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Cardiology for Finals

Cardiology for Finals. Andrew C Rankin. Cardiology for Finals. What do you need for Finals? The knowledge and skills required to be a FY doctor History, examination, investigations, treatments Common conditions. Cardiology for Finals OSCE. Clinical skills History Examination

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Cardiology for Finals

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  1. Cardiology for Finals Andrew C Rankin

  2. Cardiology for Finals • What do you need for Finals? • The knowledge and skills required to be a FY doctor • History, examination, investigations, treatments • Common conditions

  3. Cardiology for Finals OSCE • Clinical skills • History • Examination • Clinical Skills Website • ECG

  4. Cardiology for Finals Heart Failure

  5. Heart Failure • A 65 yr old man is admitted with heart failure • What 5 investigations would you do, and why? • ECG • CXR • Troponin • Full blood count • U&E’s • Echo

  6. Heart Failure • A 65 yr old man is admitted with heart failure • Name 4 drugs which should be prescribed at discharge from hospital • For each drug, state: • Mechanisms of action? • Why it is prescribed? • Adverse effects? • Drug class?

  7. Drugs for Heart Failure • Furosemide (frusemide) • Ramipril (and / or candesartan) • Carvedilol (or bisoprolol) • Spironolactone (or eplerenone) • Digoxin

  8. Diuretics

  9. Disease Modifying Therapy Sympathetic NS Renin-Angiotensin-Aldosterone System  Noradrenaline  Adrenaline  Renin  AT I Na retention K excretion Fibrosis  ACE  1-adrenoreceptors AT II   Aldosterone   HR vasosconstriction cardiotoxicity ATII type I receptor vasoconstriction

  10. Symptomatic Heart Failure CONSENSUS I(NEJM 1987) 253 NYHA IV Enalapril vs placebo Mean FU : 188 days1 yr Mortality Enalapril Placebo 26% 44% SOLVD (T) (NEJM 1991) 2569 LVEF 35% + CHF Enalapril vs placebo Mean FU : 41.4 months4 yr MortalityEnalapril Placebo 35% 40% P=0.002 P=0.0036

  11. Carvedilol in severe CHF 2289 patients; NYHA IV Heart failure 100 All-cause mortality 90 Carvedilol 80 % Survival 70 Placebo 60 P=0.00014 50 0 4 8 12 16 20 24 28 Months Packer et al, NEJM 2001

  12. Beta Blockers in Heart Failure “Start low, go slow” carvedilol 3.125mg bd for 2 weeks - double every 2 weeks until 25mg/bd bisoprolol 1.25mg od for 2 weeks - double every 2weeks until 10mg diuretics may have to be increased

  13. CIBIS-II MERIT-HF (1999) SOLVD (1991) 15 10 5 0 15.6 12.4 11.9 % death at 1 year 7.8 Diuretic digoxin Diuretic digoxin ACEI Diuretic digoxin ACEI Diuretic digoxin beta-blocker ACEI Drug treatment of CHF

  14. NICE 2010 - Heart Failure

  15. Cardiac Resynchronisation Therapy RA pacing LV pacing (via cardiac vein) RV pacing

  16. CARE-HF Cleland et al. N Engl J Med 2005;352:1539-49.

  17. Cardiology for Finals Cardiomyopathy

  18. Cardiomyopathies Normal Hypertrophic Dilated From Davidson’s Principles & Practice of Medicine

  19. Cardiology for Finals Coronary Artery Disease

  20. Coronary Artery Disease • A 55 yr old man is admitted with severe central chest pain • What investigation would you do first, and why? • ECG • CXR • Troponin • Full blood count • U&E’s • Echo

  21. ST elevation

  22. Call to balloon time >90 min Thrombolysis PCI Centre No reperfusion Cath/PCI within 24hrs Rescue PCI ENHANCED REPERFUSION THERAPY FOR STEMIPatients presenting to SAS/DGH 2008 STEMI/Posterior MI Shock No Shock Thrombolysis contraindicated Call to balloon time <90 min* PCI Centre PCI Centre Primary PCI Primary PCI Reperfusion *Maximum journey time 40 min* Return to local DGH within 24hrs or when stable

  23. ISIS-2.Lancet 1988

  24. Left anterior descending coronary artery in a patient with STEMI b a c • Occluded LAD • Post-thrombolysis • Post-PCI Widimsky P Eur Heart J 2010;31:634-636

  25. Thrombolysisvs Angioplasty for STEMI Danami-2 Study; 1572 patients with STEMI Busk et al, Eur Heart J 2008

  26. Myocardial infarction redefined WHO definition: (2 of 3) • Typical symptoms (chest pain) • Typical ECG changes (Q waves) • Enzyme rise • ESC/ACC redefinition 2000 • Troponin rise, with one of: • Chest pain • ECG changes (Q waves or ST segment) • PCI

  27. ST elevation No ST elevation - Unstable Angina Acute Coronary Syndrome Chest pain Presentation Working Diagnosis Acute coronary syndrome ECG Troponin Final diagnosis + + STEMI NSTEMI Myocardial Infarction

  28. Cardiology for Finals Evidence based medicine

  29. Evidence based Cardiology • Why do we use a treatment? • Because it saves lives! • Evidence of improved outcome

  30. Parachutes: Evidence Base Smith & Pell 2003 BMJ 327:1459-61

  31. Cardiology for Finals Arrhythmias

  32. Cardiac Arrhythmias Atrial Junctional Ventricular “Supraventricular”

  33. Narrow or wide QRS? Irregular? AF P waves? Adenosine Terminates AV block Atrial SVT

  34. Supraventricular Tachycardia Accessory pathway AV reentry tachycardia

  35. Adenosine and SVT Accessory pathway Termination of AVRT Adenosine

  36. Carotid Sinus Massage

  37. Atrial Flutter Atrial Flutter

  38. Adenosine and Atrial Flutter Adenosine

  39. Radiofrequency ablation Ablation catheter Accessory pathway

  40. AF affects 1.0-1.5% of the population in the developed world Life-time risk 1-in-4 for >40 year olds Increased prevalence with age 10% >80 years 1% of health care budget in UK Atrial Fibrillation – an new epidemic

  41. Algorithm for treatment of AF! Paroxysmal Persistent Permanent Peters N, et al. Lancet 2002

  42. Risk of embolism Rhythm control Rate control Atrial Fibrillation Atrial fibrillation

  43. “Natural” time course of AF ESC AF Guidelines 2010

  44. All-cause death at Year 5: 23.8 versus 21.3% for rhythm versus rate control 30 25 20 Rhythm control 15 Cumulative mortality (% patients) Rate control 10 5 (p=0.08; N=4060 ) 0 0 1 2 3 4 5 Years Rhythm vs Rate control in AFFIRM AFFIRM=Atrial Fibrillation Follow-up Investigation of Rhythm Management The AFFIRM Investigators. N Engl J Med 2002; 347(23): 1825–33

  45. Amiodarone vs Sotalol for AF Singh et al (SAFE-T) NEJM 2005;352:1861

  46. Warfarin prevents strokes in AF • Warfarin prevents 20-30 strokes • per 1000 patient years • 6 - 8 serious bleeding episodes • per 1000 patient years

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