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Year 3 Cardio Crash Course Pt. 1 ISOC MedEd 31/10/24Introduction ● Who are we? ● Our mission ● Our team ● Our plan 2The Year 3 ISoc MedEd Team Leads: Teachers: ● Kalsoom Adil ● Amina Yasmin ● Manam Mahmood ● Ayesha Waseem ● Raiyan Aseri ● Daniel Choudhary ● Deylan Dyare ● Hana Farman ● Mainur Kazi ● Nabihah Hussaini ● Noorulanne Younis ● Sufian Naseer *Today’s lineup in bold* ● Zahin Khan 3Upcoming Events ● Cardiology Crash Course Part 2 - Tue 19th Nov ● Gastro Crash Course Part 1 - TBC 4 HEART MURMURSnur Kazi THEHEART It works as a pump to move the blood around the body.ValvesSYSTOLE The phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries. DIASTOLE The phase of the heartbeat when the heart muscle relaxes and allows the chambers to fill with blood NormalHeart Sounds SI S2 Closing of mitral and tricuspid valves at Closing of aortic and pulmonic valves at transition from diastole to systole transition from systole to diastole Heard best at apex Heard best at upper sternal borders AdditionalHeartSounds S3 and S4 are extra heart sounds that can sometimes be heard after S2 and before S1. S3 S4 When: Right after the "dub" of S2 (early diastole When: Just before the "lub" of S1 (late diastole) when mitral valve opens) Why: S4 happens if the atria are pushing blood Why: S3 happens when there is rapid filling of a into a stiff/ hypertrophied ventricle. This can compliant/ dilated ventricle. This can cause happen if the ventricles are thicker/ less compliant. vibrations that create a faint sound. Normal or Not?: S4 is rarely normal and usually Normal or Not?: In teenagers/ athletes, hearing happens because of heart problems, especially in S3 can actually be normal since the heart can older people. E.g., Aortic stenosis, hypertension, be more elastic. But in older adults, it can left ventricular hypertrophy indicate volume overload: MR, heart failure, - Can’t occur in AF, why?? requires atrial dilated cardiomyopathy systole Sound: lub-dub-da Sound: Often described as "ta-lub-dub" MURMURS What is a murmur? Turbulent blood flow across heart valve/ heart Who is affected? Commonly seen in newborns, congenital, acquired diseases and degenerative 70+ How are heart valve diseases diagnosed? Auscultate a murmur when examining the patient, echocardiogram/ cardiac tests How is heart valve disease treated? -Watchful waiting: Most are asymptomatic, observed in secondary care/ community overtime, ● Symptomatic, severe= open heart valve surgery = cardiopulmonary bypass ad valve replacement/ repair surgery, transcatheter therapiesCAUSES OFMURMURS 1 Stiff valves - calcification- stenosis 2 Leaky valves - prolapse- regurgitation 3 Stretched out ventricle- dilated 4 Stiff ventricle - hypertrophy 5 Congenital defect - septal OtherCauses 1 Increased blood flow- pregnancy, fever, anaemia, or hyperthyroidism 2 Structural variation- anatomical variations so heart sounds heard more clearly Exercise related- increased heart 3 rate/ blood flow- transient murmur Infective Endocarditis- ‘new 4 valvular regurgitation’- major 5 Dehydration and many others! HOWDOIDESCRIBEAMURMUR??? - Timing - Systolic, diastolic, continuous - Location and Radiation - Shape - Crescendo-Decrescendo, Decrescendo, Uniform (holosystolic) - Pitch - High, low, mix (harsh) - Intensity - Grading - Quality - Blowing/ rumbling/ musical etc - Response to manoeuvres Grading Levine scale: loudness of murmur numerically graded ***Thrill- palpable murmurEjection SystolicAortic Stenosis Causes ● >65= senile calcification ● <65= bicuspid valve, rheumatic fever Features ● Best heard: aortic area ● Ejection systolic murmur, radiate to carotids ● Narrow pulse pressure, slow rising pulse ● Apex is forceful ● Quality: crescendo-decrescendo ● S2 quiet in calcified valves with severe stenosis ● Can have LV heave ● Harsh, louder on expiration Ix with ECG (LVH, P mitrale), echo shows flow, pressure and degree of stenosis Management ● Observe ASx ● Sx (angina/SOB/syncope) needs valve replacement or balloon valvuloplasty (TAVI if unsuitable for surgery)HypertrophicObstructiveCardiomyopathy/ Causes HCM● Autosomal dominant inheritance ● LV outflow obstruction from asymmetrical septal hypertrophy ● Commonly affects LV septum Features ● Presyncope/syncope ● Angina and ischaemia ● Arrhythmia ● Severe cases have CCF, orthopnoea ● Systolic thrill at LLSE ● Harsh ejection systolic murmur Ix with cardiac MRI= gold standard to show LV wall abnormalities (can do echo) Management ● Beta-blockers or verapamil ● Amiodarone for arrhythmias ● Septal myomectomy ● Consider implantable defibrillator HOCM causes sudden cardiac death in the youngAtrialSeptalDefect Causes ● Congenital defect Features ● Ejection systolic murmur radiating to the back ● Fixed split second heart sound ● Ostium primum presents early and is associated with Down Syndrome ● Ostium secundum is often ASx until there is reversal of L to R shunt leading to pulmonary HTN and reverse shunting (Eisenmenger’s syndrome) ○ Cyanosis, HF and chest infections Ix- echo is diagnostic Management ● If adults get Sx then transcatheter closure with surgeryAortic Sclerosis ● Due to senile degradation of the valve ● Ejection systolic murmur ● No radiation to the carotid or changes in pulse pressureCoarctation oftheaorta Causes ● Congenital narrowing of descending aorta Features ● Radio-femoral delay and weak femoral pulses ● HTN ● Systolic murmur heard best over scapula ● Can lead to HF and infective endocarditis Ix- CT or MRI angiogram used for Dx Management ● Stenting or surgeryMitralValveProlapse Causes ● Seen in congenital disorders, patent DA, ASD or cardiomyopathy Features ● Mid-systolic click and late systolic murmur ● Chest pain and palpitations Ix- Echo is diagnostic Management Beta-blockers for palpitations and valve replacementPansystolic/HolosystolicMitral Regurgitation Causes ● Calcification with age ● Infective endocarditis ● Post-MI rupture of papillary muscles ● Mitral valve prolapse (Marfan’s) ● Rheumatic fever Features ● Pansystolic murmur, radiates to axilla ● Apex beat is strong and displaced ● Blowing/ musical murmur ● Soft S1 from incomplete mitral closure, S2 heard ● Can be ASx or have pulmonary HTN and oedema (dyspnoea, palpitations) ● RV heave Ix with ECG (AF, P mitrale, LVH), echo to assess LV function Management ● Treat the LV failure (ACEi to reduce afterload) ● Valve replacementVentricularSeptalDefect Causes ● Can be congenital or post-MI Features ● Pansystolic murmur with systolic thrill ● Patients can be ASx or have severe HF ● Larger holes are quiet with signs of pulmonary HTN Ix- CXR: can show large pulmonary arteries, cardiomegaly Management ● Tx with surgery if medical therapy fails, patient is showing Sx or there is shuntingTricuspidRegurgitation ● Pansystolic regurgitation ● RV dilatation from rheumatic fever and infective endocarditis ● Features: ascites, dyspnoeaDiastolicAortic Regurgitation Causes ● Infective endocarditis ● Autoimmune disorders (SLE, RA) ● Connective tissue (Marfan’s) ● Aortic dissection Features ● EARLY diastolic ● exertional dyspnoea and orthopnoea ● Decrescendo, “blowing” (high pitched) ● Best heard- LLSE sitting forward, on expiration Associated with: ● Collapsing, bounding pulse, wide pulse pressure ● Thrusting apex beat ● Quincke’s sign (pulsating nail beds) ● Corrigan’s sign (exaggerated carotid pulse) ● De Musset’s sign (head bobbing with carotid pulsation) Ix with Echo, ECG Management ● ACEi to reduce afterload ● Valve replacement Tricuspid stenosis- same but in tricuspid region Mitral Stenosis Causes ● Rheumatic fever ● Congenital Features ● MID-LATE diastolic murmur best heard in expiration ● Palpable S1 ● Rumbling sound ● Opening snap in early diastole ● Parasternal heave ● Patients can have malar flush, dyspnoea ● LA dilatation can compress on structures can cause hoarseness and bronchial obstruction Ix with ECG to show AF, P mitrale, echo- stenosis, CXR shows left atrial enlargement and pulmonary oedema + HTN Management ● Treat AF ● Diuretics to reduce preload ● Valve replacementContinuous murmur-machinelike Abnormal connection between the aorta and the pulmonary artery, - Normally closed in infancy - Since aortic pressure is higher than pulmonary pressure, a continuous murmur occurs. - This murmur is often described as a machinery murmur, or Gibson's murmur. Echocardiogram and nearby blood vessels.d scan that uses sound waves to create an image of the heartThingstoremember!! Learnthis !!! CCAs- Cardio examination- potential additional questions Focused examination on aortic regurgitation (lots of clinical signs if severe) Ask the CCA examiner if they would like you to perform any dynamic manoeuvresQUESTION 1 🫣EXAMQUESTION 2 😳 Kalsoom Adil Aortic Dissection, Pericardial DiseasePericarditis 6 1 2 3 4 5 WHAT IS PERICARDITIS? Inflammation of pericardium Causes: ● Infection ● Autoimmune - SLE, Rheum A ● Uraemia - raised urea secondary to renal impairment ● Injury to pericardium ● Cancer ● Methotrexate ● Idiopathic 42 CLINICAL PRESENTATION PC : Chest pain S - Central O - Acute/subacute onset - Sharp, stabbing pleuritic pain C R - Neck, shoulders, arm A - Fever, cough, SOB, gen unwell T - Constant pain E - Worse lying down, better sitting forwards S - 6/7 43 O/E Pericardial friction rub 44 Investigations Bedside: Bloods: Imaging: ● Temp ● Sputum sample ● FBC - raised WCC ● ECG ● U+Es - renal impairment ● CXR - exclude ● Troponin - suggests pneumonia myocardial involvement ● ECHO ● CRP - raised ● Serum urea ● Lactate - why? ● Selective blood tests 4546474849 Management ● Generally manage as outpatient unless pt has high risk features e.g. fever > 38’ ● Treat underlying causes ● Medical: ○ 1st line = NSAIDs + colchicine for 1-2 weeks until pain resolves ○ 2nd line = oral corticosteroids ● Restrict physical activity for about 3 months 50The case of the Grinch 51A patient comes into the ED complaining of chest pain and SOB. He was diagnosed with acute pericarditis, which resolved a week ago. He is breathless, HR 92 bpm, RR 25/min, BP 88/58 mmHg. His JVP is raised, heart sounds are muffled and his radial pulse disappears during inspiration. What’s going on doc? 52 Cardiac Tamponade - vvvvvv serious! Accumulation of pericardial fluid under pressure Clinical Features: Beck’s Triad Ix: ● ECG - electrical alternans ● Hypotension ● ECHO ● Raised JVP ● Muffled heart sounds ● CXR - massive cardiac silhouette ● Chest pain Mx: ● SOB ● A-E ● Tachycardic ● EMERGENCY needle ● Pulsus paradoxus -? pericardiocentesis ● Syncope ● Treat underlying cause ● Peripheral oedema 53A patient comes into the ED complaining of chest pain and SOB. He was diagnosed with acute pericarditis, which resolved a week ago. He is breathless, HR 92 bpm, RR 25/min, BP 88/58 mmHg. His JVP is raised, heart sounds are muffled and his radial pulse disappears during inspiration. What’s going on doc? 54 Constrictive pericarditis Inflammation > 3 months → Rigid pericardium → less filling during diastole Ix: ● CXR - pericardial calcification Causes: Any cause of pericarditis esp TB ● ECHO Features: ● SOB ● Right sided HF Mx: ● Pericardial knock - loud S3 ● Symptom control ● Pericardiectomy = ● Kussmaul sign +ve surgical removal of thickened pericaridum 5556AORTIC DISSECTION 5758Stanford Classification > Stanford Type A: Affects Ascending aorta > Stanford Type B: Affects descending aorta DeBakey - DePointless Type 1 - Ascending → Arch +/- Distal aorta Type 2 - Ascending aorta only Type 3 - Descending aorta → even more distal 59 Risk Factors ● Congenital: HOT TEA BREWS PRODUCE ○ Connective tissue disorders - like?????? CALMING TRADITIONS & (younger pts) STORIES ○ Turner’s syndrome ○ Congenital bicuspid aortic valve - HTN - Trauma ● Acquired - Bicuspid aortic valve ○ HTN (older pts) ○ Male - Pregnancy - CTDs (Marfan’s, ED) ○ Iatrogenic - CABG - Turner’s - Syphillis 60 Clinical Features Symptoms: Signs: ● Sudden onset severe ● Difference in BP between limb > ‘tearing/ripping’ chest pain 20mmHg ● Radiates to back ● Weak/absent pulses ● Abdominal pain ● HTN (but hypo if in shock) ● SOB ● Tachycardic ● Syncope ● If due to AR → diastolic murmur ● Decreased breath sounds → haemothorax Atypical presentations: ● Neurological deficit - limb weakness, paraesthesia 61 Investigations Bedside: ● ECG - myocardial ischaemia ● OBs Bloods: ● FBC, U+Es, LFTs, coagulation screen ● ABG ● Serum lactate - look for tissue ischaemia ● Group and save and crossmatch ● Troponin - MI Imaging: ● Urgent CT Angiogram of whole aorta = DIAGNOSTIC ● CXR - widened mediastinum, double.irregular aorta, haemothorax, normal ● TOE - if hemodynamically unstable 6263 Management ● A-E ● Refer to cardio, involve cardiothoracics ● High flow O2 ● IV access ● Strong IV opiate analgesia ● BP control ○ 1st line = IV labetalol I’m gonna ask you abt ○ 2nd line= 1V CCB = nicardipine this in a sec so commit ● Surgical Management - for which type? this to your memories Type A = Aortic root replacement Type B = BP control 66Have you rlly been listening?THANKS FOR LISTENING Any qs? Amina Y asmin Heart Failure, Infective EndocarditisCardiology Part 1 : Heart Failure + InfectivAMINA YASMINisHEART FAILURE CLASSIFICATION HEART FAILURE : EJECTION FRACTION HEART FAILURE BY AFFECTED SIDE REDUCED / systolic: LEFT SIDED HF: The hearts left ventricle cannot pump blood effectively Left side of the the heart can’t effectively pump blood due to weakness or damage to the heart muscle . A around the body – blood backs up into the lungs causing reduced EF is less than 40% pulmonary congestion Can result in ventricular stretch, dilatation and remodeling RIGHT SIDED HF: PRESERVED/ diastolic: Right side of the heart is unable to pump blood to the Occurs when the heart muscle is too stiff and cannot lungs for exygenation – leads to a back of blood in the relax properly despite maintaining a normal ejection body causing fluid retention and swelling fraction (above 50%). This leads to inadequate filling of the heart and reduced blood flow around the bodyNYHA CLASSIFICATION NYHA CLASS 1 NYHA CLASS 2 - Mild symptoms - NO symptoms - Slight limitation of physical activity - NO limitation (ordinary physical exercise (comfortable at rest but ordinary doesn’t cause fatigue / dyspnoea / activity results in fatigue / palps / palps) dyspnoea) NYHA CLASS 3 NYHA CLASS 4 - Severe symptoms - Moderate symptoms - Unable to carry out physical activity - Marked limitation of physical activity – without discomfort: symptoms of heart comfortable at rest but less than failure are present even at rest with ordinary activity results in symptoms increased discomfort with any physical activity SometimesLHFcanleadtopulmonarycongestionwhich inturnspushestherightventricleintofailure(congestive SIGNS + SYMPTOMS heartfailure) • SignsandsymptomsofbothLHFandRHFmaybe present LEFT SIDED HF : RIGHT SIDED HF: Symptoms: - SOB (exacerbated by lying flat) Sym- Reduced exercise tolerance Symptoms: 1. S- Oedema 1. Ankle swelling (oedema) – can lead upto abdomen 2. O- Fatigure 2. Weight gain 3. Signs:smal Nocturnal Dyspnoea 3. Abdominal swelling 4. Cough – with pink frothy sputum 4. Fatigue - Cyanosis 5. F- Tachycardia 5. Shortness of breath - Elevated JVP Signs:isplaced apex beat Signs: 1. Tachypnoea crackles 1. Raised JVP 2. Bibasal fine crackles 2. Pitting oedema 3. S3 heart sounds 3. Tender smooth hepatomegaly 4. Cyanosis 4. Ascites and pleural effusions 5. Hypotension INVESTIGATIONS: bedside / bloods / imaging BEDSIDE: BLOODS: IMAGING: FULL CARDIAC HISTORY • SOCRATES 1. FBC CHEST X RAY • SOB (frothy pink sputum / 2. U+Es Trans thoracic echo: how far can they walk 3. CRP/ESR Confirms the presence of without breathlessness) 4. Troponins ventricular dysfunction - ejection • Leg swelling 5. BNP!!!! fraction. • Use of pillows (PND) ProBNP •HFrEFdiagnosis= • PMH : valve disease / MI High >2000pg/ml SymptomsofHF+evidence • DH/ FH / SH ofEF<40% FULL CARDIO EXAM: Raised 400-2000 •HFpEFdiagnosis= • General inspection Normal <400 • Inspection SymptomsofHF+evidence HIGH LEVELS -> refer urgently to ofEF>50%+raisedBNP+ • Palpation (thrills, heaves, apex) be seen within 2 weeks (echo) structural/functionalheart • Auscultation (heart valves + lung Raised -> refer urgently to be diseaseevidence bases) seen in 6 weeks • Legs (pitting oedema)CHEST X RAY INTERPRETATION: A – Alveolar Bat Wing oedema B – Kerley B lines C – cardiomegaly D – Dilated upper lobe vessels E – effusion (pleural) MANAGEMENT PRESERVED EJECTION FRACTION: Conservative management: weight loss / smoking cessation / salt and fluid restriction / exercise group rehab / annual influenza + one off pneumococcal vaccinations Medical: furosemide / assess comoribidities REDUCED EJECTION FRACTION : FIRST LINE -> ACEi + Beta blockers (give ARB if they cant tolerate ACEi) (elenapril / bisoprolol) SECOND LINE -> aldosterone antagonist (spironolactone) +/- SGLT2i THIRD LINE -> specialist treatment (ivabradine/ valsartan / hydralazine / digoxin)* ACUTE HEART FAILURE – a life-threatening emergency Definition: A sudden onset / worsening of heart failure DIAGNOSIS: symptoms – also known as acute left ventricular failure. Bloods + BNP– check for anaemia / abnormal Usually caused by decompensating heart failure. electrolytes / thyrotoxicosis / infection CXR – oedema / cardiomegaly Common precipitating causes: ACS/ HTN crisis / acute Echo – particularly if they are in cardiogenic shock arrhytmia / valvular disease Management : POUR SOD P – POUR fluid out of patient S – sit patient upright O – if sats <94% give Oxygen -> CPAP if in resp failure D – Diuretics (furosemide IV)INFECTIVE ENDOCARDITISSIGNS + SYMPTOMS Presenting Symptoms:(non specific for KEY EXAMINATION FINDINGS: an infection) - NEW murmur FEVER + NEW MURMUR = IE - Splinter hemorrhages - Petechiae - Janeway lesions - Fever - Oslers nodes - Fatigue - Roth spots - Night sweats - Splenomegaly - Muscle aches - Finger clubbing - Anorexia CAUSES: STAPH AUREUS: Culture Negative causes: NON INFECTIVE: Most common!! Prior Abx IVDU Coxiella burnetti SLE or 2 months after valve Bartonella Malignancy surgery Brucella RISK FACTORS: HACEK Rheumatic valve disease / prosthetic valves / heart defects / IVDU STEP EPIDERMIS: STREP VIRIDANS: STREP BOVIS: WITHIN 2 months of Poor dental hygiene Colorectal cancer prosthetic valve / following a dental surgery procedureINVESTIGATIONS : INITIAL - Blood cultures BEFORE antibiotics - 3 blood culture samples 6 hours apart AND from different sites - ECHOCARDIOGRAPHY - Transoesophageal Echo – more sensitive and specific – vegetations may be seen - FDG PET/CT / SPECT-CT for patients with prosthetic heart valves INVESTIGATIONS: Modified Duke Criteria MAJOR CRITERIA: Infective endocarditis diagnosed if 1. POSITIVE BLOOD CULTURES!! - pathological criteria positive, or 1. 2 positive bloods showing typical organisms (strep viridans / - 2 major criteria, or HACEK) or… - 1 major and 3 minor criteria, or 2. 2 blood cultures taken over 12 hours apart with: persistent - 5 minor criteria bacteraemia / 3 or more positive bloods where the pathogen is less specific (staph aureus / epidermis) 3. Positive serology for COXIELLA BURNETTI, bartonella or chlamydia psittachi 2. Evidence of endocardial involvement (positive echo*/ new valve Pathological Criteria: regurge) Positive histology or microbiology of pathological material –(pathological MINOR: material = vegetations, embolic - Predisposing heart conditions fragments.. ) - IVDU - Fever >38 - Vascular phenomena* - Immunological phenomenaMANAGEMENT POOR PROGNOSTIC FACTORS: 1. Staph aureus 2. Prosthetic valve 3. Culture negative endocarditis 4. Low complement levelsKEY NOTES!! FEEDBACK !! 126Thanks for coming! 127