Transcript Guide to cardiology for interns

Dr Hui-Chen Han
Austin/Northern Health Services
Topics
Ischaemic heart disease
 Arrhythmia management
 Congestive cardiac failure

Chest pain
One of the most common reasons for
review
 Typical: central, squeezing, radiation to
arms/jaw, associated with SOB/nausea,
many risk factors
 Atypical: sharp, pleuritic, mechanical,
good exercise tolerance w/o pain,
few/no risk factors
 Can’t tell: most cases

Important investigations
ECG
 Cardiac enzymes
 CXR
 Previous stress tests, echocardiograms,
angiograms
 Previous ‘non-cardiac’ investigations
(V/Q, CTPA, gastroscopies)

ECG in IHD
Old ECG for comparison
 STEMI: 1mm contiguous limb leads (II,
III, aVF, aVL, I, aVR) or 2mm contiguous
chest leads or new LBBB
 Territories: inferior (II, III, aVF), anterior
(V1-3), lateral (V4-6, I, aVL)
 Dynamic changes are important (may be
subtle)

Troponin rules (1)

History is important
 Slight elevations a concern with typical chest
pain and risk factors
 Slight elevations less of a concern with sepsis,
heart failure, tachycardia  may indicate some
myocardial damage, however, conventional ACS
treatments may not have same benefit

Repeat the troponin
 Need one sample at least 6 hours after the
onset of symptoms
 Earliest repeat is at 3 hour mark
Troponin rules (2)

Consensus guidelines from the
NHF/CSANZ 2011:
 “At 3 hours after presentation (with at least
one assay performed >6 hours from
symptom onset), a test using a high
sensitive troponin assay should be
interpreted as negative if the level is <99th
percentile OR change from baseline is
<50%”
Troponin or CK
Troponin more sensitive marker of myocardial damage
CK useful in determining early reinfarction
Medical management (1)

Antiplatelet therapy
 Aspirin 300mg loading; 100mg ongoing
 Adenosine diphosphate receptor blockers
(clopidogrel, prasugrel, ticagrelor)

Beta-blockers as HR & BP tolerates
 Metoprolol 25mg bd
 Ensure patient is not in florid APO

Statins
 Atorvastatin 80mg
Medical management (2)

ACEi as BP tolerates
 Perindopril 2.5mg
 Monitor renal function

Anticoagulation
 SC clexane 1mg/kg bd for 48hrs
 UFH aiming APTT 50-70s

Ensure patient is pain free: SL GTN 
morphine  GTN infusion
Managing the atypical CP

Truly atypical:
 Analgesia
 Reassurance

Can’t tell:
 No guidelines
 May consider cardiac enzymes if it is first
episode

Other causes of CP: PE, dissection,
pneumonia, pleural effusion, mass,
musculoskeletal, anxiety, dyspnoea
Functional testing

No perfect test
 Stress ECG lowest sensitivity & specificity
 Nuclear scan higher sensitivity (~85-90)
 Stress TTE higher specificity (~75-80)

May need to adapt test to patient
 Nuclear scan if obese
 Stress TTE if also assessing valves,
structural abnormalities

High risk patients should get an
angiogram
Tachycardia
Consider MET call criteria (140bpm)
 Regular or irregular
 Narrow or broad complex

Regular
Irregular
Narrow Sinus tachycardia
A flutter
SVT
AF
MFAT
A flutter with variable
conduction
Broad
AF with aberrant conduction
VT
SVT with aberrant
conduction
Paced
Atrial fibrillation

Thoughts:
 Reason for AF if it is new onset
 Rate vs rhythm control
 How fast to let them run
 Anticoagulation or not
Causes of AF
None identified
 Age
 Cardiac: AMI, CCF, valvular, structural
diseases
 Infection, thyroid dysfunction, PE, postoperative (especially cardiac surgery)
 Electrolyte disturbance
 Fluid status

Medications

Rate control
 Metoprolol 25bd
 Atenolol, diltiazem CR, verapamil SR
 Digoxin

Rhythm control
 Amiodarone 400 tds  wean weekly (200
daily as maintenance)
 Flecainide (need to know LV function)
 Sotalol (better at maintaining SR than
conversion)
Medications

rAF
 Treat reversible causes
 Usual medications
 IV amiodarone (300mg load, 0.9-1.2g
infusion)
 Digoxin loading (500, 250, 250)

Anticoagluation if new AF
 Clexane 1mg/kg bd
Rhythm vs rate control

AFFIRM trial (2002)
 Randomised, multicenter
 AF likely to be recurrent
 4080 patients, mean age 69.7 +/- 9.0 years,




3.5 year mean f/u
2033 rhythm control, 2027 rate control
No difference in primary end-point (all-cause
mortality)
↑ hospitalisations in rhythm control group
↑ adverse events in rhythm control group
Rhythm vs rate control

RACE trial (2002)
 Randomised, multicenter
 Persistent AF after previous electrical




cardioversion
522 patients, mean age 68 +/- 8.5 years, 3 year
f/u
266 rhythm control, 256 rate control
No difference in primary end-point (composite
death)
↑ side effects from antiarrhythmic medications in
rhythm control group
Strict vs lenient rate control
(how fast?)

RACE II trial (2010)
 Randomised, multicenter
 Permanent AF for 12 months, age <80 years,






resting HR >80 bpm, on oral anticoagulation
Strict: resting rate <80, exercise rate <110
Lenient: resting rate <110
614 patients, mean age 68 +/- 8 years, 3 year
f/u
303 strict control, 311 lenient control
Medications: combinations of BB, digoxin, CCB
Lenient rate control non-inferior to strict rate
control
Long term anticoagulation

CHADS₂ score (only for non-valvular
AF)
CCF, HT, Age >75, DM, Stroke (2)
Long term anticoagulation
CHADS2
score
0
Risk level
low
Treatment
recommendations
no therapy or aspirin
1
moderate
oral anticoagulant or aspirin
2 or more
high
oral anticoagulant
AF summary
Rate control is a safe option
 Lenient rate control is a safe option
 Always think about anticoagulation

Bradycardia
Consider MET call criteria (40bpm)
 Symptomatic or not
 Regular or irregular
 Map out p-waves if present

Bradycardia
MEDICATIONS
 Other causes: age, sick sinus, vagal
activity, ↑ICP, AMI (RCA), OSA, athletes
 Management:

 Withdraw of medications
 Atropine, isoprenaline, telemetry monitoring
 Temporary pacing wire
 Pacemaker
Class I indications for a
pacemaker

Sinus dysfunction
 Symptomatic bradycardia (pauses,
chronotropic incompetence, tachy-brady)

AV block
 Complete heart block
 Advanced second degree (Mobitz type II)

Fascicular block
 Alternating bundle branch block
Congestive cardiac failure
Acute management
 Chronic management

Acute pulmonary oedema
Lasix (IV 40-80mg, need to double usual
dose)
 Morphine (SC 2.5mg)
 Nitrates (GTN patch 5 or 10mg if BP
tolerates, consider GTN infusion)
 Oxygen
 Positioning
 Positive pressure (CPAP)

APO/CCF precipitants









MI
Arrhythmias
Drugs (NSAIDs, BB), non-compliance
HT
Anaemia
Toxic (infection)
Thyrotoxicosis
Excess fluids
Respiratory (PE)
CCF disease course
Chronic management (non
pharmacological)
Treat reversible causes
 Fluid restriction (1.5L), salt restriction
 Daily weighs
 Chronic disease clinic – weigh daily,
increase frusemide if 2kg increase
 Cardiac rehabilitation
 Smoking & alcohol
 Vaccinations

Chronic management
(pharmacological)

ACEi
 NYHA I-IV
 Perindopril/ramipril 2.5mg daily, titrate for BP

BB
 NYHA II-IV
 Bisoprolol, carvedilol, metoprolol XR,
nebivolol
 Bisoprolol 2.5mg daily, titrate for HR & BP
Chronic management
(pharmacological)

ARB if ACEi intolerant
 NYHA II-IV
 Candesartan 4mg daily, titrate for BP

Aldosterone antagonists
 NYHA III-IV  spironolactone 25mg daily
 Post MI with LV dysfunction  eplerenone

Morbidity benefit: frusemide, digoxin
Chronic management
(interventional)

ICD (implantable cardiac defibrillator)
 Primary prevention if EF <35%
 Secondary prevention if VF or sustained VT
 Mortality benefit; ? Worse QoL

CRT (cardiac resynchronisation therapy)
 CRT (BiV PPM) if EF <35%, QRS duration
>120ms, NYHA III-IV, sinus rhythm