosis • 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.

10. Clinical scenario • 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

12. Heart Failure with cachexia • 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

13. ECGs

14. Clinical Scenario 1 • 65 yr old • Admitted with severe central CP for 2 hrs • Sweaty and clammy • BP 90/60, Pulse 50/min, SR

15. ECG 1

16. Inferior STEMI • Aspirin 300mg + Prasugrel 60 mg loading • IV morphine • Primary PCI

17. Scenario 2 • 49 yr old smoker • CP for 30 min, improved with IV Morphine • Now comfortable, normal BP and pulse • Troponin T elevated

18. ECG 2

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

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

21. ECG 3

22. Recent STEMI • 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%)

23. Scenario 4 • 25 yr old lady, non smoker • Flu like illness for 7 days • Sharp CP on inspiration for 24 hrs, better on sitting forward

24. Compare with previous ECG

25. Pericarditis • 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

26. Scenario 5 • 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

27. ECG 4

28. ECG 5

29. Ventricular Tachycardia • 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

30. Scenario 6 • Gentleman suddenly has cardiac arrest again

31. ECG 6

32. Ventricular Fibrillation • Emergency DC shock • Check all as for VT • ICD

33. Scenario 7 • 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.

34. ECG 7

35. SVT/AVNRT • Carotid sinus massage, valsalva • IV Adenosine, IV Verapamil • DC shock-usually not required

36. Scenario 8 • 74 yr old man • Severe central CP for 2 hrs with sweating • Stable BP and pulse

37. ECG 8

38. LBBB + Prolonged chest pain • Treat as STEMI

39. Scenario 9 • 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

40. ECG 9

41. Atrial Flutter • 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

42. CHA2DS2-VASc score for stroke risk in atrial fibrillation

43. Scenario 10 • Later her ECG changed • ? Any change in management

44. ECG 10

45. Atrial Fibrillation • Management same as for atrial flutter • New agents for oral anticoagulation in non valvular AF: Dabigatran, Rivaroxaban

46. Scenario 11 • Asymptomatic young and fit man has had these ECGs as part of his employment check

47. ECG 11

48. ECG 12

49. First and Mobitz Type 1 AV block • Not indications for pacing

50. Scenario 12 • 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