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BIMA Clinical Series: Cardiology Core Conditions Part 2 By Callum Cutinha 7pm, 18 January BRITISH INDIAN MEDICAL @BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS ASSOCIATION @BIMA BIMA Clinical SeriesSession plan • ECG interpretation • Introduction to acute coronary syndrome • Stable angina • Unstable angina • ST elevation myocardial infarction (STEMI) • Non-ST elevation myocardial infarction (NSTEMI)ECG interpretationECG interpretation system 1.Patient ID + if symptomatic at time of ECG 2.Heart rate 3.Rhythm 4.Cardiac axis 5.P waves 6.PR interval 7.QRS complex 8.ST segment 9.T waveECG territories of the heart Lead I avR V1 V4 Septal Anterior Lateral Circumflexartery Leftantartery (LAD)ing Rightcoronary artery Lead II aVL V2 V5 Inferior Lateral Septal Rightcoronary artery circumflexartery Leftanteriordescending Lateral circumflexartery artery (LAD) Lead III aVF V3 V6 Inferior Inferior Anterior Rightcoronary artery Rightcoronary artery Rightcoronary artery Lateral circumflexarteryStable AnginaDiagnostic criteria of stable angina •NICE diagnostic criteriafor stable angina • Clinical history in keeping with anginal chest pain • Significant coronary artery disease on CT coronary angiography or • Reversible myocardial ischaemia on non-invasive functional imaging •NICE criteriaof anginal chest pain • Constricting discomfort, front of chest/neck/shoulder/jaw/arms • Precipitated by physical exertion • Relieved by rest or GTN within about 5 minutesInvestigations Specialist and Bedside Bloods Imaging scoring • Cardiac • Cardiac risk • Echo • Rapid access examination • HbA1c • CT angiogram chest pain • Vital signs • Lipids • Exercise ECG clinic • ECG • Exacerbating stress test • Invasive factors coronary • FBC (anaemia) angiography • TFTs • Q risk score • U&Es • LFTsManagement of stable angina Conservative Medical Surgical • Acute relief • Health education • CABG • Smoking cessation • Anti-anginal • PCI • Cardiac risk • Diet • Exercise management • Normal weightManagement -medical Short term •GTN spray nitrate •For acute symptom relief, PRN •1 – β-blocker(e.g.bisoprolol)or CCB(eg diltiazemor verapamil) •2d– dualtreatment(β-blocker+CCB) Anti-anginal •3 – monotherapywith either:Long-actingnitrate;Ivabradine;Nicorandil; •4 – tripletherapy • Aspirin Secondary • ACEi prevention • Atorvastatin • HTN treatmentIntroduction to acute coronary syndromeAcute coronary syndrome Refers to spectrum of cardiac disease where myocardial perfusion is compromised Includes: ○Unstable angina ○Non-ST elevation MI (NSTEMI) ○ST elevation MI (STEMI) Underlying pathology ○Most commonly due to atherosclerosis Shared risk factors ○Non-modifiable – age, male, FHx, ethnicity ○Modifiable – smoking, HTN, DM, hyperlipidaemia, obesity, sedentary lifestylePresentation of ACS Cardiac chest pain Sympathetic symptoms • Nausea andvomiting • Sweating • SOB Silent MI symptoms • Syncope • Pulmonary oedema • Epigastric pain • Acute confusion • Hyperglycaemic state (DM) • palpitationsCardiac chest pain Features differentiating chest pain vs cardiac chest pain Suddenonsetsevere,central,crushingchestpain • May radiate to arms,jaw or back • Constant, lasting >15 minutes • Unstable angina – onsetat rest • Worse on exertion • May have complete or partial relief with GTN/restInvestigations in the acute setting - ACS Specialist Bedside Bloods Imaging or scoring • ECG • Cardiac enzymes • CXR • Cardiac angiography • Examine (cardio + - Troponin • Echocardiogram • GRACE score resp) - CK-MB • Vitals •FBC, U&E, lactate •Risk factors (glucose, lipids)Unstable anginaUnstable angina Refers to cardiacchestpain which may occur at rest and is notrelievedby rest or GTN • No dynamic ECG changes • Biochemistry isn’t in keeping with acute MI NICE recommends initialtreatmentin line with NSTEMI managementMyocardial infarctionNSTEMI vs STEMI • Both are associatedwith an ischaemicinjury of the myocardium • Biochemistry is expected to be positive in both • STEMI New ST elevation in consecutive leads New onset LBBB • NSTEMI Any other ischaemic features on ECG Eg T wave inversion, ST depressionECG evolution in STEMI • HyperacuteT-waves(minutesto hours) • ST elevation(0-12hours) • PathologicalQ waves(1-12hours) • ST backtobaseline,Twave inversion(2-5days) • T wavenormalization(weeksto months) • PathologicalQ wavesintheaffectedleadsareusuallypermanentchanges IfanteriorsegmentSTelevationpersists, LV aneurysmshouldbe suspected.T waves in ischaemia HyperacuteT wave Inverted T waveST segment changes in ischaemia ST elevation ST depressionPathological Q wavesLeft bundle branch block WiLLiaM MaRRoWWhat’s the pathology?Acute management –NSTEMI and unstable angina 1. Hospital, admission + A-E resuscitation 2. Oxygen if saturations < 94% 3. 300mg PO aspirin 4. GTN spray 5. IV morphine + anti-emetic 6. Anti-thrombin treatment – fondaparinux or LMWH (unless immediate PCIor very high bleeding risk) 7. Second anti-platelet loading ifhigh risk 8. Coronary angiography + PCI within 72 if high riskAcute management -STEMI 1. Hospital, admission + A-E resscitation 2. Oxygen if saturations < 94% 3. 300mg PO aspirin 4. Loading with second anti-platelet 5. GTN spray 6. IV morphine + anti-emetic 7. Treatment: • Coronary angiography + PCI (<12hrs onset of pain + <2hrof presentation • Thrombolysis (if PCI is unavailable, streptokinase + fondaparinux, must be ICU)Long term management Cardiac rehabilitation • Physicalactivity • Lifestyleadvice • Stressmanagement • Healtheducation Secondary prevention • ACEi • Dualantiplatelettherapy • Beta-blocker • High dose statin • SpironolactoneComplications of myocardial infarction Complication type Manifestation Ischaemic - Angina - Re-infarction - Infract extension Mechanical - Heart failure –acute orchronic - Mitral valve dysfunction (papillary muscle rupture/infarct) -Cardiac rupture (ventricle free wall -Arrhythmia Arrhythmia -Heart block common in inferior MI as RCAsupplies SA node Embolic -Thromboembolism due to mural thrombus formation Inflammatory -Dressler’s syndrome (pericarditis)Case based discussion A 65-year-old gentleman presents to A&E with central chest pain which he describes as someone sitting on his chest. The pain started 30 minutes ago and is spreading up his left jaw. He has vomited twice since the pain started and is feeling sweaty. He has never had this pain before. He is a smoker with a 40 year pack history. He is a type 2 diabetic on diet control, with a BMI of 32. He does not take any regular medication. No significant family history. On arrival at A&E his observations are: HR 120, BP 110/80, saturations 92%, temperature 37.2, RR 18Case based discussion What is the next most appropriate step? 1. ECG 2. Start oxygen 3. Put out an arrest call 4. Give 300mg aspirin 5. Check his blood sugarCase based discussion What is the next most appropriate step? 1. ECG 2. Start oxygen 3. Put out an arrest call 4. Give 300mg aspirin 5. Check his blood sugarThis is his ECGWhat is the next most appropriate next step? 1. GTN spray 2. Loading dose of 300mg aspirin and 180mg ticagrelol 3. IV fluids 4. Fondaparinuxand transfer to ICU for thrombolysis 5. TroponinWhat is the next most appropriate next step? 1. GTN spray 2. Loading dose of 300mg aspirin and 180mg ticagrelol 3. IV fluids 4. Fondaparinuxand transfer to ICU for thrombolysis 5. TroponinCase based discussion The patient is admitted to the hospital and treated with PCI. Before discharge, the FY1 is asked to review the patient’s lifestyle and identify modifiable factors which increase the risk of a future cardiac event. Select all that apply: 1. Male 2. Smoking 3. History of paternal MI at 80 4. T2DM 5. ObesityCase based discussion The patient is admitted to the hospital and treated with PCI. Before discharge, the FY1 is asked to review the patient’s lifestyle and identify modifiable factors which increase the risk of a future cardiac event. Select all that apply: 1. Male 2. Smoking 3. History of paternal MI at 80 4. T2DM 5. ObesityCase based discussion After his PCI the patient is asking how long he needs to take blood thinners for? Select the correct answer: 1. He can stop on discharge 2. He needs both lifelong 3. He must continue both for 1 year and then take aspirin lifelong 4. On discharge he only needs to take the aspirin 5. He can stop 6 weeks after PCICase based discussion After his PCI the patient is asking how long he needs to take blood thinners for? Select the correct answer: 1. He can stop on discharge 2. He needs both lifelong 3. He must continue both for 1year and then take aspirin lifelong 4. On discharge he only needs to take the aspirin 5. He can stop 6 weeks after PCITHANK YOU FOR LISTENING ANY QUESTIONS INSERTQR CODE FOR FEEDBACK FORM BIMA Clinical Series