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Edinburgh Student Surgical Society FINALS DAY: CARDIOLOGY Dr Laura Clark FY3WHAT WE'LL COVER: Acute Coronary Syndromes Heart Failure Hypertension Arrhythmias Cardiac Arrest OtherACUTE CORONARY SYNDROMES Unstable Angina NSTEMI STEMICase 1 56 year old female, presents to hospital with 4 hour history of sudden onset, crushing central chest pain, which radiates into both arms. Vomited 3 times at home. Partner phoned 999. PMH: Nil of note NKDA Nil regular meds FH: Father had an MI in his 50s SH: Minimal alcohol Smokes 10 cigarettes per day Works as a medical secretaryECG Obtained by ambulance crew:What's the diagnosis? A - Anterior NSTEMI B - Takotsubo cardiomyopathy C - Posterior STEMI D - Anterior STEMI E - PericarditisWhat's the diagnosis? A - Anterior NSTEMI B - Takotsubo cardiomyopathy C - Posterior STEMI D - Anterior STEMI E - PericarditisSTEMI History ECG: ST elevation - criteria? New LBBB Territory Serial TroponinsSTEMI Type 1 – spontaneous, plaque rupture thrombotic Type 2 – ischaemic imbalance (oxygen supply demand) (anaemia, post op, shock, arrhythmia etc) Type 3 – death, no biomarker Type 4a, 4b, 5- PCI / stent thrombosis, CABGWhat is the best management? A - Fibrinolysis B - Medical management C - Primary PCI D - Secondary PCI E - CABGWhat is the best management? A - Fibrinolysis B - Medical management C - Primary PCI D - Secondary PCI E - CABGWhat if the angiogram was normal?What if the angiogram was normal? (Hansen, 2007)Case 2 56 year old female, presents to hospital with <24 hour history of sudden onset, crushing central chest pain, which radiates into both arms. Vomited 3 times at home. Partner phoned 999. PMH: Nil of note NKDA Nil regular meds FH: Father had an MI in his 50s SH: Minimal alcohol Smokes 10 cigarettes per day Works as a medical secretaryECG Obtained in A&E:What's the diagnosis? A - NSTEMI B - Takotsubo cardiomyopathy C - Posterior STEMI D - Anterior STEMI E - PericarditisWhat's the diagnosis? A - NSTEMI B - Takotsubo cardiomyopathy C - Posterior STEMI D - Anterior STEMI E - PericarditisYou've discussed the case with your registar. She is scheduled for angiogram tomorrow. Which medical therapies should she be given initially? A - Aspirin 300mg Stat B - Aspirin 75mg OD C - Clopidogrel 300mg Stat D - Fondaparinux 2.5mg OD E - Apixaban 5mg BDYou've discussed the case with your registar. She is scheduled for angiogram tomorrow. Which medical therapies should she be given initially? A - Aspirin 300mg Stat B - Aspirin 75mg OD C - Clopidogrel 300mg Stat D - Fondaparinux 2.5mg OD E - Apixaban 5mg BDSecondary Prevention Which medications should be given (ideally) to all patients following a heart attack? A - DAPT, Beta-blocker, Apixaban, statin B - DAPT, ACEi, Beta-blocker, Statin C - Single antiplatelet, ACEi, Beta-blocker, Statin D - Single antiplatelet, Beta-blocker, Apixaban, statin E - DAPT, Beta-blocker, StatinSecondary Prevention Which medications should be given (ideally) to all patients following a heart attack? A - DAPT, Beta-blocker, Apixaban, statin B - DAPT, ACEi, Beta-blocker, Statin C - Single antiplatelet, ACEi, Beta-blocker, Statin D - Single antiplatelet, Beta-blocker, Apixaban, statin E - DAPT, Beta-blocker, StatinFollowing an MI ECHO Driving advice STEMI Minimum 48-72 hours in hospital Cardiac rehab Follow-upUnstable Angina No evidence of infarction History Angina on exertion, frequency (crescendo) Recurrent and unpredictable at rest Prolonged unprovoked angina, will have trop changes ECG Normal ST dep / TWI which resolves HEART FAILURE Acute Chronic (Acute on Chronic)Case 3 74 year old male, attended GP due to increased breathlessness. Over last month has been unable to sleep in bed. Unable to walk more than a few metres before getting breathless. PMH: IHD with CABG x 3 in 2001 COPD BPH NKDA Regular inhalers Secondary prevention SH: Retired, widowed Ex-smoker 50 pack years No alcoholCase 3 A - E examination: A - Patient's own B - Visibly increased WOB, RR 22, sats 96% on 6L FM, coarse creps heard bilaterally to auscultation C - WWP, HS I+II+quiet ESM, HR 86, BP 156/78 mmHg D - GCS 15, PEARL, afebrile E - Pitting oedema to knees, abdo SNT ECG: Nil acute changes CXR FINDINGS A – Alveolar oedema B – kerley B lines (interstitial oedema) C – Cardiomegaly D – Diverted pulmonary veins E – pleural EffusionCase 3 What would your acute management be?Case 3 Oxygen IV furosemide 50mg (titrate as needed), urine output (catheter) 1.5L fluid restriction Daily weights Daily U&E (renal function) – AKI hypoperfusion Check echo – up to date if none recent (GTN spray / morphine) – not routinely offered NICEHEART FAILUREHEART FAILURE New York Heart Association Classification Class Description Symptoms No limitation of Ordinary physical activity does not cause undue fatigue, I physical activity. palpitation or shortness of breath. Slight limitation of Comfortable at rest. Ordinary physical activity results in II physical activity. fatigue, palpitation, shortness of breath or chest pain. Marked limitation of Comfortable at rest. Less than ordinary activity causes III physical activity. fatigue, palpitation, shortness of breath or chest pain. IV Symptoms of heart Any physical activity causes further discomfort. failure at rest.Long-Term Management HFrEF HFmrEF HFpEF Depends on type/cause of heart failure: Symptoms +/- Signs HFpEF vs HFrEF LVEF ≤40% LVEF 41–49% LVEF ≥50% Objective evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction/raised LV filling pressures, including raised natriuretic peptides Signs may not be present in the early stages of HF (especially in HFpEF) and in optimally treated For the diagnosis of HFmrEF, the presence of other evidence of structural heart disease (e.g. increased left atrial size, LV hypertrophy or echocardiographic measures of impaired LV filling) makes the diagnosis more likely. For the diagnosis of HFpEF, the greater the number of abnormalities present, the higher the likelihood of HFpEF. **Don’t worry about this table, it’s just to highlight that there are different types of heart failure, based on ejection fractionLong-Term Management - HFrEF Which medications would you aim to introduce to patients with HFrEF to reduce mortality? A - Aldosterone antagonist, SGLT2 inhibitor, ACEi/ARB, Beta-blocker B - Thiazide diuretic, SGLT2 inhibitor, ACEi/ARB, Beta-blocker C - Loop diuretic, aldosterone antagonist, ACEi/ARB, calcium channel blocker D - Loop diuretic, thiazide diuretic, ACEi/ARB, Beta-blockerLong-Term Management - HFrEF Which medications would you aim to introduce to patients with HFrEF to reduce mortality? A - Aldosterone antagonist, SGLT2 inhibitor, ACEi/ARB, Beta- blocker B - Thiazide diuretic, SGLT2 inhibitor, ACEi/ARB, Beta-blocker C - Loop diuretic, aldosterone antagonist, ACEi/ARB, calcium channel blocker D - Loop diuretic, thiazide diuretic, ACEi/ARB, Beta-blockerHYPERTENSION Case 4 A 42 year old caucasian male presents to your GP surgery for his annual check-up He is found to have hypertension with systolic reading 156mmHg. What would be your first-line antihypertensive agent? A - ACEi/ARB B - CCB C - Thiazide diuretic D - Beta-blocker E - Doxazocin Case 4 A 42 year old caucasian male presents to your GP surgery for his annual check-up He is found to have hypertension with systolic reading 156mmHg. What would be your first-line antihypertensive agent? A - ACEi/ARB B - CCB C - Thiazide diuretic D - Beta-blocker E - Doxazocin Complications Hypertensive crisis (SBP >200) Intraparenchymal haemorrhage / lacunar infarcts / haemorrhagic stroke Aortic dissection / AAA HTN cardiomyopathy Retinopathy [I-IV] Nephropathy Ischaemic heart disease TACHYARRHYTHMIAS Narrow vs Broad Regular vs Irregular General Approach A-E Examination Stable vs unstable ECG/Cardiac Monitoring Narrow vs broad Rhythm Cause Narrow Complex Regular Atrial flutter 2:1 AV nodal reentrant (AVNRT): paroxysmal SVT AV re-entry tachycardia (AVRT): WPW (accessory pathway) Sinus tachycardia Irregular Atrial fibrillation Atrial flutter with variable AV conduction (variable block) Narrow Complex: SVT ECG: regular narrow complex Tachycardia Adverse feature Synchronised DCCV Call med reg / 2222 Stable, regular Vagal manoeuvres ECG / rhythm monitoring – underlying rhythm? No effect - Adenosine 6mg IVAdenosine Mechanism: blocks AV node Half-life: 10-20 seconds LARGE bore, LARGE vein, fast speed, close to heart 20ml flush Side Effects: Chest pain, tingling, impending doom, flush Contraindications: asthma/COPDAtrial Flutter Most common AV ratio 2:1 Atrial rate 300/min; ventricular rate 150/min Higher degree ‘AVN block’ from rate limiting medications result in lower ventricular rates (3:1, 4:1) 2:1 = 150bpm 3:1 = 100bpm 4:1 = 75bpm Management = atrial fibrillation Can be offered ablation therapy Atrial Fibrillation Classification Lone AF Paroxysmal - < 7 days [ reverts back to SR ] Persistent - > 7 days Permanent - > 1 year rhythm control unsuccessful Atrial Fibrillation Causes: Cardiac IHD, heart failure, MR Endocrine Thyrotoxicosis Electrolyte disturbance Phaeochromocytoma Alcohol/caffeine/drugs Atrial Fibrillation Loss of atrial kick, decrease diastolic filling time Fibrillation, static blood -> clot formation Systemic embolism: stroke Stroke risk: CHA2DS2-VASc offer anticoagulation to those score 2 and above symptomatic / asymp paroxysmal, persistent, permanent AF Bleeding risk: HASBLED Consider alternatives to anticoagulation if 3 or more Atrial Fibrillation - Management Stable vs Unstable Treat underlying cause Electrical vs Pharmacological +/- anticoagulation [CHADVASc] Atrial Fibrillation - Management Synchronised DCCV – 100-150J unstable, <48 hours, fit (less in elderly, frail) >48 hours -> 4/52 anticoag + echo Rate control (preferred method) Beta blocker (often first choice) - usually Bisoprolol, titrated to effect Digoxin (still used) - loading dose e.g. 500 micrograms 12 hourly then reduced to maintenance e.g. 125 micrograms daily Anticoagulation DOAC first line unless contra-indicated Broad Complex Irregular Ventricular fibrillation Polymorphic VT (Torsades) AF with BBB VENTRICULAR FIBRILLATION Not compatible with life 2222, cardiac arrest TORSADES DE POINTES Often short-lived but can degenerate to VF 1-2g Magnesium sulphate IV Broad Complex Regular Monomorphic VT SVT with BBB Ventricular Tachycardia Pulseless Cardiac arrest, 2222 Unstable Synchronised DCCV Amiodrarone through central line Stable/non-sustained Pharmacological e.g. Beta-blockade Ventricular Tachycardia Treat reversible causes MI/ischaemia Electrolyte imbalances Heart failure Some patients may need ablation therapies or ICDsBRADYARRHYTHMIAS Bradyarrhythmias First degree heart block Prolonged PR interval Second degree heart block Mobitz type 1 - Increasing PR interval until QRS dropped Mobitz type 2 - constant PR interval, intermittent conduction Third degree (complete) heart block No relation between p wave and QRS Sinus pause /arrest1ST DEGREE HEART BLOCKMOBITZ TYPE I - WENCHEBACHMOBITZ TYPE II - HAYCOMPLETE HEART BLOCK Bradyarrhythmias - Management Unstable: 2222, medical emergency Atropine 500 micrograms IV Pacemakers Dual chamber recommened by NICE for symptomatic sick sinus syndrome, AV block or combination : CARDIAC ARREST Shockable Rhythm Non-Shockable Rhythm Cardiac Arrest Shockable: 1mg IV adrenaline and 300mg IV Amiodarone after 3rd shock Repeat IV Adrenaline 1mg every 3-5 minutes Further 150mg IV amiodarone after 5th shock Non-Shockable: 1mg IV adrenaline asap Repeat IV Adrenaline 1mg every 3-5 minutes Cardiac Arrest - Reversible Causes What are the 4 Hs? Hypoxia Hypo/Hyperkalaemia - other electrolyte disturbances Hypovolaemia Hypo/hyperthermia What are the 4 Ts? Tamponade Tension PTx Thrombus (MI, PE, etc) Toxins (Medications and drugs) Cardiac Arrest - Reversible Causes What are the 4 Hs? Hypoxia Hypo/Hyperkalaemia - other electrolyte disturbances Hypovolaemia Hypo/hyperthermia What are the 4 Ts? Tamponade Tension PTx Thrombus (MI, PE, etc) Toxins (Medications and drugs) OTHERS TO KNOW Infective Endocarditis Valvular DiseaseQuestions?References All ECGs/Rhythm strips from Life In the Fast Lane Nice Guidelines - ACS, heart failure, hypertension, symptomatic bradycardia Hansen, P.R. (2007) Takotsubo cardiomyopathy: An under-recognized myocardial syndrome, European Journal of Internal Medicine. Elsevier. Available at: https://www.ejinme.com/article/S0953-6205%2807%2900165-3/pdf (Accessed: January 15, 2023) Schulbert, R. (no date) Radiopedia - Radiology quiz 18991, Radiology Quiz 18991. Available at: https://radiopaedia.org/cases/18991/studies/18953? lang=gb&referrer=%2Farticles%2Fheart-failure- summary%3Flang%3Dgb%23image_list_item_2208535 (Accessed: January 15, 2023). Resuscitation Council (UK) - Tachycardia, Bradycardia and ALS algorithms (2021). McDonagh, T., Metra, M., Adamo, M., Gardner, R., Baumbach, A., & Böhm, M. et al. (2021). 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 42(36), 3599-3726.doi: 10.1093/eurheartj/ehab368 Thanks to Dr Hannah Douglas - some slides adapted from her previous ESSS presentationContact Details: Twitter: @L_eClark Email: laura.clark8@nhs.scot