1. + Cardiology in the ED Dr Jessica Spedding StR BRI September 2014

2. + Cardiology in ED What comes in: Chest pain C?C Palpitations Breathlessness due to cardiac causes What ENPs see: All of the above! Minors BRI = Majors anywhere else!

3. + Today’s session Cases to cover patients who often present to Minors

4. + Case 1 84y woman Presents following collapse on way to bathroom at 6am Brief LOC without features of seizure In ED – had breakfast and feels ‘back to normal’

5. + What is important history?

6. + More history HPC: No CP, SOB, palpitations, headache immediate pre or post faint No recent illness, no hosp admissions for >10y PMH – HTN, hypothyroid (last check 3m ago), breast cancer 14y ago DH: amlodipine, bendroflumethazone, ramipril (started 4d ago), levothyroxine SH: lives with husband, both well, independent, stairs at home, family supportive

7. + Examination Looks well Afeb, BP 120/76, HR 72, sats 99 RR 12 CVS N HS, JVP normal, minimal ankle pitting oedema RS Abdo Neuro grossly normal What else do you want?

8. + Syncope: ED investigation Postural BP – 120/76 lying stand up then wait 2 mins, 91/70 BM – 6.1 FBC U&E TFT all normal ECG…

9. + ECG interpretation:

10. + Differential diagnosis in C?C

11. + Vasovagal – secondary to: hunger, dehydration, intercurrent illness, stress, micturition and… Postural hypotension: Recognised complication of ACE-I (and all BP lowering meds) Increased likelihood with autonomic dysfunction of age Can also indicate acute bleed – think occult GI bleed (Hb, Ur)

12. + Differential diagnosis Arrhythmia (brady or tachy) – not always persistent on ECG, look for clues (PR, QTc) Heart failure – CCF / HOCM ACS Neuro – seizure, SAH AAA / thoracic aortic dissection Hypoglycaemia Other metabolic causes (Na, Ca… which can contribute to an arrhythmia or a seizure)

13. + American College of Physicians Guidelines Admit: Hx Coronary Artery Disease, CCF, VT Chest pain Signs of CCF, valve dis, stroke, focal neuro ECG ischaemia, arrhythmia, long QTc or BBB Usually admit: Sudden LOC with injury, palpns, exertional syncope Frequent episodes Suspicion of arrhythmia or CAD Mod to sev postural hypotension Over 70y Don’t need to admit: The rest!

14. + Course of action for Case 1 Admit Stop ramipril Watch BPs ECHO Home after 24h

15. + What we must do Thorough history ruling out each potential serious diagnosis Exam focussing on evidence of arrhythmia, heart failure, BP, aorta assessment and neuro concerns Focussed ix: ECG, post BP, bloods If home – consider GP ref for ECHO

16. + Case 2 43y man Chest pain – severe for 20 mins but by arrival resolved ECG and obs at triage normal HTN for past 5y Smoker

17. + More info? Pain was chest and between shoulder blades, very sharp, 10/10 then settled Pain in right arm earlier Hasn’t been taking BP meds as thought caused impotence

18. + Examination normal except for BP 160/100

19. + What do you do?

20. + Investigations?

21. + ECG

22. + Aortic dissection Rare Fatality high (80%) if unrecognised, mortality 1% per hour whilst untreated What is it?

23. + Tear in intima => False lumen => tracking of blood into false lumen => limits blood flow down branching arteries coronary – MI carotid – dense stroke renals – renal failure coeliac / mesenterics – gut ischaemia

24. + Management Think of it… then CT aortogram Get into resus 2 large lines Xm blood Call cardiothoracics

25. + theNNT.com

26. + Case 3 22y male Out jogging in icy conditions Slipped and banged head with brief LOC Ongoing severe headache, otherwise well and felt well prior to fall No PMH

27. + What else do you want to know?

28. + Investigation CT head normal

29. + ECG

30. + QT interval: beginning of QRS complex to end of T wave most machines will calculate the QTc = the QT length corrected to a rate of 60bpm normal = less than 450 (or thereabouts!)

31. + Young fit collapses Most are vasovagal…. Less common in males…. Just think of 1. Arrhythmias – familial sporadic or iatrogenic long QT predisposes to ventricular arrythmias and cardiac arrestr 2. Cardiomyopathies

32. + HOCM: Young fit men/boys Sudden collapse whilst exercising Due to obstructed outflow of blood from LV to aorta Demand exceeds supply Syncope May present as VF or PEA arrest

33. + Summary Thought about 3 cases that may walk in to minors That may not ring alarm bells Need to: Have an open mind Know differential diagnosis Know the ED tests that will rule out the rare and serious diagnoses ANY QUESTIONS?