1. Cardiology for Finals FY1s Poornima Mohan & Ghazal Saadat

2. Overview Scars Acute coronary syndromes Valvular heart disease
Infective Endocarditis
Dextrocardia
Arrhythmias

3. Midline sternotomy scar
Name 3 procedures (valve replacement, VSD, CABG)
What scar would you next look for to give you clue as to which it is? (Leg)
Where else can they take it from? (internal mammary)
What type of valves are there? Prosthetic and tissue
How can you tell the difference without asking the patient? Prosthetic valves click and tissue valves are silent
What is this scar?
Which 3 procedures would cause this scar?
What else would you look for? 3

5. Grafts

6. What are the indications? Where else should you look?
Which procedures are lateral thoracotomy scars used for? MV replacement
Pacemaker/ICD scar – what are the indications?
What could this be?
What are the indications?
Where else should you look? 6

8. “We have this patient with chest pain”
66 year old with a background of DM type 2, hypertension and a 40 pack yr smoking hx. Day 1 post inguinal hernia repair.
Has been having central crushing chest pain for last 15 minutes. No relief from GTN. Hot & sweaty, vomited twice.
Obs: BP- 120/60 P-75 RR- 24 Sats 98% on RA

9. Investigations for each of them
STEMI  Primary PCI , call the cath lab. Start ACS protocol. MONA. Asprin , Clopidogrel (loading dose??). To have a primary PCI they need to be there within 12 hours.
secondary prevention - Ace , B –blocker, Asprin and Clopidogrel, OMACOR, simvastatin
Address modifiable risk factors – stop smoking, encourage exercise, diabetes mellitus, HTN, hyperlipidaemia, avoid sex for 1 month, improved diet
Exercise ECG
Review in 3 months 9

10. What ECG features suggest an STEMI??
ST elevation in 2mm in 2 or more contigous limb leads
ST elevation in 2 or more contigous chest leads
New onset LBBB
Posterior MI
.What features suggest an to NSTEMI ???
ST depression and /or T wave inversion in 2 or more leads. Risk is assessed using the TIMI score.

11. What does this ECG show?

12. Management What would you do as an F1
Management What would you do as an F1? 1) Assess haemodynamic stability 2) oxygen(?) 3) Initiate ACS protocol 4) Nitrates 5) Analgesia STEMI - Primary PCI NSTEMI – Risk assessment and PCI Unstable angina – Functional Testing +/- Angiogram Universal Secondary Prevention and Cardiac Rehabilitation

13. FUNCTIONAL TESTING 1) EXERCISE TOLLERANCE TEST 2) CT CALCIUM SCORING
4) STRESS ECHO
3) MYOCARDIAL PERFUSION SCAN

14. Valvular heart disease
Common exam question
Can find lots of patients with valve replacement
Things to know are
- Which valve
- What the cause could have been
- Clinical signs
- Basic principles of management
Questions about complications of surgery

15. Scenario 1
“ A 72 year gentleman man presents with a history of collapse as he was rushing up a hill to catch a bus.
There was no LOC. He reports no associated weakness/numbness/tingling in the limbs, visual disturbance, slurred speech, headache, chest pain, or palpitaions. This had never occurred before.
He has noticed that he is increasingly SOB of late whilst gardening/ doing house-work etc.
He has no previous cardiac history. He suffers from hypertension and gout.”

16. Aortic Stenosis 1) Senile calcification Causes Symptoms
2) Biscuspid Aortic valve
3) strep associated – Rheumatic fever
Symptoms
Exertional : Dysponea, syncope angina
Features of AS on examination ????
Most common murmur – incidence continues to rise – we are in an aging population.

17. Management : TAVI vs Open AVR +/- CABG?
Features on Examination
narrow pulse pressure
slow rising pulse
LV heave
Forcefull apex beat
ESM radiating to the carotid- heard all over the precordium
Features of left ventricular dysfunction
Severe Stenosis → 1) Narrow PP 2) Quite or loss of S2
DDX for an ESM → 1) HOCM 2) VSD 3) Aortic sclerosis.
Management : TAVI vs Open AVR +/- CABG?
Exam tip : Which heart sound is metallic in an AVR??

18. Mitral Regurgitation Causes
“ A 72 year old lady presents with a history of increasing SOB, orthoponea and palpitations over a few months. She has a history of Angina, Hypertension. She is found to be in Atrial fibrillation”
Causes
Valve Annulus
Leaflets
Papillary Muscle
ACUTE
Infective
Endocarditis
MyocardiaIschemia
CHRONIC
Function – Chronic ischemia (post MI)
CCF (LV dilatation)
Prolapse
Connective tissue disorders
Amyloid- infiltration of the chords.

19. Mitral Regurgitation Clinical features AF small volume pulse
displace apex beat
loud PSM radiating to the axilla
bibasal crepitations
MGX: mitral valve clip vs Open MVR +/- CABG. Discuss indication. Decision is often based on a TOE.

20. Mitral Regurgitation Management Medical : Diuresis
Consider patients pre-morbid state
Medical : Diuresis
Rate control
Anti coagulation
ACE inhibitors and B-blockers.
Surgical : Assessment with an TTE / TOE and angiogram Mitral clip or an open Valve Replacement

21. Mitral Stenosis Cause: Congenital Rheumatic Heart disease
Senile Degeneration
Clinical Signs
Malar flush
Irregular pulse
Tapping apex beat – palpable 1st HS
Left parasternal heave / Enlarged LA
Loud 1st heart sound
Opening snap
Mid-diastolic murmur.

22. On investigation
CXR- Enlarged left atrium, calcified valves and pulmonary oedema.
ECG – p-mitrale and AF

23. Management Medical : Rate control (digoxin)
Anti-coagulate
Valvuloplasty
Surgical : Valve replacement
Valveotomy (open / closed)

24. Aortic Regurgitation Causes : Acute (inf. Endocarditis)
Chronic: Connective tissue disorders (RA), Rheumatic heart disease, syphilitic heart disease . Aortitis: Marfans / Anklysing spondylitis
Clinical features:
Wide PP
collapsing pulse – hyperdynmaic apex beat
Eponymous signs
Early diastolic murmur

25. Aortic Regurgitation Other causes of a collapsing pulse? Management
Anything that causes a high circulating volume:
Pregnancy
Anaemia
PDA
Thyrotoxicosis
Management
Valve replacement vs conservative management

26. Murmurs Summary Aortic Stenosis Aortic regurgitation Mitral Stenosis
Mitral regurgitation
Pulse
Slow-rising
Collapsing
Often AF
Apex beat
Forceful, not displaced
Displaced
Tapping, not displaced
Thrusting, +/- displaced
Murmur
Ejection systolic
Early diastolic
Rumbling mid-diastolic
Pansystolic
Best heard
Aortic area
Tricuspid area
Mitral area
Radiation
Carotids
Axilla
Aortic regurgitation – Corrigan’s sign (carotid pulsation), de Musset’s sign (head nodding), Traube’s sign (pistol-shot femorals). If severe AR, Austin-Flint murmur may be heard. 26

27. Complications of Valve replacements
INFECTION : early vs late.
FAILURE OF VALVE: early vs late
DISLODGEMENT
THROMBUS FORMATION vs HAEMMOHRAGE
Does anyone know how to tell the difference between aortic stenosis and sclerosis? 27

28. Management What would you do as an F1? ECG CxR Inform seniors Echo
Conservative: if AF, rate control. Diuretics improve symptoms
Surgical: Valve repair/ replacement

29. “ A 54 year old lady initially presents with an abscess.
She vascular infarcts on CT and is admitted to the acute stroke unit. She has no major risk factors for a CVA.
On doing base line bloods she has CRP 300
Urine dip show blood +++
She’s on the stroke ward, she has some left sided weakness. Obs stable, and apyrexial so far “

30. Infective endocarditis
What is the diagnosis???
Infective endocarditis
What would you look for ???

31. What would you look for? Signs of sepsis
New murmur or change in existing murmur
Microscopic haematuria, ARF, splenomegaly
Embolic features e.g. abscesses

32. What would you do as an FY1?
Bloods
Blood cultures
ABG
Urine dip & MCS
CxR
ECG
Echo (TOE)
Inform seniors

33. Common questions 1. Risk factors? 2. Organisms?
Lifestyle factors (IVDU), cardiac lesions, aortic or mitral valve disease, PDA, VSD, coarctation, prosthetic valve
2. Organisms?
Strep viridans (35-50%), HACEK (Haemophilus, actinobacillus, cardiobacterium, Eikenella)
Fungi
SLE – Libman-Sachs endocarditis
3. Criteria for Diagnosis?

34. Duke criteria for diagnosis
2 major OR 1 major and 3 minor OR all 5 minor criteria
Major
+ve blood culture
typical organism in 2 separate cultures or persistently +ve blood cultures
Endocardium involved
Positive echo or new valvular regurgitation
Minor
Predisposition
Fever >38C
Vascular/immunological signs
+ve blood cultures that do not meet major criteria
+ve echo that does not meet major criteria

35. Management MDT decision
Conservative management: Long-term antibiotics and serial echos
Surgical management: Valve replacement

36. Dextrocardia
A congenital defect where the heart is situated on the right side of the body
2 types:
Isolated dextrocardia – heart placed further to the right in thorax, associated with other cardiac abnormalities
Dextrocardia situs inversus – heart placed to the right side as a mirror image

37. Dextrocardia CxR

38. Dextrocardia ECG

39. SVT
Management : 1) valsalva / Carotid sinus massage
2) adenosine (remember- warn the patient that it can be an unpleasant feeling, as you are effectively stopping their heart for a few seconds) 3)

40. Atrial Fibrillation

41. VF
Note : there are different types of VF and they have different characteristic patters.
Torsades de point (often seen in those who degenerate into VT following a prolonged QT)
Often see fusion beats and capture beats.

42. WPW
Features : short PR interval, delta wave (note the slurred upstroke and the delta wave are seen on the ECG as a result of the accessory pathway through the bundle of kent)

43. Ventricular fibrilation

45. THANK YOU