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ResearchEazy OSCEazy Media OSCE SERIES THE CARDIOLOGY ST A TION PART 1 Nish Dalavaye PROUDLY IN COLLABORATION WITH CHEST AIN 1 2 PALPIATIONS COMMON CARDIOVASCULAR 3 SHORTNESS OF BRETH SYMPTOMS 4 SYNCOPE ANKLE 5 SWELLINGINSTRUCTIONS SPOT DIAGNOSIS A 60 year old woman presents with chest pain that develops when she walks up the stairs. The pain resolves when she takes her GTN spray and 5 Stable angina minutes after she rests. Her BMI is 32. A 65 year old women presents with pleuritic chest pain that improves when she sits up. The pain is sharp and does not last long. She recently had an Acute Pericarditis upper respiratory tract infection and she still has a fever. There are ECG changes. A 50 year old woman presents with pleuritic left sided chest pain. She is not Pulmonary embolism able to take a full breath. She has a history of a right-sided mastectomy for breast cancer, 3 months ago. She also has palpitations. A 54-year old man presents with severe crushing chest pain at rest. The pain radiates to the jaw and arm. He has a past medical history of type 2 Acute coronary syndrome diabetes and high cholesterol. He is a heavy smoker. A 23 year-old man has a sharp, aching pain that is aggravated by movement such as deep inspiration, coughing or sneezing. He has tenderness on the costochondritis side of the sternum CHEST PAIN HISTORY TAKING • Site: retrosternal, peripheral • Onset: sudden, gradual, triggers – on exertion, after food, on coughing, deep inspiration • Character: constricting, sharp, central crushing pain History of • Radiations: shoulder/arms, neck/jaw, epigastrium presenting • Associations: shortness of breath, nausea/vomiting, sweat, chest wall tenderness, palpitations, cough • Timing: Any change in symptoms complaint • Exacerbating factors: walking, exercise, painkillers • Relieving factors: rest, glyceryl trinitrate (GTN), antacids, leaning forward • Severity: Rating of pain from 0-10 • Dyspnoea – Do you get breathless? • Orthopnoea – Do you ever get breathless when lying flat? How many pillows do you sleep with at night? • Paroxysmal nocturnal dyspnoea – Do you ever wake up gasping for breath? System review • Palpitations – Do you ever get palpitations or an awareness of your heart beating? If so, are they fast, slow, regular or irregular? • Cough – Have you noticed a cough? Do you bring anything up? Any blood? • Constitutional – Have you noticed any weight loss? Do you feel sick with the pain? Has it made you sweat? Red flags • MSK – Is the pain worse on movement? Does it hurt to press on the area? • Sudden onset • Duration >10 minutes • Feelings and effect on life – How have your symptoms affected you? • Ideas – Do you have any idea yourself what might be causing the pain? • Not relieved by GTN ICE • Concerns – Is there anything you are particularly concerned could be causing the pain? Is there anything in • Associated dyspnoea general that concerns you about the chest pain? • Exertional • Expectations – I understand the chest pain must be a worry. Would I be right in thinking you came today to • Risk factors for PE • Weight loss check if it was something serious? Was there anything else you were hoping for? • Angina, diabetes, reflux, hypertension • New dyspepsia >55 y/o Past medical and • PE risk factors – clotting disorders, cancer, recent surgery, recent long flight surgical history • Previous surgery – coronary artery bypass graft • Current medications: NSAIDs, COCP, GTN, antacids etc. Medications • Over the counter medications e.g. painkillers • Allergies Family history • Coronary artery disease, hypertension, hypercholesterolaemia, clotting disorders • Smoking, alcohol and recreational drug use • Diet • Exercise tolerance Social history • Housing status • Occupational status • Driving status • Travel CHEST PAIN CHARACTERISTICS ISCHAEMIC PLEURITIC MUSCULOSKELETAL SITE Central & retrosternal Focal (single finger point) Variable CHARACTER Heavy or ‘tight’ Sharp or ‘stabbing’ Tender PRECIPITATING FACTORS Exercise, cold, stress etc. Deep inspiration & coughing Movement, postural change, palpation RELIEVING FACTORS Rest, nitrates Shallow breathing Staying still RADIATION Into jaw and into arms and back Rare Rare COMMON CAUSES Ischaemic heart disease Pneumonia, pulmonary embolism Trauma, costochondritis Summarising the history Patient details, occupation central crushing chest pain. speaking to Roy Kent, a 60-year-old taxi-driver, who presented with & key presenting complaint He has been experiencing recurrent episodes of chest discomfort, which he feels is most History of presenting complaint prominent at the centre of his chest. These episodes began approximately 2 weeks ago and have become more frequent recently. They typically last 5-10 minutes long. He described the pain as a 'heavy discomfort' that doesn't move anywhere. The attacks are triggered by activities like running and cycling. Relevant negatives There is no history of fever, weight loss or trauma Relevant PMH/PSH/SH/DH He has cardiovascular risk factors with a long-standing history of hypertension and he is a taking ramipril and has no known drug allergies.had cardiac surgery in his late 60s. He is currently Ideas, concerns & expectations His main concern is he is worried he might have a heart attack soon. My top differential is stable angina based on the characteristics of his chest pain on exertion and Top differential & why his cardiovascular risk factors Other differentials that I would like to rule out include acute coronary syndrome, pulmonary Other differentials embolism and pneumothoraxHow would you investigate this patient? CHEST PAIN INVESTIGATIONS TEST JUSTIFICATION Basic observations Assess for hypertension (cardiovascular risk factor) BEDSIDE Cardiorespiratory examination Assess for signs of cardiovascular or respiratory disease e.g. murmurs 12-lead ECG Assess for acute ischaemic changes/ exclude acute coronary syndrome Full blood count (FBC) Assess for anaemia (can exacerbate angina) and signs of infection Liver function test (LFT) Assess for liver function (check if safe to give statins) and biliary colic (can cause referred chest pain) Urea and Electrolytes (U&Es) Assess for renal function (check if safe to give ACEi), electrolyte abnormalities, uraemia (pericarditis) Cardiac enzymes (e.g. troponins) Assess for acute myocardial ischaemia Lipid profile Assess for hypercholesterolaemia (cardiovascular risk factor) BLOODS Clotting screen Assess for bleeding risk e.g. if on anticoagulation/ if surgery or blood transfusions are required Thyroid function test Assess for hyperthyroidism (can exacerbate angina) Arterial/ Venous blood gas (ABG/VBG) Assess for hypoxia, acid-base disturbance and lactate Serum glucose/ HbA1c Assess for hyperglycaemia/ diabetes (cardiovascular risk factor) Group & Save/ Crossmatch In case blood transfusions will be required e.g. aortic dissection Chest X-ray Assess for heart failure and different causes of chest pain CT coronary angiogram Assess for coronary artery disease IMAGING CT aortogram Assess for aortic dissection CT pulmonary angiogram (CTPA) Assess for pulmonary embolism Echocardiogram (e.g. TTE/TOE) Assess left ventricular function, valvular pathology, pericardial fluid and any motion abnormalities SPECIAL TESTS Functional cardiac testing Assess for ischaemia when the heart is stressed e.g. exercise ECG, stress echo, single-photon emission CT, cardiac MRI Invasive angiography For diagnosis and treatment of coronary artery disease Please interpret these results Name Roy Kent Age 60 Date of study07/03/2023, 15:00 pm Normal sinus rhythm 1. Patientdetails 2. Rate 3. Rhythm 4. Cardiac axis 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. Conclusion Troponin 12 (0-14 ng/L) Acute condition = immediate & ongoing care Chronic condition = conservative, medical & surgical How would you manage this patient? Stable Angina Management Conservative Medical Surgical • MDT approach • Short-acting nitrate • Primary Coronary Intervention (PCI) • 1 line - Beta blocker/ Calcium • Charities & support groups • Coronary artery bypass graft (CABG) Channel blocker • Smoking cessation • 2 line - Beta-blocker + Calcium • Alcohol reduction channel blocker • Dietary modification • Secondary prevention • Driving advice • Aspirin • ACE inhibitor • Exercise • Statin • Treatment of hypertension • Target BMI <25 & diabetes Stable angina GTN spray Beta blocker (e.g. bisoprolol) or Non-dihydropyridine calcium channel blocker (e.g. verapamil) Beta blocker (e.g. bisoprolol) AND Dihydropyridine calcium channel blocker (e.g. nifedipine/amlodipine) Add additional agent: Refer for revascularisation • e.g. nicorandil • e.g. ivabradine • e.g. long-acting nitrateINSTRUCTIONSPlease interpret these results Name Ted Lasso Age 52 Date of study07/03/2023, 10:00 am Please interpret these results Name Ted Lasso Age 52 Date of study07/03/2023, 10:00 am Anterolateral STEMI 1. Patientdetails 2. Rate 3. Rhythm 4. Cardiac axis 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. ConclusionHow would you initially manage this patient? • ABCDE approach and escalate to a senior • Repeat observations and ECG • Establish intravenous access with two wide-bore cannulae • Dual antiplatelet therapy • Reperfusion therapy – PCI vs fibrinolysis • Analgesia – IV morphine, GTN spray • Maintain oxygen saturations • Antithrombin • Once stable, order an echocardiogram / coronary angiogram and discuss with the Cardiology SpR ACUTE CORONARY SYNDROMES Exertional central chest pain relieved by GTN ECG Troponin DIAGNOSIS YES NO NORMAL ABBNORMAL NORMAL INCREASED STABLE ANGINA ✓ ✓ ✓ UNSTABLE ANGINA ✓ ✓ ✓ NSTEMI ✓ ✓ ✓ STEMI ✓ ✓ ✓ BASED ON NICE GUIDELINES SUSPECTED ACS IV MORPHINE 2.5 – 5mg, ANTIEMETIC ABCDE ASSESSMENT OXYGEN GTN URGENT ECG ASPIRIN 300mg STEMI YES Presents within 12 hours of onset ofNOhest pain AND PCI available in 2 hours SECOND SECOND ANTITHROMBOTIC ANTITHROMBOTIC ANTI-PLATELET ANTI-PLATELET PRASUGREL UNFRACTIONATED HEPARIN TICAGRELOR CLOPIDOGREL IF ON CLOPIDOGREL IF HIGH ORAL ANTICOAGULANT CONSIDER GP IIb/IIIa INHIBITORS BLEEDING RISK CORONARY ANGIOGRAPHY IF FAILED IF CORONARY INDICATED CORONARY REPERFUSION ECG 60-90 PCI ANGIOGRAPHY FIBRINOLYSIS MINUTES LATER BASED ON NICE GUIDELINES SUSPECTED ACS IV MORPHINE 2.5 – 5mg, ANTIEMETIC ABCDE ASSESSMENT OXYGEN GTN TRANSTHORACIC ECHOCARDIOGRAPHY URGENT ECG ASPIRIN 300mg STRESS ECHOCARDIOGRAPHY CARDIAC MRI CORONARY ANGIOGRAPHY NSTEMI OR UNSTABLE CONSIDER ISCHAEMIA TESTING ANGINA ANTITHROMBOTIC CALCULATE GRACE SCORE LOW RISK UNSTABLE CLINICAL CONDITION HIGH/ INTERMEDIATE RISK TICAGRELOR PRASUGREL/ CONSIDER CORONARY ANGIOGRAPHY IMMEDIATE CORONARY PRASUGREL (CLOPIDOGREL IF HIGH BLEEDING RISK) TICAGRELOR +/- PCI WITHIN 72 HOURS ANGIOGRAPHY +/- PCIPlease interpret these results Name Ted Lasso Age 52 Date of study07/03/2023, 18:00 pm Please interpret these results Name Ted Lasso Age 52 Date of study07/03/2023, 18:00 pm Ventricular tachycardia 1. Patientdetails 2. Rate 3. Rhythm 4. Cardiac axis 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. ConclusionHow would you initially manage this patient? • ABCDE approach and escalate to a senior if haemodynamically unstable • Follow the tachycardia algorithm by Resuscitation Council • Stay calm, reassure patient • Establish intravenous access with a wide-bore cannula • Oxygen • IV morphine • Move to ‘crash room’ • Start cardiac monitoring • Portable chest x-rayINSTRUCTIONS PALPITATIONS HISTORY TAKING MEANING EXAMPLE QUESTION “What does it feel like?” F FEELING (character) “When they occur, does your heart pound fast or slow?” “Do they feel regular or irregular?” L LENGTH “How long does it last?” U UNCONSCIOUSNESS “Have you ever lost consciousness?” “How frequently are you having palpitations?” T TIMING “How long do they last for?” “Do they come on at a particular time? During exercise?“ T ‘TAPPABLE’ (rhythm) “Can you tap out the rhythm?” EXACERBATING/ “Does anything make it better/worse” E RELIEVING FACTORS R RELATED SYMPTOMS “What other symptoms are you experiencing?”How would you investigate this patient? PALPITATIONS INVESTIGATIONS TEST JUSTIFICATION Basic observations Assess for haemodynamic instability, hypoxia and fever BEDSIDE Cardiorespiratory examination Assess for signs of cardiovascular or respiratory disease e.g. murmurs 12-lead ECG Assess for arrhythmias Full blood count (FBC) Assess for anaemia and signs of infection Liver function test (LFT) Assess for liver function (especially if amiodarone is given) Urea and Electrolytes (U&Es) Assess for electrolyte abnormalities & chronic kidney disease Bone profile Assess for calcium/phosphate abnormalities BLOODS Thyroid function tests (TFTs) Assess for hyper/hypothyroidism Clotting screen Assess for bleeding risk C-reactive protein (CRP) Assess for infection Brain natriuretic peptide (BNP) Assess for heart failure Serum glucose/ HbA1c Assess for hyperglycaemia/ diabetes Chest X-ray Assess for acute infection, heart failure etc. IMAGING CT / MRI (e.g. head/limb/abdomen) Assess for embolic event e.g. stroke SPECIAL TESTS Echocardiogram (e.g. TTE/TOE) Assess for structural heart disease e.g. valvular disease, thrombus in left atrial appendage etc. Performing an ECG ü Introduce yourself MID MID AXILLARY ü Confirms name & date of birth of patient (against wristband if present) CLAVICULAR ‘Ride your green bike’ LINE LINE ü Explain & gain consent ü Offer chaperone and expose patient from waist up ü Wash hands ü Offer to shave hair ü Input details into machine and check paper settings ü Place leads correctly V1 V2 V3 V4 V5 V6 ü Check all leads, calibration and asks patient to lie as still as possible ü Print and label the ECG ü Remove pads and offer tissues ü Thank patient and offer to help get dressed ü Wash hands Presenting the ECG 01 Patient details 02 Rate 03 Rhythm Hospital number Date of birth Time of ECG Calibration of ECG Cardiac axis P waves & PR interval 06 QRS morphology 04 05 07 ST segments 08 QT interval 09 Conclusion & T waves Please interpret these results Name Harvey Specter Age 49 Date of study07/03/2023, 9:00 am Supraventricular tachycardia 1. Patientdetails 2. Rate 3. Rhythm 4. Cardiac axis 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. ConclusionHow would you manage this patient? Immediate: • ABCDE approach and escalate to a senior if haemodynamically unstable • Follow the tachycardia algorithm by Resuscitation Council • Vagal manoeuvres and carotid sinus massage • IV Adenosine (verapamil if asthmatic) – up to 18mg • If adverse signs are present or if other treatments fail, synchronised electrical cardioversion can be performed Ongoing: • Long-term treatment may include radiofrequency ablation • Any electrolyte imbalances should be corrected Regular SVT ABCDE assessment CHEST PAIN HEART FAILURE YES Synchronised DC Adverse features SHOCK SYNCOPE cardioversion NO CAROTID SINUS MASSAGE Vagal manoeuvres VALSALVA MANOUEVER IF FAILS 6mg Adenosine IF FAILS 12mg Adenosine IF FAILS IF FAILS 18mg Adenosine Verapamil or Beta-blockerINSTRUCTIONSPlease interpret these results Home blood pressure readings Day Reading Monday 155/94 Tuesday 169/95 Stage 2 Hypertension Wednesday 160/85 Thursday 158/96 Friday 155/87 Saturday 161/84 Clinic BP taken today: 170/100, 168/98, 165/95 Hypertension Clinic BP < 140/90 mmHg 140/90 - 179/119 mmHg > 180/120 mmHg No hypertension; monitor Offer ABPM Severe hypertension at least every 5 years (or HBPM if ABPM not tolerated) < 135/85 mmHg 135/85 – 149/94 mmHg > 150/95 mmHg White coat hypertension: >20/1ABPM/HBPM measurementseen clinic & Stage 1 hypertension Stage 2 hypertension ABPM = Ambulatory blood pressure monitoring HBPM = Home blood pressure monitoringHow would you investigate this patient?Please interpret these results Hypertensive retinopathy • Grade 1: Silver wiring • Grade 2: Arteriovenous nipping • Grade 3: Retinal haemorrhages, cotton wool spots, exudates • Grade 4: Papilloedema HYPERTENSION INVESTIGATIONS TEST JUSTIFICATION Basic observations Assess for haemodynamic instability Cardiorespiratory examination Assess for signs of cardiovascular or respiratory disease e.g. murmurs BEDSIDE Urinalysis/ urinary albumin-to-creatinine ratio Assess for proteinuria and haematuria Fundoscopy Assess for hypertensive retinopathy 12-lead ECG Assess for cardiac pathologies e.g. LVH Full blood count (FBC) Assess for anaemia and signs of infection Urea and Electrolytes (U&Es) Assess for kidney disease BLOODS Lipid profile Assess for hypercholesterolaemia HbA1c Assess for diabetes Brain natriuretic peptide (BNP) Assess for heart failure IMAGING CT Head Exclude intracranial causes of papilledema Ambulatory blood pressure monitoring Diagnose hypertension SPECIAL TESTS Renal ultrasound Assess for polycystic kidney disease Endocrine testing (e.g. aldosterone:renin ratio) Assess for endocrinopathies e.g. primary aldosteronismHow would you manage this patient? Hypertension Management Conservative Medical • MDT approach • Lifelong medication • Counselling on adherence • Charities & support groups • Smoking cessation • Counselling on side effects • Counselling on monitoring • Alcohol reduction • Secondary prevention • Dietary modification (low sodium) • Statins • Regular exercise • Anti-platelet therapy • Regular follow-up to assess for complications Hypertension < 55 years or with T2DM > 55 years or African/Caribbean descent Step 1 A C Step 2 A+C or A+D C+A or C+D Step 3 A+C+D • Confirm resistant HTN Step 4 • Consider specialist advice or *< 4.5mmol/L: Add spironolactone > 4.5mmol/L: Add alpha-blocker/beta-blocker add fourth agent*INSTRUCTIONS Please interpret these results Torsades de pointes 1. Patientdetails 2. Rate 3. Rhythm 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. Conclusion Please interpret these results Left bundle branch block 1. Patientdetails 2. Rate 3. Rhythm 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. Conclusion Please interpret these results Atrial fibrillation 1. Patientdetails 2. Rate 3. Rhythm 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. Conclusion Please interpret these results Complete heart block 1. Patientdetails 2. Rate 3. Rhythm 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. Conclusion Please interpret these results Ventricular fibrillation 1. Patientdetails 2. Rate 3. Rhythm 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. Conclusion Please interpret these results Trifascicular block 1. Patientdetails 2. Rate 3. Rhythm 5. Pwaves, QRS complexes 6. STsegments andTwaves 7. QTintervals 8. ConclusionPLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO THE REST OF OUR OSCE SERIES ECG Credits: litfl.com, Wikimedia commons