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Peer2Peer Cardiology Ischaemic Heart Disease, Hypertension sdevlin41@qub.ac.uk Created by Stephen Devlin Ischaemic Heart Disease Created by Stephen DevlinContents IHD Clinical Coronary presentations anatomy The ECG Investigations, SA and ACS management Complications Created by Stephen DevlinBackground You’re working at the rapid access chest pain clinic where patients with chest pain are referred from their GP or casualty, assessed and managed appropriately. Created by Stephen DevlinPatient 1 Created by Stephen DevlinPatient 1 Mr Smith is a 55 year old gentleman who complains of chest pain ‘on and off’ for the past 6 months. Yesterday, whilst playing golf with colleagues, he experienced this chest pain, and his wife insisted he attended the clinic to investigate it. He localises the pain to his breast bone and it does not radiate. He describes it as a tight sensation, episodes lasting several minutes and relieved by sitting. His wife is worried because Mr Smith’s father died aged 52 with ‘heart problems’. Mr Smith is a non-smoker, but enjoys an lavish lifestyle. His BMI is calculated at 34 kg / m . Created by Stephen Devlin Patient 1 Summary: 55 year old gentleman, exertional chest pain, tight sensation, relieved by sitting, Mr Smith’s father died aged 52 with 2 ‘heart problems’, BMI is calculated at 34 kg / m . What is the most likely diagnosis? 1. Myocardial infarction 2. Atypical angina 3. Stable angina 4. Pericarditis 5. Unstable angina Created by Stephen Devlin Patient 1 Summary: 55 year old gentleman, exertional chest pain, tight sensation, relieved by sitting, Mr Smith’s father died aged 52 with 2 ‘heart problems’, BMI is calculated at 34 kg / m . What is the most likely diagnosis? 1. Myocardial infarction 2. Atypical angina 3. Stable angina 4. Pericarditis 5. Unstable angina Created by Stephen Devlin Stable Angina Features / Presentation / Pathology: Management (mostly 2º prevention): • Predictable chest pain due to stable Non-pharma Diet and lifestyle advice atherosclerotic plaque (usually), relieved by rest / nitrates Immediate relief GTN spray • Radiates to jaw / neck / arm Pharmacological 1. βB / CCB • Nausea / dyspnoea 2. (LA nitrate, ivabradine, nicorandil) Investigations: 2º prevention 1. Aspirin 75 mg 1. ECG 2. Atorvastatin 80 mg 2. Bloods: TnT, FBC, U&E, LFTs, BM, 3. ACEi lipids, etc. Resistant PCI / CABG 3. Stress ECG / echo 4. Stress myocardial perfusion scan 5. Cardiac catheterisation Remember: • GTN • 4x As (atenolol / amlodipine, aspirin, atorvastatin, ACEi) Created by Stephen DevlinPatient 2 Created by Stephen DevlinPatient 2 You’re typing a letter to Mr Smith’s GP with regards to his new medications whenever you hear some commotion in the waiting room. You look outside and see another clinic attendee, Mr Murphy, is sitting on the floor at the reception desk looking pale, sweaty, short of breath and retching. You have previously met Mr Murphy, a 64 year old gentleman, and remember he has a history of unstable angina, T2DM and hypertension. He has been a smoker all his life and worked in a sedentary job, and recall his wife who complained about non-compliance with medications at the last appointment. Created by Stephen Devlin Patient 2 Conveniently you’re in the RVH and quickly alert your interventional colleague to prepare the cath lab. Given the most likely diagnosis, what procedure is going to be performed? 1. Coronary intravascular ultrasound 2. Primary percutaneous coronary intervention 3. Alcohol ablation 4. Loop recorder implantation 5. TAVI Created by Stephen Devlin Patient 2 Conveniently you’re in the RVH and quickly alert your interventional colleague to prepare the cath lab. Given the most likely diagnosis, what procedure is going to be performed? 1. Coronary intravascular ultrasound 2. Primary percutaneous coronary intervention 3. Alcohol ablation 4. Loop recorder implantation 5. TAVI Created by Stephen DevlinPatient 2 An ECG is obtained: Created by Stephen DevlinPatient 2 In what coronary artery is the stent going to be placed? 1. Posterior descending artery 2. Left circumflex artery 3. Aorta 4. Left anterior descending artery 5. Right marginal artery Created by Stephen DevlinPatient 2 In what coronary artery is the stent going to be placed? 1. Posterior descending artery 2. Left circumflex artery 3. Aorta 4. Left anterior descending artery 5. Right marginal artery Created by Stephen DevlinPatient 2 ST elevation in leads V1-V4, indicating anteroseptal ischaemia → LAD occlusion Created by Stephen DevlinACS Anatomy (LAD) Created by Stephen DevlinACS ECG leads Created by Stephen Devlin Remember: • I, aVL, V5 and V6 are lateral on the paper ACS • II, III and aVF are inferior on the paper ECG findings Lateral Septal Anterior Inferior Lateral Septal Lateral Inferior Inferior Anterior Lateral Other ECG changes in MI: 1. ST elevation / depression (ST-T changes) These may / may 2. New LBBB not be present, 3. Pathological Q-waves depending on the 4. Hyperacute T-waves → T-wave inversion timing of the ECG Created by Stephen Devlin ‘Contiguous leads’ = leads which look at the same ACS area of the heart ECG findings summary Location Leads Vessel % Anterior (V1, V2,) V3, V4 LAD 40-50% Lateral I, aVL, V5, V6 Circumflex a. 15-20% Anterolateral V3, V4, V5, V6, I, aLCA <10% Inferior II, II, aVF RCA 30-40% The ECG leads do not look directly at the posterior aspect of the heart, therefore a posterior MI will usually present with ST depression in V1-V3. Confirm this with leads V7-9. Created by Stephen DevlinACS Less severe More severe (Stable angina) ACS Unstable NSTEMI STEMI angina The term ACS refers to a group of conditions that result from a sudden and unpredictable disruption in coronary blood flow. They can be imagined on a spectrum (as above), ranging from myocardial ischaemia (unstable angina), to myocardial infarction and necrosis (NSTEMI / STEMI). Created by Stephen Devlin ACS Less ACS More severe severe Unstable NSTEMI STEMI angina What combination of ECG and blood biomarker changes will be seen in Mr Murphy’s case? 1. ST elevation, elevated troponin, normal myoglobin 2. ST elevation, elevated troponin, elevated myoglobin 3. No ST elevation, elevated troponin, elevated myoglobin 4. ST depression, normal troponin, normal myoglobin 5. No ST elevation, normal troponin, normal myoglobin Created by Stephen Devlin ACS Less ACS More severe severe Unstable NSTEMI STEMI angina What combination of ECG and blood biomarker changes will be seen in Mr Murphy’s case? 1. ST elevation, elevated troponin, normal myoglobin 2. ST elevation, elevated troponin, elevated myoglobin 3. No ST elevation, elevated troponin, elevated myoglobin 4. ST depression, normal troponin, normal myoglobin 5. No ST elevation, normal troponin, normal myoglobin Created by Stephen Devlin ACS Less ACS More severe severe Unstable angina NSTEMI STEMI Myocardial Myocardial Myocardial • Myoglobin Pathology ischaemia infarction necrosis rises within 1 hour • Troponin ECG changes No ST elevation No ST elevation ST elevation rises within 6 hours • Normal • Raised • Raised Biochemical troponin troponin troponin changes • Normal • Raised • Raised myoglobin myoglobin myoglobin Created by Stephen DevlinACS Investigations Management – check local guidelines 1. Serial ECGs General ACS: 2. Bloods: serial TnT, FBC, N Nitrates U&E, LFTs 3. CXR O Oxygen (if low sats) 4. (Echo) M Morphine 5. Coronary angiography A Antiemetic (metoclopramide) D Dual antiplatelet therapy • Aspirin 300 mg • Clopidogrel 300 mg S Statin Created by Stephen Devlin Nitrates Mode of Action Relaxes vascular smooth muscles, dilation of coronary / systemic vessels → Which of these is the main contraindication improved myocardial O supply, and to GTN? 2 reduced preload 1. Elderly 2. Hepatic impairment Side effects 3. Pregnancy • Headache 4. On paracetamol • Postural 5. Hypotension hypotension • Tachycardia • Flushing • Tolerance issues Created by Stephen Devlin Nitrates Mode of Action Relaxes vascular smooth muscles, dilation of coronary / systemic vessels → Which of these is the main contraindication improved myocardial O supply, and to GTN? 2 reduced preload 1. Elderly 2. Hepatic impairment Side effects 3. Pregnancy • Headache 4. On paracetamol • Postural 5. Hypotension hypotension + recent MI, HF, hypothyroidism • Tachycardia • Flushing • Tolerance issues Created by Stephen DevlinSTEMI Management – check local guidelines 1. PPCI (within 2 hours) 2. If PPCI not available within 90-120 minutes, thrombolysis • Alteplase Some people remember BATMAN NSTEMI / UA for an NSTEMI Management – check local guidelines 1. Medical – consider the following: • Anticoagulation (fondaparinux) without angiography • Glycoprotein IIb/IIIa inhibitors, with angiography (± PCI) Created by Stephen DevlinAcute Treatment Summary NOMADS Unstable STEMI NSTEMI angina PPCI Fondaparinux Fondaparinux GP2b/3a GP2b/3a inhibitors inhibitors Proceed to post-acute management Created by Stephen Devlin Post-Acute Management / 2º Prevention 1. Non-pharmacological • Diet, exercise, smoking cessation, lifestyle 2. Pharmacological • Nitrates • Beta blocker • Dual anti-platelet therapy (aspirin 75 mg, clopidogrel 75 mg / ticagrelor 90 mg BDS) • Statin • ACE inhibitors Like stable angina: • GTN • 4x As (atenolol, aspirin (and another), atorvastatin, ACEi) Created by Stephen Devlin Based on evidence available at that time and trust protocols, recommendations will change – so have a general idea of how diseases are managed but don’t worry about the details John A Goudevenos, Sigrun Halvorsen, Gerhard Hindricks, Adnan Kastrati, Mattie J Lenzen, Eva Prescott, Marco Roffi, Marco Valgimigli,a, Christoph Varenhorst, Pascal Vranckx, Petr Widimský, ESC Scientific Document Group, 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC),European Heart Journal, Volume 39, Issue 2, 07 January 2018, Pages 119–177, https://doi.org/10.1093/eurheartj/ehx393 Created by Stephen DevlinACS Complications D Death R Recurrence, rupture E Oedema (HF), embolism A Arrhythmia, aneurysm D Dressler syndrome Created by Stephen DevlinHypertension Created by Stephen DevlinContents Hypertension Clinical Investigations, Hypertension presentations management pharmacology Classifications Epidemiology Hypertensive emergencies Created by Stephen DevlinPatient 1 Created by Stephen Devlin Patient 1 Mrs Taylor is a Caucasian 58 year old teacher who attends her GP for a medication review after having to visit A&E for a minor injury. She has her blood pressure checked (3 readings taken) and the nurse says the reading is high. What is the next step to take in order to diagnose hypertension? 1. Offer ambulatory blood pressure monitoring 2. Tell Mrs Taylor to calm down and retake the reading 3. Tell Mrs Taylor to improve her lifestyle and diet and return in 2 weeks for a repeat reading 4. Prescribe amlodipine 5. Try another blood pressure machine Created by Stephen Devlin Patient 1 Mrs Taylor is a Caucasian 58 year old teacher who attends her GP for a medication review after having to visit A&E for a minor injury. She has her blood pressure checked (3 readings taken) and the nurse says the reading is high. What is the next step to take in order to diagnose hypertension? 1. Offer ambulatory blood pressure monitoring 2. Tell Mrs Taylor to calm down and retake the reading 3. Tell Mrs Taylor to improve her lifestyle and diet and return in 2 weeks for a repeat reading 4. Prescribe amlodipine 5. Try another blood pressure machine Created by Stephen Devlin >140/90 mmHg (usually) Hypertension (1) Investigations: Clinical features: • Clinic BP • Usually asymptomatic • ABPM / HBPM • Symptoms related to underlying cause, • Additional: U&Es, eGFR, for example, headaches, palpitations, echocardiogram, ECG, fasting blood sweating glucose, lipids, etc. • Symptoms caused by complications of the disease Management: What is the purpose of the additional investigations above? • Diet and lifestyle advice • Treat cause • Medications: 1. Categorise the HTN 2. Assess for the most suitable • βB pharmacological intervention • CCB 3. Rule out a renal cause of HTN • ACEi • ARB 4. Assess for complications • Thiazide diuretic 5. All of the above • Direct renin inhibitors Created by Stephen Devlin >140/90 mmHg (usually) Hypertension (1) Investigations: Clinical features: • Clinic BP • Usually asymptomatic • ABPM / HBPM • Symptoms related to underlying cause, • Additional: U&Es, eGFR, for example, headaches, palpitations, echocardiogram, ECG, fasting blood sweating glucose, lipids, etc. • Symptoms caused by complications of the disease Management: What is the purpose of the additional investigations above? • Diet and lifestyle advice • Treat cause • Medications: 1. Categorise the HTN 2. Assess for the most suitable • βB pharmacological intervention • CCB 3. Rule out a renal cause of HTN • ACEi • ARB 4. Assess for complications • Thiazide diuretic 5. All of the above • Direct renin inhibitors Created by Stephen DevlinHypertension (2) Mrs Taylor is: • Caucasian • 58 years old • does not have T2DM What drug would be given to treat Mrs Taylor’s hypertension? Created by Stephen DevlinHypertension (2) Mrs Taylor is: • Caucasian • 58 years old • does not have T2DM Therefore, the first-line treatment for her hypertension is a CCB, for example: • Amlodipine • Nifedipine This is a common exam question, usually first-line treatment and knowing whether to give a CCB (-dipine), ACEi (-pril), or an ARB (-sartan). Created by Stephen DevlinCreated by Stephen Devlin Patient 1 Following a normal examination, Mrs Taylor has the following results from investigations: FBC U&Es LFTs Others Hb 134 Na 137 PO4 1.01 ALP 44 TSH 2.3, T4 12 [Results all normal] WCC 6.0 K 4.4 Creat 67 GGT 24 Triglycerides 1.45 Plts 350 Ca 2.2 AST 33 Glucose 4.2 Urea 3.1 ALT 25 Dexamethasone suppression Normal What kind of hypertension is this? 1. Hypertension of endocrine cause 2. Essential hypertension 3. Hypertension 2º to PCKD 4. Tertiary hypertension 5. Hypertension 2º to T2DM Created by Stephen Devlin Patient 1 Following a normal examination, Mrs Taylor has the following results from investigations: FBC U&Es LFTs Others Hb 134 Na 137 PO4 1.01 ALP 44 TSH 2.3, T4 12 [Results all normal] WCC 6.0 K 4.4 Creat 67 GGT 24 Triglycerides 1.45 Plts 350 Ca 2.2 AST 33 Glucose 4.2 Urea 3.1 ALT 25 Dexamethasone suppression Normal What kind of hypertension is this? 1. Hypertension of endocrine cause 2. Essential hypertension 3. Hypertension 2º to PCKD 4. Tertiary hypertension 5. Hypertension 2º to T2DM Created by Stephen DevlinHypertension (3) Definitions: • Essential hypertension – no secondary cause, 95% • Secondary hypertension – due to another disease, 5% Cause of secondary hypertension: R Renal • Diabetic nephropathy, PCKD, atherosclerosis, fibromuscular dysplasia E Endocrine • Cushing’s, phaeochromocytoma, aldosteronoma M Medications • Including the contraceptive pill, steroids, NSAIDs, some SNRIs A Coarctation of the aorta P Pregnancy Created by Stephen Devlin HTN affects around 1/3 of patients aged 45-54 and around 70% of patients 75+ Hypertension (4) Epidemiology: Figure 1: Prevalence of essential Hypertension by age and aggregated ethnic groups, using low east London GLA population estimates as denominator. Values are population percentages (95% CIs). Created by Stephen DevlinPatient 2 Created by Stephen DevlinPatient 2 Mr Martin is a 73 year old Caucasian gentleman who is brought to A&E in an ambulance with a severe headache, chest pain, and epistaxis (which has since stopped). He also reports generalised blurring of his vision over the course of the last 48 hours. A full examination is performed, and the F2 doctor notes the following abnormal fundoscopy: Created by Stephen DevlinPatient 2 What key feature(s) on fundoscopy indicates the development of malignant hypertension? 1. Papilloedema & flame haemorrhages 2. Cotton-wool spots 3. Flame haemorrhages 4. A cherry-red spot & flame haemorrhages 5. Neovascularisation Created by Stephen DevlinPatient 2 What key feature(s) on fundoscopy indicates the development of malignant hypertension? 1. Papilloedema & flame haemorrhages 2. Cotton-wool spots 3. Flame haemorrhages 4. A cherry-red spot & flame haemorrhages 5. Neovascularisation Created by Stephen Devlin Usually with a Hypertensive Emergencies couple of medications • No defined blood pressure threshold, but usually: • Systolic blood pressure (top number) > 180-220 mmHg • Diastolic blood pressure (bottom number) > 120 mmHg • Requires immediate BP reduction (10% in 1st hour, 15% in subsequent hours) 1. Hypertensive urgency • No end-organ damage present (no eye signs, cerebral disease, renal failure, etc.) 2. Accelerated hypertension • Severe hypertension, end organ damage, retinopathy, no papilloedema 3. Malignant hypertension • Severe hypertension, end organ damage, retinopathy, papilloedema Created by Stephen DevlinHypertension (5) Complications: Eyes Hypertensive retinopathy Cardiovascular LV hypertrophy, HF, arrhythmias Kidneys CKD, glomerulosclerosis, hypertensive nephropathy Brain Stroke, haemorrhage (SAH, intracerebral haemorrhage), impaired cognition, hypertensive encephalopathy Rarely, hypertensive emergencies (previous slide) may result from prolonged, uncontrolled HTN Created by Stephen DevlinThank you! Questions? sdevlin41@qub.ac.uk This presentation was created by Slidesgo, including icons by Flaticon, and infographics & images by Freepik Created by Stephen DevlinResources • European Society of Cardiology (ESC) guidelines • British Cardiovascular Society, British Undergraduate Cardiovascular Association (BUCA) • Textbooks: • Medicine in a Minute • Oxford Handbook of Clinical Medicine • Online: • Zero to Finals, Geeky Medics • Instagram: • @qubims, @qubcardiosoc, @qubscrubs • @europeansocietyofcardiology • @cardiologymadeeasy • @cardiovisual Created by Stephen Devlin