Transcript Cardiology Finals Revision

Cardiology Finals Revision
Andrew Degnan
PALI
Wednesday 12th September 2012
Why Cardiology?
Why Cardiology?
• 2005
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–
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Paper 1-Heart failure
Paper 2-Unstable angina
Resit 1-Aortic stenosis
Resit 2-Infective endocarditis and
pericarditis
• 2006
– Paper 1-Heart failure
– Paper 2-Primary prevention
• 2007
– Paper 1-Heart failure and
pericarditis
– Paper 2-None
• 2010
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Paper 1-None
Paper 2-Postural hypotension
Resit 1-Aortic stenosis
Resit 2-Infective endocarditis
• 2011
– Mock-Heart failure
– Paper 1-None
– Paper 2-Infective endocarditis and
heart failure
– Resit 1-Acute MI
– Resit 2-Postural hypotension
• 2012
– Paper 1-None
– Paper 2-Unstable angina and
postural hypotension
2012 Mock Paper
Unstable Angina
MEQ 1.8
• A 39 year old Asian man was admitted to the medical
admissions unit with pains in his chest and neck. He admitted
to smoking 20 cigarettes per day and a blood cholesterol had
been measured at 7.2mmol/L (reference range 3.55.0mmol/L). His average HR on admission was 90 bpm and his
blood pressure was 170/100mmHg. An initial diagnosis of
unstable angina was made.
(a)
 What are his risk factors for coronary artery disease? (2 marks)
MEQ 1.8
• A 39 year old Asian man was admitted to the
medical admissions unit with pains in his chest
and neck. He admitted to smoking 20
cigarettes per day and a blood cholesterol had
been measured at 7.2mmol/L (reference range
3.5-5.0mmol/L). His average HR on admission
was 90 bpm and his blood pressure was
170/100mmHg. An initial diagnosis of
unstable angina was made.
Risk Factors for CVD
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Unmodifiable Factors
Male
Increasing age
Asian decent
Post-menopause
Family History
•
•
•
•
•
•
Modifiable Risk Factors
Smoking
Hyperlipidaemia
Obesity (diet and exercise)
Diabetes
Hypertension
Stress
(b)

You decide to admit him to hospital. What drug therapy could he be
started on? List 4 potentially beneficial drugs (2 marks) and give a
reason for prescribing each (2 marks).
Immediate Treatment of NSTEMI and
UA
• Anti-ischaemic therapy (decrease myocardial oxygen demand)
– Nitrates (GTNIV), venodilation, decrease venous return
– Beta-blockers, decrease sympathetic drive and so decrease
O2 demand
• Anti-thrombotic therapy (prevent further development of
partially occluded thrombus)
– Aspirin, prevents platelet aggregation and activation
– Clopidogrel, alternative action on platelets. Can be used in
combitaion with or in place of aspirin
– Heparin, usually LMWH, breaks down any clots
• Results of blood tests revealed a Troponin T of
0.35ng/ml (normal=unrecordable), peak CK
was 180iu/ml (reference range: 25-200iu/ml)
on day 2
(c)
 List the 2 cardinal ECG features of an acute full thickness anterior
myocardial infarction and outline their electrophysiological cause
(4 marks)
The Easy Bit
http://en.wikipedia.org/wiki/File:12_Lead_EKG_ST_Elevation_tracing_color_coded.jpg
The Hard Bit
Is it enough to
answer with “It just
does”?
• ST Elevation
– Changes in the action potentials produced by necrotic
tissue
– Abnormal firing of action potentials leads to early
repolarisation secondary to ischaemia, causing this
abnormal wave
• Pathological Q Waves
– Any initial downward movement of the QRS is a Q wave.
– Pathological Q waves are Q waves developing after MI
which have a width of ≥ 1 small box and a depth > 25% of
the total QRS height
– Develop from living tissue behind the infarct which is
picked up by the ECG as a downward movement as
impulses move away from the anterior leads
Cardiac Enzymes
http://en.wikipedia.org/wiki/File:AMI_bloodtests_engl.png
Discussion Points?
2005 Paper 1
Left Ventricular Failure
MEQ 1.2
• A 78 year old man had a large anterior myocardial infarction
three years ago. Initially he made a good recovery, but has
had to take a diuretic for ankle swelling since. In the last 2
months he has become short of breath on exertion. You
suspect that he has developed left ventricular failure
(a)
 Give 2 additional symptoms that would support this diagnosis (2
marks)
MEQ 1.2
• A 78 year old man had a large anterior myocardial infarction
three years ago. Initially he made a good recovery, but has
had to take a diuretic for ankle swelling since. In the last 2
months he has become short of breath on exertion. You
suspect that he has developed left ventricular failure
(a)
 Give 2 additional symptoms that would support this diagnosis (2
marks)
Left Heart Failure
• Exertional dyspnoea
• Orthopnoea
• Paraxysmal nocturnal
dyspnoea
• Fatigue and weakness
• Poor exercise tolerance
• Cardiac wheeze
• Nocturnal cough with frothy
pink sputum
• Impaired urine output during
the day and nocturia at night
• Impaired metal status
• Cold peripheries
Right Heart Failure
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•
•
•
Peripheral oedema
Abdominal discomfort
Weight gain
Anorexia and nausea
Left Heart Failure
• Exertional dyspnoea
• Orthopnoea
• Paraxysmal nocturnal
dyspnoea
• Fatigue and weakness
• Poor exercise tolerance
• Cardiac wheeze
• Nocturnal cough with frothy
pink sputum
• Impaired urine output during
the day and nocturia at night
• Impaired mental status
• Cold peripheries
Right Heart Failure
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•
•
•
Peripheral oedema
Abdominal discomfort
Weight gain
Anorexia and nausea
Left Heart Failure
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Cachexia
Cyanosis
Sweating
Tachopnoea
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Tachycardia
Pulses alternans
Bilateral basal crackles
Displaced apex beat
Extra heart sounds and
murmurs (depends on
cause)
Right Heart Failure
• Cachexia
• Oedema
• Increased JVP with positive
hepatojugular reflex
• RV heave
• Hepatomegaly
• Ankle oedema
• Sacral oedema
• Ascities
(b)

You arrange for a chest X-ray. Give four features that would support
the diagnosis of left ventricular failure (4 marks)
Adapted from http://www.e-radiography.net/technique/chest/chest_eval.htm
Adapted from http://www.learningradiology.com/archives2007/COW%20267Pulmonary%20edema-CHF/caseoftheweek267page.html
Adapted from http://en.wikipedia.org/wiki/Kerley_lines
Adapted from http://www.radiologysingapore.com/lectures/plain-films-withdiagnosis-6/
(c)
 Give 2 neurohormonal mechanisms which may be
activated in heart failure (2 marks)
4 Neurohormonal Mechanisms
1. Sympathetic Nervous System Activity
–
Fall in CO detected by baroreceptors, sympathetic drive
increases, ↑ HR and BP
2. RAAS
– Decreasing renal perfusion activates RAAS which ↑ PVR
(angiotensin II) and blood volume (aldosterone) which both play
a role in ↑ BP
3. ADH
–
Released in response to low BP and release of angiotensin II.
↑ blood volume and hence BP
4. Natriuretic Peptides
–
Both ANP and BNP. Both inhibit RAAS and so ↓ blood volume
and BP. Beneficial effect, but not released in sufficient enough
quantities. BNP=prognostic marker
These all have an effect on…?
• Frank Starling Mechanism
• Improved venous return improves LV contraction
• Preload vs. afterload
And this combination leads to
• Symptoms of LV HF
• Hypertrophy
(d)

If starting this patient on an ACE inhibitor, what precautions would
you take? (3 marks)
Side-effects
Contra-indications and Cautions
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First dose hypotension
Persistent cough
Hyperkalaemia
Renal impairment
• Hypersensitivity
• Bilateral renal artery
stenosis
• Pregnancy
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Headache
Dizziness
Fatigue
Nausea
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Impaired renal function
Aortic stenosis
Cardiac outflow obstruction
Hypovolaemia
Haemodialysis
Other Precautions
• Check baseline BP (first dose hypotension) and
Us+Es (hyperkalaemia, renal dysfunction)
• Start low, tritrate dose up
• Continue to monitor Us+Es
• Drug interactions
Discussion Points?
2011 Paper 2 (also 2005 Resit 1
and 2010 Paper 2)
Infective Endocarditis
MEQ 2.6
A 32 year old woman, who is a known alcoholic and abuser of
intravenous drugs, presents to A+E complaining of gradual onset
malaise, fever, weight loss and night sweats. She is pyrexial
(38.5°). She has a pansystolic murmur which is thought to be a
new finding and you suspect she has a diagnosis of infective
endocarditis
(a)
 Name 4 additional clinical signs that may be found on examination in
this patient (2 marks)
MEQ 2.6
A 32 year old woman, who is a known alcoholic and abuser of
intravenous drugs, presents to A+E complaining of gradual onset
malaise, fever, weight loss and night sweats. She is pyrexial
(38.5°). She has a pansystolic murmur which is thought to be a
new finding and you suspect she has a diagnosis of infective
endocarditis
(a)
 Name 4 additional clinical signs that may be found on examination in
this patient (2 marks)
http://medicalpicturesinfo.com/janeway-lesion/
http://en.wikipedia.org/wiki/File:Splinter_hem
orrhage.jpg
http://en.wikipedia.org/wiki/File:Osler_Nodules_Hand.jpg
http://en.wikipedia.org/wiki/File:Acopaquia.jpg
Signs of Infective Endocarditis
• Hands
– Splinter haemorrhages
– Janeway lesions
– Osler’s nodes
– Clubbing
Signs of Infective Endocarditis
• Hands
– Splinter haemorrhages
– Janeway lesions
– Osler’s nodes
– Clubbing
• Eyes
– Roth Spots
http://www.aao.org/theeyeshaveit/optic-fundus/roth-spot.cfm
Signs of Infective Endocarditis
• Hands
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Splinter haemorrhages
Janeway lesions
Osler’s nodes
Clubbing
• Eyes
– Roth Spots
• Heart
– New murmur
– Signs of HF
• Others
– Abscess
– Splenomegaly
– Petechia
(b)
Name the 2 most likely organisms likely to be implicated in
infective endocarditis (2 marks)
Agent
Route
Strep. Viridans
Dental procedures
Staph. aureus
IVDU/Thoracotomy/Peripheral
lines
Enterococci
UTI
Candida
Peripheral lines/catheters
Strep. Bovis
Colorectal carcinoma
(c)
Your FY2 asks you to dip the urine. What would you expect to
find and what is the pathology behind this abnormality? (2
marks)
• Blood (microhaematuria)
• Pathology
– Micro-emboli from vegetation on heart valve
– Can block vessels in the glomerulus, causing
glomerularnephritis and ARF.
– Micro-emboli cause other clinical signs
(d)
 Name two investigations that are mandatory to confirm your diagnosis
(1 mark)
• Blood Cultures
• Echo
– 3 sets
– Different times
– Different places
– Trans-oesophageal more
sensitive
– >2mm for trans-thoracic
Dukes Criteria
Major Criteria (x2)
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•
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Positive blood culture
– Typical organism in 2 separate
cultures
– Persistently +’ve over time
Echo evidence of valvular
involvement
New valvular regurgitation
(murmur)
Minor Criteria (x5)
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Risk factors
Fever
Vascular phenomenon
Immunological phenomenon
Positive blood cultures not
meeting requirement for major
criteria
• Echo evidence not meeting
requirement for major
requirement
1 Major + 3 Minor
(e)
Other than IVDU, name 4 risk factors for this condition (2 marks)
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Environment favourable to
Infection
Allow Implantations and Growth
of Organism
IVDU
Dental surgery
Thoracotomy
Catheterisation
Peripheral/central lines
Immunosuppression
• Prosthetic heart valve
• Pre-existing valvular disease
– Rheumatic
– Acquired
– Congenital
On further examination you can also hear the pansystolic
murmur. This is loudest at the left sternal edge and you
demonstrate the JVP is elevated with giant “v” waves. In addition
she also has tender pulsatile hepatomegaly.
(f)

What is the most likely cardiac lesion to be responsible for this, given
the above history and examination? (1 mark)
On further examination you can also hear the pansystolic
murmur. This is loudest at the left sternal edge and you
demonstrate the JVP is elevated with giant “v” waves. In addition
she also has tender pulsatile hepatomegaly.
(f)

What is the most likely cardiac lesion to be responsible for this, given the
above history and examination? (1 mark)
Tricuspid Regurgitation
Murmurs
Systolic
• Loud
• Radiate
• Ejection Systolic
– Aortic Stenosis
• Pansystolic
– Mitral Regurge
Diastolic
• Quiet
• Accentuated by
manoeuvres
• Early-mid diastolic
– Aortic regurge
• Late diastolic
– Mitral stenosis
• Remember DARMS
Discussion Points?
Thank You!