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BIMA Chronic CardioTopics - Hypertension - Valvular Diseases - Rheumatic Fever - Infective Endocarditis - HOCMSBA 1 A 83-year-old gentleman comes into the GP practice for the results of his ambulatory blood pressure readings. The average BP is 145/87. He has no other presenting complaints and his past medical history is significant for an appendicectomy when he was 14. Based on the above information, what is the best management of this patient’s hypertension? • A: Amlodipine • B: Bisoprolol • C: Candesartan • D: Ramipril • E: MonitorSBA 1 A 83-year-old gentleman comes into the GP practice for the results of his ambulatory blood pressure readings. The average BP is 145/87. He has no other presenting complaints and his past medical history is significant for an appendicectomy when he was 14. Based on the above information, what is the best management of this patient’s hypertension? • A: Amlodipine – Would be first line if patient <80 and had symptoms/ BP >150/95… • B: Bisoprolol – Third line • C: Candesartan – Second line in over 55’s • D: Ramipril – Second line in over 55’s • E: Monitor – No PMHx or worrying signs. >80. No treatment necessaryHypertension Definition: • BP >140/90 (Ambulatory BP >135/85) Aetiology: • Idiopathic • Endocrine: Phaeochromocytoma (Adrenal tumour), Cushing’s (Hypercortisolism)… • Renal: Renal artery stenosis (RAAS ↑) • Pain, emotional stress….. Clinical Features: • Often incidental finding Complications: • Headaches, visual disturbance, kidney injury, heart failure…Hypertension diagnosis End-Organ Damage: • Heart: Ischaemic ECG changes • Renal: Urine ACR, U&E’s • Eyes: Papilloedema, retinal haemorrhage CVD risk – qRISK score. If Clinic BP >180/120: • Specialist Assessment: • Eye Issues • You’re worried: Heart failure/ AKI/ Chest Pain/ Headache/ Palps… • Investigate End organ Damage • Present?  Treat immediately • Not present  Repeat BP in 7 days.SBA 2 A 73-year-old Caucasian gentleman comes into the GP practice for the results of his ambulatory blood pressure monitoring. His average blood pressure at home is 170/105mmHg. His past medical history includes hypercholesterolaemia and Type 2 diabetes mellitus. He has no known drug allergies What is the most appropriate management of this patient’s hypertension? • A: Ramipril • B: Candesartan • C: Bisoprolol • D: Amlodipine • E: VerapamilSBA 2 A 73-year-old Caucasian gentleman comes into the GP practice for the results of his ambulatory blood pressure monitoring. His average blood pressure at home is 170/105mmHg. His past medical history includes hypercholesterolaemia and Type 2 diabetes mellitus. He has no known drug allergies. What is the most appropriate management of this patient’s • A: Ramipril – ACE-inhibitor first line in T2DM, irrespective of race/age • B: Candesartan - If ACE-I not tolerated • C: Bisoprolol – Step 4 • D: Amlodipine – >55 or Afro-Caribbean, if no T2DM • Peripherally acting -pinesctive calcium channel blocker. For hypertension -SBA 3 A 58-year-old Afro-Carribbean gentleman comes into the GP practice as his blood pressure is still not appropriately controlled. He has a past medical history of asthma and is currently on Ramipril, Indapamide, Amlodipine and a rescue salbutamol inhaler. His Ambulatory BP is 143/90. His recent U&E’s are below. What is the most appropriate next step in this patient’s mA: Losartan ElectrolyteValue Normal B: Bisoprolol C: Doxazosin Ur 6.2 (2.0-7.0 mmol/L) Na 138 (135-145 mmol/L) D: Spironolactone K 4.7 (3.5-5.0 mmol/L) E: BendroflumethiazideSBA 3 A 58-year-old Afro-Carribbean gentleman comes into the GP practice as his blood pressure is still not appropriately controlled. He has a past medical history of asthma and is currently on Ramipril, Indapamide, Amlodipine and a rescue salbutamol inhaler. His Ambulatory BP is 143/90. His recent U&E’s are below. What is the most appropriate next step in this patient’s A: Losartan – Already on ACE-i. Don’t prescribe together ElectrolyteValue Normal B: Bisoprolol – CI as asthma C: Doxazosin – Alpha-blocker next up Ur 6.2 (2.0-7.0 mmol/L) Na 138 (135-145 mmol/L) D: Spironolactone – If K+ <4.5mmol/L K 4.7 (3.5-5.0 mmol/L) E: Bendroflumethiazide – Already on Indapamide (Thiazide Like)Management Lifestyle: Low salt diet, lose weight… Medical: Examples • ACE-inhibitor: Ramipril, Enalapril… • Calcium Channel blocker: Amlodipine, felodipine • Thiazide-Like diuretic: Indapamide • Alpha blocker: Doxazosin, Prazosin, Terazosin, Tamsulosin, • Beta-blockers: Bisoprolol, AtenololHypertensive complications Cardiac: • Cardiac Hypertrophy • MI • Heart Failure • Aortic Dissection Neurological • Stroke • TIA • Vascular Dementia • Retinopathy Renal • CKDSBA 4 A 62-year-old man comes for review. Recently he has several episodes of syncope. He reports feeling 'groggy' for only a few seconds after the episodes and felt slightly breathless with occasional chest pain. On examination pulse is 90bpm and regular, blood pressure 110/86 mmHg, his lungs are clear and there is a systolic murmur loudest in the aortic region which radiates to the carotid area. What is the likely cause of his symptoms? A- Aortic Stenosis B- Mitral regurgitation C- Aortic Sclerosis D- Paroxysmal Atrial fibrillation E- Aortic RegurgitationSBA 4 syncope. He reports feeling 'groggy' for only a few seconds after the episodes and felt slightly breathless with occasional chest pain. On examination his pulse is 90bpm and regular, blood pressure 110/86 mmHg, his lungs are clear and there is a systolic murmur loudest in the aortic region which radiates to the carotid area. What is the likely cause of his symptoms? • A- Aortic Stenosis- Systolic murmur  Carotids = AS • B- Mitral regurgitation- pan systolic, radiates to axilla, • C- Aortic Sclerosis – Ejection systolic murmur DOES NOT radiate to the carotids • D- Paroxysmal Atrial fibrillation – classically ‘palpitations’, pulse irregular, no murmur • E- Aortic Regurgitation- diastolic murmur, wide pulse pressure, multiple eponymous signs.Valve Disease and MurmursValvular disease 101 • Disease: • Stenosis (hard to open) • Regurgitation (leaky) • IRL. Ask is it systolic/ diastolic and where it is. • Systolic Murmurs: • Left side (of heart): AS/ MR • Right side: PS/ TR • Diastolic Murmurs: • Left side: AR/ MS • Right side: PR/ TS • R Inspiratory L Expiratory (RILE) • Metal valves (Clunky) • If stuck Rheumatic Fever and IE cause any murmur. Common valvular issues Description of murmur Causes (IE and RhF for all) Notes Aortic Ejection Systolic, loudest in aortic region Senile Calcification Low rising pulse (Slow upstroke) Stenosis radiating to the Carotids Congenital (bicuspid) Aortic Ejection systolic, loudest in aortic region, no Senile Calcification Sclerosis radiation to the carotids Mitral Valve Mid-systolic click +/- late systolic murmur Common (5-10%) of people. Can lead to regurgitation Prolapse loudest in the mitral region Connective tissue disease Mitral Pansystolic murmur loudest in the mitral Prolapse, CXR: Cardiomegaly (Atrial Enlargement) Regurgitation region which radiates to the axilla Papillary Muscle Rupture, ECG: P-mitrale (M-shaped P wave) Heart dilatation Aortic Early Diastolic murmur loudest in Erb’s area Connective tissue disease Collapsing pulse rd Regurgitation (Left sternal edge, 3 intercostal space) Wide pulse pressure (>60mmHg) Dancing Carotids (Corrigan’s) Head bobbing (De Musset) Mitral Mid-late diastolic with an opening snap Malar flush (due to increased CO2 Stenosis retention and vasodilatation)Management • Echo for diagnosis. • If asymptomatic -> monitor • If symptomatic -> surgery • Metallic valve - Lifelong (and requires life-long anticoagulation) • Biological (pig or bovine) - Calcifies • Balloon valvuloplasty for stenosis if valve replacement cant be done. • Treat complications: HF, Arrhythmia etc.SBA 5 A 13-year-old Bangladeshi girl is brought into A&E profusely unwell. Her complained of joint pain in her arms and legs. You notice that there is a widespread rash on her skin and she appears to be making strange rhythmic movements as you approach the bed. She is currently pyrexial and her ECG shows a 1st degree heart block. She has no known drug allergies. Given the most likely diagnosis which of the following is the most appropriate treatment option? A. IV Chlorphenamine B. IV Erythromycin C. IV Flucloxacillin D. PO Doxycycline E. IV Benzylpenicillin SBA 5 A 13-year-old Bangladeshi girl is brought into A&E profusely unwell. Her father tells you she had a sore throat three weeks ago and yesterday complained of joint pain in her arms and legs. You notice that there is a widespread rash on her skin and she appears to be making strange rhythmic movements st you approach the bed. She is currently pyrexial and her ECG shows a 1 degree heart block. She has no known drug allergies. Given the most likely diagnosis which of the following is the most appropriate treatment option? A. IV Chlorphenamine – This is RhF, not an allergy B. IV Erythromycin – If PenA C. IV Flucloxacillin – Good for Staph D. PO Doxycycline – Could be used for strep throat, not acute RhF E. IV Benzylpenicillin – Strep susceptible to BenPenRheumatic feverRheumatic fever • Streptococcus pyogenes  type II hypersensitivity reaction Diagnosis • Evidence of streptococcal infection (strep Abs, positive throat swab, positive rapid group A strep antigen test) + JONES criteria (2 Major or 1 major and 2 minor) Major: • Joints (Arthritis) – Swollen and painful • Obviously the heart (Pancarditis) – Pericardial rub • Nodules • Erythema Marginatum • Sydenham’s chorea Minor: • Fever (>38.0’C) • Arthralgia - Painful • Inflammatory markers raised (CRP or ESR) • Lengthened PR interval (If pancarditis not major) Management • Antibiotics: BenPen Phenoxymethylpenicillin • Analgesia: NSAID’s (commonly aspirin).SBA 6 A 47-year-old IV drug user comes into A&E with a seven day history of a fever and fatigue. On auscultation of his chest you notice he has a pansystolic murmur which has not been documented before. He has had no previous surgical history. His observations are as follows: BP 87/56, HR: 112, T: 38.2’C, RR: 23, O2: 97% (RA) Given the most likely diagnosis, in which location is the murmur likely to be loudest? A. A: 2nd intercostal space, right sternal edge B. B: 2nd intercostal space, left sternal edge C. C: 3rd intercostal space, left sternal edge D. D:4th intercostal space, left sternal edge E. E: 5th intercostal space, left mid-clavicular line SBA 6 A 47-year-old IV drug user comes into A&E with a seven day history of a fever and fatigue. On auscultation of his chest you notice he has a pansystolic murmur which has not been documented before. He has had no previous surgical history. His observations are as follows: BP 87/56, HR: 112, T: 38.2’C, RR: 23, O2: 97% (RA) Given the most likely diagnosis, in which location is the murmur likely to be loudest? A: 2nd intercostal space, right sternal edge – Aortic Area B: 2nd intercostal space, left sternal edge – Pulmonary area C: 3rd intercostal space, left sternal edge – Erb’s area, for aortic regurgitation D: 4th intercostal space, left sternal edge – Tricuspid area. Most likely in IVDU E: 5th intercostal space, left mid-clavicular line – Mitral area. Usual most common siteSBA 7 A 58-year-old gentleman comes into A&E with a seven day history of a fever and fatigue. On auscultation of his chest you notice he has a pansystolic murmur despite a normal echocardiogram three weeks ago. He had valve replacement surgery for his tricuspid valve four months ago. His observations are as follows: BP 97/56, HR: 114, T: 38.4’C, RR: 22, O2: 95% (RA) Given the most likely diagnosis, which is the most likely causative organism? A: Staph epidermidis B: Staph aureus C: Strep pyogenes D: Strep viridans E: Strep bovis SBA 7 A 58-year-old gentleman comes into A&E with a seven day history of a fever and fatigue. On auscultation of his chest you notice he has a pansystolic murmur despite a normal echocardiogram three weeks ago. He had valve replacement surgery for his tricuspid valve four months ago. His observations are as follows: BP 97/56, HR: 114, T: 38.4’C, RR: 22, O2: 95% (RA) Given the most likely diagnosis, which is the most likely causative A:organism i ermidis - Most common for prosthetic valves within 2 months of surgery B: Staph aureus – Most common. C: Strep pyogenes – Rheumatic fever D: Strep viridans – previously most common. Associated with dental work E: Strep bovis – Colorectal cancer associationInfective endocarditisInfective Endocarditis Infection of the valvular leaflets Clinical Features Mitral>Aortic>Mitral+Aortic>Tricuspid (Unless IVDU)>Pulmonary • failure…. fever, heart Causative organisms • Fever + new murmur = IE • Strep bovis (Colorectal Cancer)trep epidermidis (previous line), until proven otherwise • HACEK organisms + Coxiella… Investigations Investigations: Duke criteria. 2 Major OR 1 Major + 3 Minor OR 5 Minor Major: BE • Blood cultures (2 separate): Both positive for typical organism or 1 positive Coxiella Janeway lesions • Echo: Showing vegetations Minor: LIVFR (Looks like Liver but not quite) • Lab: Blood cultures not meeting Major criteria • Immunological: Osler’s nodes, nephritis • Vasculitic: Emboli, Janeway’s lesions • Fever >38’C • Risk Factors: Prev cardiac lesion/valve replacement… or IVDU Splinter Osler’s Nodes haemorrhagesInfective Endocarditis - Management Initial: • Native valve: Amoxicillin +/- Gent • Sepsis/ PenA: Vancomycin + Gentamicin • Prosthetic valve: Vancomycin + Rifampicin + Gentamicin Confirmed: • Native valve, Staph: Fluclox (PenA: Vanc + Rifampicin) • Prosthetic valve, Staph: Fluclox + Rifampicin + Gent (PenA: Vanc, Rifampicin, Gent) • Fully sensitive Strep: Benpen (PenA: Vanc + Gentamicin) • Not full sensitive Strep: BenPen + Gent (PenA: Vanc + Gent) Surgery indications: Replace the valve for either functional or antibiotic benefit. • Valvular incompetence • Cardiac Failure • Aortic Abscess (indicated if lengthening PR interval)] • Infection is resistant • Recurrent Emboli after antibiotic therapy.SBA 8 A 24 year old man has come to A&E as he passed out in the middle of playing football. This is the fourth time this has happened. On auscultation you hear an ejection systolic murmur loudest in the left lower sternal border. His mother comes in and tells you the patient’s father died aged 32 following a similar presentation. Given the most likely diagnosis, which investigation findings would be most likely? A. Echo – mitral regurgitation and asymmetric hypertrophy B. ECG – right ventricular hypertrophy C. Full Blood count – Hb 76 D. ECG - ST elevation E. Echo – aortic regurgitation and symmetrical hypertrophy SBA 8 A 24 year old man has come to A&E as he passed out in the middle of playing football. This is the fourth time this has happened. On auscultation you hear an ejection systolic murmur loudest in the left lower sternal border. His mother comes in and tells you the patient’s father died aged 32 following a similar presentation. Given the most likely diagnosis, which investigation findings would be most A. Elik lymitral regurgitation and asymmetric hypertrophy – HOCM, MR SAM ASH B. ECG – right ventricular hypertrophy – Usually LVH in HOCM C. Full Blood count – Hb 76 – Anaemia can cause murmurs/ syncope, less likely given FHx D. ECG - ST elevation – Could be seen, but more likely LVH and T-wave inversion E. Echo – aortic regurgitation and symmetrical hypertrophy – Usually MR and Asymmetrical HypertrophyHypertrophic Obstructive Cardiomyopathy (HOCM) Epidemiology: 1 in 500. Autosomal Dominant Pathophysiology: • Defect in genes coding for contractile proteins • Asymmetrical Septal Hypertrophy  obstructed blood flow from LV (Murmur)  LV Hypertrophy • LVH  Mitral Regurg and Systolic Anterior Movement of the anterior leaflet of the mitral valve. • LVH  Arrhythmias and Sudden Cardiac Death Presentation: • Asymptomatic • Syncope • ESM murmur louder on Valsalva • Sudden Cardiac Death (Fabrice Muamba)HOCM investigations and management • ECG: • LVH:HOCM Investigations and Management ECG: Stop Arrhythmias: • Left ventricular Hypertrophy • Amiodarone • T wave inversion • Beta-blockers • Can have AF/ Deep Q waves (Symptoms) Echo: MR SAM ASH • Cardioverter-defibrillator • Dual Chamber • Mitral Regurgitation • Systolic Anterior Motion of the Pacemaker anterior mitral leaflet • Asymmetrical Septal Hypertrophy THANK YOU FOR LISTENING! FEEDBACK Please fill in to receive a certificate of attendance and for the slides