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Cardiology for Finals FY1s Poornima Mohan & Ghazal Saadat

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Presentation on theme: "Cardiology for Finals FY1s Poornima Mohan & Ghazal Saadat"— Presentation transcript:

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

4

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

7

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

44

45 THANK YOU


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