Transcript Cardio Teaching phase 2a

Phase 2a
Sasan Panbehchi & Areeb Mazhar
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Aims
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Valvular disease
Hypertension
Stable vs Unstable Angina
Myocardial Infarction
Heart Failure
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Heart Valves
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Aortic Stenosis – Aetiology
• Congenital – biscuspid valve
• Senile Calcification – most common cause,
mostly in the elderly
• Autoimmune/infection: Rheumatic Fever
• Others: William’s Syndrome
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Aortic Stenosis – Clinical presentations
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Symptoms:
– Usually none until AS is moderately severe (aortic orifice is ≤ 1/3 of its normal
size
Severe AS
– S – Syncope (exercise induced)
– A – Angina (from LV hypertrophy)
– D – Dyspnoea (due to pulmonary oedema from heart failure)
Signs
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Carotid Pulse: small volume, slow-rising, narrow pulse pressure
Thrill: systolic thrill may be palpable over aortic area
Auscultation: ejection systolic murmur radiating to the carotids
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Aortic Stenosis - Investigation
• ECG
• CXR
• Exercise testing
• ECHO!!!
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Aortic Stenosis-Management
1. Modify atherosclerotic RF as high risk of IHD
2. Digoxin, ACE-I, diuretics if symptomatic
(careful!)
3. Monitoring
4. AVR-mortality 4-8%
5. Balloon valvuloplasty-efficacy?
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Aortic Regurgitation-Aetiology
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Rheumatic heart disease
SLE
Marfans
Ehler Danlos Syndrome
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AR-Clinical Presentations
• Symptoms
• LV hypertrophy-dizziness, angina on exertion (< flow
to CA), palpitations
• If severe=heart failure symptoms
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Signs
Characteristic early diastolic murmur
Water hammer pulse, de musset sign
Low diastolic pressure
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AR-Investigation and management
• Ix
• Echo again
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Mx
Monitor
Treat heart failure
Valve replacement
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Mitral Stenosis-Aetiology
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Rheumatic fever
Degenerative calcification
Congenital
Amyloid, RA etc
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Mitral Stenosis-Clinical presentation
• Symptoms
• SOBOE, orthopnea, PND,
• AF and systemic emboli
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Signs
mid diastolic murmur
Malar flush
RV heave
Raised JVP
Laterally displaced apex beat
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Mitral Stenosis-Investigation and management
• Ix
• Same as before!
• Mx
• Monitoring
• Medication-diuretics and long acting nitrates for
dysponea. Anticoagulation.
• PMC-percutaneous mitral balloon valvuloplasty
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Mitral Regurgitation-Aetiology
• MI
• Infective endocarditis
• Ehler danlos, marfan and SLE
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Mitral Regurgitation-Clinical presentation
• Symptoms
• Acute can cause life threatening pul. Oedema
• Chronic usually well tolerated but can get dysponea
• Signs
• Pansystolic murmur
• Often not much
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Mitral Regurgitation-Investigation and
management
• Investigation
• Rinse and repeat
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Management
If acute give nitrates, diuretics, positive inotropes
If HF give ACE-I and spironolactone
Valve replacement
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Hypertension
• If BP in GP is >140/90mmHg then offer ABPM. If high
normal then continue reviewing annually.
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NICE suggests:
Stage 1 HTN: >140/90mmHg
Stage 2 HTN: >160/100mmHg
Stage 3 HTN: >180/110mmHg
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Hypertension-aetiology
• Essential/primary HTN (most common)
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Secondary:
HTN and pre-eclampsia in pregnancy
Cushings, conns and phaechromocytoma
Coarctation of aorta
Renal disease
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Hypertension-clinical presentation
• Usually asymptomatic but rule out secondary causes.
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Take a full DH
Ever get headaches, palpitations, sweating episodes?
FH kidney disease? Palpable kidneys?
Cushingoid appearance?
Consider their lifestyle and contributing factors: salt,
obesity, lack of exercise, CV risk factors
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Hypertension-Investigations
• End organ damage: urine dipstick, serum creatinine
and eGFR, 12 lead ECG, echo
• CV disease prevention: fasting blood glucose and
serum lipids
• Secondary causes: renin/aldosterone ratio, 24hr
urinary metanephrines, MRI renal arteries etc
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Hypertension-Management
• Lifestyle interventions-lose weight, reduce salt, encourage exercise, stop
smoking
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Stable angina-aetiology
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Smoking
Diabetes
Obesity
Sedentary lifestyle
Metabolic syndrome
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Stable angina-Clinical presentation
• 3 factors:
• 1. constricting pain in chest, may radiate to back,
shoulders or neck
• 2. exercise is the precipitant
• 3. relieved by rest or GTN spray
• Typical, atypical and non-anginal pain
• If prolonged, worse on inspiration, not related to
exercise etc then not likely to be angina
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Stable angina-Investigations
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12 lead ECG
FBC?
TFT
Cardiac enzymes
Echo
• Diagnosis is clinical
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Stable angina-Management (NICE)
• 1st line-BB or CCB
• If symptoms do not improve then use both or if one
is contraindicated then add in a long acting nitrate,
nicorandil or ivabradine.
• Only add a 3rd anti angina drug if symptoms still not
adequately controlled
• Also all patients should be on aspirin and statins
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Unstable Angina
• Definition: angina of increasing frequency or
severity; occurs on minimal exertion or at rest;
associated with increased risk of MI.
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Unstable Angina- Management
• Conservative: Modify risk factors, i.e. Stop smoking,
exercise, weight loss and control hypertension and
DM.
• Medical: Aspirin, beta-blockers, Ca2+ channel
blockers, GTN for symptomatic relief.
• Surgical: Percutaneous transluminal coronary
angioplasty (PTCA) involves balloon dilatation of the
stenotic vessel(s). Indications: poor response to
medical treatment or not suitable for CABG etc.
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Acute Coronary Syndromes
• Includes:
1. Unstable Angina
2. STEMI (i.e. acute MI)
3. NSTEMI
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ACS
Risk Factors:
Modifiable:
Non-modifiable:
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• Age
• Gender
• Family history
Smoking
Hypertension
DM
Hyperlipidaemia
Obesity
Sedentary life-style
Controversial Risk factors: stress, type A personality, hyperinsulinaemia,
ACE genotype, etc.
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ACS
• Incidence 5/1000 per annum (UK) for ST-segment
elevation (declining in UK)
• Several diagnostic criteria exist. Most common one is
a symptomatic patient + initially increasing and then
decreasing cardiac biomarkers as well as ECG
changes etc.
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ACS- Signs and Symptoms
• Symptoms:
• Signs:
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Distress, anxiety, pallor, sweatiness, pulse
increased or decreased, BP high or
low, 4th heart sound. There may be
signs of heart failure (raised JVP, 3rd
heart sound, basal crepitation) or a
pansystolic murmur (papillary muscle
dysfunction/rupture, VSD). Lowgrade fever may be present. Later, a
pericardial friction rub or peripheral
oedema may develop.
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Acute central chest pain, lasting
>20min, which radiates to left side
of the jaw and left arm, often
associated with nausea, sweatiness,
dyspnoea, palpitations.
BUT, BE CAREFUL!!!!
May present without chest pain
specially in the very elderly or
diabetics.
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Management of Acute MI
1. MONA
2. Attach ECG monitor and record a 12-lead ECG
3. IV access and Bloods incl. FBC, U&Es, Glucose and
specially Cardiac enzymes. Cardiac troponin levels (T and I)
are the most sensitive and specific markers of myocardial necrosis.
Serum levels increase within 3–12h from the on- set of chest pain, peak
at 24–48h, and decrease to baseline over 5–14 days.
4. B-blockers
5. Primary PCI or thrombolysis (Streptokinase or
Alteplase)
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Long term management
• Start Regular Aspirin, B-blocker, ACE-I, Statin and
address the modifiable risk factors.
• Review regularly- VERY IMPORTANT!!!
• Complications can be devastating….
• Examples include:
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Cardiac arrest
Pericarditis
Cardiac tamponade
Heart failure
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Heart failure
Definition:
Cardiac output is inadequate to meet body’s
metabolic demands.
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HF- Basic concepts
• Different ways of classifying it such as systolic vs
diastolic, acute vs chronic, low-output vs high output but the most common is LEFT sided vs RIGHT
sided heart failure.
• Prevalence is 1-3% of general population and
prognosis is not great. If hospital admission is
required there is a 5yr mortality of 75%.
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Left Vs Right
• May occur independently or together as CCF.
Right sided heart failure:
Left sided heart failure:
Symptoms:
Symptoms:
Peripheral oedema (up to thighs,
sacrum, abdominal wall), ascites,
nausea, anorexia, facial engorgement,
pulsation in neck and face (tricuspid
regurgitation)
Causes: LVF, pulmonary stenosis,
lung disease. (cor pulmonale)
Dyspnea, poor exercise tolerance, fatigue,
orthopnoea, paroxysmal nocturnal
dyspnoea (PND), nocturnal cough
(±pink frothy sputum), wheeze (cardiac
‘asthma’), nocturia, cold peripheries, weight
loss, muscle wasting.
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Signs:
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Diagnosis can be made
using Framingham
criteria (see BOX).65
Other signs:
exhaustion, cool
peripheries, cyanosis,
High BP, narrow pulse
pressure, pulsus
alternans, displaced
apex (LV dilatation),
RV heave (pulmonary
hypertension),
murmurs of mitral or
aortic valve disease,
wheeze.
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Diagnostic Criteria:
• Don’t
forget
BNP!!!
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Management:
• Once again, conservative, medical and surgical
interventions to offer.
• Treat the underlying cause such as vacuities,
hypertension and cardiomyopathy
• Medical treatment (Next slide).
• Surgical interventions such as valve replacement etc.
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Medical management
• Medications are divided into ones that improve
prognosis and ones that help with the symptoms.
• What medications are given to people with HF?
1. Diuretics (Furosemide +/- Spironolactone)
2. ACE-i (if intolerant because of side effects for
example use Vasodilators)
3. B-blockers
4. Digoxin
5. Aspirin
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