Countdown to Finals: Cardiology · Eponymous sign = Kussmaul’s sign – increased JVP with inspiraon Constric9ve pericardi9s can be caused by TB but is oen idopathic. It causes

CountdowntoFinals:Cardiology

AimsandObjec9ves

Bytheendofthissessionyoushouldbeableto:KnowthekeyareasinCardiologythatcancomeupcommonlyinexams.OutlinewhatareasneedtoberevisedGetusedtoexamstyleques9ons

Someoftheques9onsmayseemdifficult,buttheyareunderpinnedwithcoreprinciplesandsothatiftheydocomeupyouknow.

Acutevs.Chronic

Hypertension

Angina

AtrialFibrilla9on

Valvularheartdisease

ACS

PulmonaryOedema

Tachyarrhythmias

Bradyarrhythmias

PLUS:Cardiomyopathy,pericardialdisease,myocardialdiseaseandrelevantclinicalpharmacology

Scenario1

A53yearoldgentlemanpresentstoA&Ewithacuteshortnessofbreath.Hedoesn’tspeakanyEnglishandisunabletogiveaclearhistory.Telephonetransla9onprovesdifficultbecauseofhisdistress.

Scenario1

Onexamina6on:A–pa9entsownB–RR26,SpO292%onRABP108/59HR102Wheeze,bibasalcoarsecracklesC–HSI+II+clickD–GCS15/15E–largeabdomen,unclearifnewtense,pibngperipheraloedematoupperthighs

Scenario1

Youmanagetoexplainandgetbloodtestsaswellasachestx-ray.

Scenario1

•  Insertpulmonaryoedemacxr

MitralvalvereplacementMidlinesternotomyPulmonaryconges9onFluidinthehorizontalfissureCardiomegaly(butAP)

Scenario1

ABG:pH:7.52pO2:9.1pCO2:3.1Bicarb:23Bloods:Chronicallylowhaemoglobin,mildAKI,NT-proBNP>1500,elevatedlipidprofile

Sinusrhythm,1stdegreeAVblock,Lelaxisdevia9on(IandIIIpoin9ngaway)(NBRightaxisdevia9onIandIIIpoin9ngtowardseachother),LateralTwaveinversionandLelventricularhypertrophy(DeepestSwaveinV1/2+tallestRinV5/6>35mm=Sokolov-Lyoncriteria)

Scenario1

Diagnosis:AcutePulmonaryOedema

Scenario1

Treatment:IVaccessPosi9onOxygenDiure9cs(dobutamine)MorphineAdjuncts(NIV)Nitrates

CPAP/BiPAPCPAP BiPAPWhenven9lla9onisgoodbutoxygena9onispoori.e.Type1respiratoryfailure.Usedforcondi9onswhereendexpiratorypressureisnecessary.I.e.tohelpkeepalveoliopenduetoexternalpressure/resistance–pulmonaryoedema,asthma

Whenven9lla9onispoori.e.Type2respiratoryfailure.Incondi9onswherebothinspira9onandexpira9onarepoori.e.inlungswithpoorcompliance/elas9ci9y-COPD

MitralRegurgita9on

Management:Mild-conserva9vetreatment.ACEiinheartfailure+/-spironolactone,b-blockers.Mod–valverepairorsurgicalreplacement–opencardiacsurgerywitheitherprosthe9cor9ssuevalvereplacement.

HeartFailure

•  Rightsided/Lelsidedheartfailure

Diagnosisandmanagement

•  NYHAgrading:severitygradedaccordingtodegreeofexer9onrequiredtoelicitsymptoms/

•  BNP/NT-proBNP:highlysensi9vebutnotspecific.IfnormalcanexcludeHFbutifraiseddoesn’ttellyouanythingmore,e.g.canalsoberaisedinAF.LookattheNICECKSguidelinesforHF.

•  ECHO:transthoracicECHO.•  Aimsoftreatmenta)  Prognos9cbenefit:ACEI,BB,andAAb)  Symptoma9cbenefit:Diure9cs

Management•  Commonlyprescribed:ACEI,BB+/-spironolactone/eplerenone.

•  AF+HF=+digoxin•  Diure9cs:furosemide/bumetanideforsymptoma9crelief

•  Avoidratelimi9ngCCB=nega9veinotropiceffect.

•  Non-pharmacological:Cardiacresynchronisa9ontherapy(HF+LBBB),Implan9blecardiacdefibrillator,LVAD/transplant.

Scenario2

A55yearoldmanpresentstoA&Ewithcrushingcentralchestpain.Hecomplainsofdizziness,swea9ngandisshortofbreath.Onexamina9onhisHRis45andwhenyouexaminetheJVPyounotecannonAwaves.

Scenario2

WhenlookingattheECGwherewouldyouexpecttoseeSTeleva9on?A.II,IIIandaVFB.V1/V2C.V3/V4D.V5/V6,I,aVLE.DiffuseSTeleva9onthroughout

II,IIIandAVF=inferiorinfarct.

Inferiorinfarct=Rightcoronaryarterybyandlarge.Everythingelse=Lelcoronaryartery

InferiorInfarcts

TherightcoronaryarterysuppliestheAVnode.Thereforeischaemiainthisregioncancausecompleteheartblock.CompleteheartblockleadstocannonAwaves.Thisisadescrip9onofatriacontrac9ngagainstaclosedTVleadingtoanabnormalJVPwaveformCardiogenicshock:proximalLAD

AcutecoronarySyndrome-whatyoushouldknow

Presenta9on:centralcrushingchestpain+/-lelarm/jaw.ECGs:thebarndoorSTeleva9onineachregionsoknow:lateral,anterior,inferior,septalandposteriorSTeleva9onlookslike.Management:aspirin300mg+/-9cagrelor/prisagrel(NICEguidelinesdonotstatethenewan9-platelets).GTN,morphine,oxygentarget94-98%.Secondarypreven9onpostMI:ACEI,BB,sta9nandan9-plateletagent.

ManagementofAcuteBradycardia1.Atropine500mcgIV–repeatedupto3mg2.Isoprenaline3.AdrenalineOR4.Transcutaenouspacing5.Transvenouspacing6.Emergencypermanentpacemaker(plus,stopanymedica9onsthatmayprecipitatebradycardiai.e.beta-blockers).Thisisfairgame(resusguidelines)

Scenario3A60yearoldwomanwithpreviousacidfastbacilliposi9velungpathologyhascometoclinicwithincreasingshortnessofbreathandcomplainingofankleswelling.Sheisstablewithnormalobserva9ons.

Scenario3

Onexamina9onoftheJVPyoudiscoveritappearstoriseoninspira9on.Whatisthelikelyunderlyingdiagnosis?1.TricuspidRegurgita9on2.CardiacTamponade3.Constric9vepericardi9s4.Pulmonaryhypertension5.Dilatedcardiomyopathy

Constric9vePericardi9s

Keymessagesandprerymuchallyouneedtoknowaboutthis:Eponymoussign=Kussmaul’ssign–increasedJVPwithinspira9onConstric9vepericardi9scanbecausedbyTBbutisolenidopathic.Itcausesdiastolicheartfailureduetolimi9ngfilling.SignsofrightheartfailureManagement:surgicalexcision

Scenario4

A70yearoldgentlemanwithESRDtreatedwithdialysispresentstoA&Ewithlowbloodpressureandshortnessofbreath.Onexamina9onyoufinditdifficulttohearhisheartsounds.YouperformanECGandCXR:

2importantthings:lowelectricalcurrent(theRwavesaresmallerthanyouwouldexpect)andelectricalalternans.

Giventhehistoryandyourinves9ga9onswhatisthemostlikely

diagnosis?

1.Congenitalcardiacdisease2.Heartfailure3.CardiacTamponade4.Pericardi9s5.Aor9cRegurgita9on

CardiacTamponadeIsaformofpericardialeffusionwherethepressureofeffusionaroundtheheartcausescompression.Beck’striadispathognomonic-Lowarterialpressure,distendedneckveinsanddistant/muffledheartsounds

Causes:myocardialrupture,cancer(cancausehaemorrhagiceffusion),uraemia(i.e.inESRD),complica9onofcardiacsurgery

Scenario5A50yearoldwomanhasbeenbroughtintoA&EwithanSTeleva9onMI.Ini9altherapyincludesdualan9platelets,morphine,an9eme9candGTN.Sheissuccessfullystentedinthecatheterisa9onlab.Withinafewhoursshehasdevelopeddiplopia,strangeeyemovementsandseverejawclenching.Whatdrugcanbeusedtotreatthisproblem?A.NaloxoneB.DiazepamC.Bromocrip9neD.ProcyclidineE.Baclofen

Procyclidine

Pa9enthasdevelopedanoculogyriccrisis=SEofmetoclopramide.Metoclopramideiscommonlygivenalongsidemorphineasanan9eme9c(10mgofbothmedica9onsIV)howeverinyoungpa9entsthereisariskofthissideeffect.Treatmentisviaprocyclidine.Thisisatoughonebuthighlightsclinpharmandbringsinwhatwaslearntinpsych.

Scenario5

FourweeksalerhavinghadanMIapa9entarendsclinic.ECG:persistentSTeleva9onsothedoctororderedanECHOwhichshowedamuralthrombus.Whathashappened?A.Dressler’ssyndromeB.VentricularseptaldefectC.LelventricularaneurysmD.UnstableanginaE.Mitralregurgita9on

Lelventricularaneurysm

Commonlyoccur4-6weeksaleranMIduetoweakeningofthemyocardiumwithscar9ssueforma9on.CanpresentwithpersistentSTeleva9on.

Commoncomplica9onspostMIComplica6onType Manifesta6onsIschaemic Angina,re-infarc9on,extensionofinfarc9on

Mechanical Heartfailure,cardiogenicshock,mitralvalvedysfunc9on,aneurysms,cardiacrupture

Arrhythmic AtrialorventriculararrythmiasincludingVT/VF

Embolic CNSorperipheralembolisa9on

Inflammatory Pericardi9s–dresslers(1-3weekspost)

Thisisfairgameinexamterritory.Knowingthecomplica9onspostMIismul9-faceted.ThereisasinglepageintheOxfordHandbook:caneasilycreateatable.

Scenario663yearoldmanwithanow2monthhistoryofintermirenthaemoptysisandshortnessofbreathpresentsfollowingaboutofdizzinessandpalpita9onswhichstartedonly2daysago.Hehasanirregularheartrate.Hedoesnotcomplainofanypain.Hehadrheuma9cfeverasachildandhehasneversmoked.Whatisthelikelyunderlyingpathology?A.  Aor9cstenosisB.  LungcancerC.  MitralstenosisD.  PulmonaryembolismE.  Infec9veendocardi9s

Scenario663yearoldmanwithanow2monthhistoryofintermirenthaemoptysisandshortnessofbreathpresentsfollowingaboutofdizzinessandpalpita9onswhichstartedonly2daysago.Hehasanirregularheartrate.Hedoesnotcomplainofanypain.Hehadrheuma9cfeverasachildandhehasneversmoked.Whatisthelikelyunderlyingpathology?A.  Aor9cstenosisB.  Lungcancer(hesanon-smokerandhasn’tlostweight)C.  MitralstenosisD.  Pulmonaryembolism(notamiddleagedwomanon

contracep9on)E.  Infec9veendocardi9s(notpyrexic/IVDUorhadavalvereplaced)

MitralStenosisRheuma9cfever(olencausedbys.pyogenesintheURT)causesanautoimmunereac9onagainsttheheartvalves.MSleadstolelatrialhypertrophy/dilata9oncausingAF.Mitralstenosiscanalsoleadtohaemoptysisduetopulmonaryhypertensionmediatedsubmucosalvaricesinthebronchialwalls.Classicmurmuraudibleismid-diasyolic(usethebell)

Scenario7A22yearoldstudentwhohasbeenknowntousecocaineiscomplainingofseveretearingchestpainwhichradiatesthroughtohisback.Whenyoudoathoroughexamina9onyouno9cethathislelpupilisconstrictedandthereisapar9alptosisoftheleleyelid.Whatisthemostlikelydiagnosis?A.MIB.Myocardi9sC.OesophagealspasmD.GORDE.Aor9cdissec9on

Aor9cDissec9onTearofthetunicain9maoftheaortaallowingbloodtoflowthroughthelayersoftheaorta.Classicallypresentswithseveretearingchestpain,ifthetearextendsintothecaro9dsitcanaffectsympathe9cnerves(asinthepriorcase).Cocaineisariskfactorfordissec9on.TypeA(ascendingaorta)andTypeB(descending)Whatisthebestimagingmodalitytoconfirmanaor9cdissec9on?CT-angiogram

Scenario7

Scenario8A35yearoldladyisreadmiredtohospital2weeksaleranaor9cvalvereplacementforAor9cstenosis.Shehasdevelopedatemperatureof39degrees.Sheisawai9nganechoandhashadculturestaken.Whatcombina6onofan6bio6csshouldbeini6ated?A.Benzylpenicillin&gentamicinB.Flucloxacillin,tazocin&rifampicinC.Amoxicillin,gentamicin&rifampicinD.Vancomycin,gentamicin&rifampicinE.Meropenem&gentamicin

Prosthe9cvalveendocardi9s

Pendingbloodculturesprosthe9cvalveendocardi9sshouldbetreatedwith:vancomycin,gentamicin+/-rifampicin.Thiscanbesteppeddownbasedonsensi9vityresults.

Endocardi9s:history/examina9onfindings

•  Pyrexia•  Murmurs–generallynewonset•  Splinterorsubungualhaemorrhages•  Oslernodes–smalltenderpurplenodulesonthepulpofthephalanges

•  RothSpots–re9nalhaemorhageswithpalecentres•  Janeway’slesions–painlessmaculesonthethenar/hypothenar

•  Arthri9s–subacuteIE•  Haematuria–sep9cembolicancauserenaldamageandhaematuria

Infec9veEndocardi9sCommonorganisms:S.aureus,S.epidermidis,S.viridans,enterococcus.Classify:prosthe9cvsna9ve.Ifprosthe9c:early(within1year=coagulasenega9veStaph)orlate(mirrosna9vevalveorganisms).Presenta9on:general(pyrexic,unwell),cardiac(murmur,PRblock),immunecomplexdeposi9onmediated(OslerandJaneway,Rothspotsetc),sep9cemboli(haematuria)Diagnosis:ECHO.NormalTTEdoesnotruleoutIE.Abx:Empirical=benzylpenicillin+gentamicin4/52Prosthe9cvalve:S.aureusrequiresprolongedregimen(especiallyofaminoglycosides)+/-theuseofrifampicin.CheckouttheESCguidelinesforInfec9veendocardi9s

Scenario9

A67yearoldladyarendsherGPwithoccasionalpalpita9ons.Shehasanirregularpulseandarateofaround80bpm.AnECGdonebytheprac9cenurseprovessheisinAF.ShehasahistoryofhypertensionandhashadapreviousTIA.WhatisherCHADsVASCscore?A.1B.2C.3D.4E.5

HerScorewas5AlsoconsiderbleedingriskforbonuspointsusingHASBLED.Scoreof0(male)/1(female)=noan9-coagulantScoreof1(male)/2(female)=an9-coagulateFromESCguidelines

An9coagula9oninAF

Thereforean9coagula9onisrecommended.WarfarinorNOAC.Importanttoeducateaboutthepros/consofeither.Considera9ons:NOACsareNOTindicatedforuseinvalvularheartdiseasesoifpresen9ngwithAF+PSMwarfarinisbestchoice.InrenalimpairmentNOAC’smayneedtobedoseadjusteddependingoneGFR

Scenario10

A42yearoldwomanpresentstoA&Ewitha1dayhistoryofpalpita9onsanddizziness.Shehasnochestpain.Shehasnoothersignificantmedicalhistory.Onexamina9on:HR150,BP84/60,Apyrexial,RR20,SaO294%andsheisalerttovoice.HSI+II+0.Chestclear.JVPnotelevated.GiventheECGwhatisthemostappropriatedefini9vemanagement?

GiventheECGwhatisthemostappropriatedefini9vemanagement?A.  VagalmanoeuvresB.  Adenosine6mgIVC.  Amiodarone300mgIVover20-60minutesD.  SynchronisedDCcardioversionE.  DesynchronisedDCcardioversion

Tachyarrhythmias

•  ALSguidelines..Isthereapulse?..No..CPR•  Adversefeatures:synchronisedDCshock– Shock(SBP<90,pallor,swea9ng,cold,clammy,confusionorimpairedconsciousness)

– Syncope(transientLOC)– Myocardialischaemia(typicalischaemicchestpainand/evidenceofSTeleva9ononECG)

– Heartfailure(PO+/-raisedJVP+/-peripheraloedema/liverenlargement)

A24yearotherwisewellmanhasanECGwhichshowsaRBBBparernandSTeleva9oninV1,V2andV3.Hehasnosymptomsofpastmedicalhistory.Whatistheunderlyingdiagnosis?A.  Silentrightsidedinfarc9onB.  TetralogyofFallotC.  BrugadasyndromeD.  VentricularaneurysmE.  Myocardi9s

A70yearoldwomanwithAFisreviewedinclinic.Sheiscurrentlyonbisoprolol,ramiprilanddigoxin.Shehasmildsignsofheartfailure.Anewdrugisaddedtohermedica9ontoimprovehersymptoms.7dayslatershepresentsacutelywithxanthopsia,nausea,vomi9ngandconfusion.Whichofthefollowingdrugsdidthecardiologistadd?A.  HydralazineB.  VerapamilC.  IndapamideD.  AmilorideE.  Spironolactone

•  DigoxinisacardiacglycosidewhichinhibitstheNa/Kpumpinthemyocardiumthuscausingincreasedintracellularcalcium.Thisresultsinaposi9veinotropiceffectandreducedheartrate.UsedtotreatHFandAF.

•  Digoxinisrenallyexcretedandhasalonghalflife.•  Digoxintoxicitypresentswithnausea,vomi9ng,confusion,arrhythmias

andxanthopsia.•  Digoxinlevelsaredone6hours(ideally8-12hours)postdose.•  Commonprecipitantsinexams:hypokalaemia,hypomagnesaemiaand

hypercalcaemia.Otherprecipitantsoftoxicityincludehypothyroidism,hypoalbuminaemiaandalonglistofmedica9ons.

•  Spironolactonecancausetoxicitybecausedespiteitbeingapotassiumsparingdiure9citalsocompetesforthesamereceptorforexcre9onasdigoxin.

•  Otherdrugsthatcancausetoxicity:amiodarone,verapamilanddil9azem.•  Donotneedtorou9nelydoplasmadigoxinlevels:canmonitorresponse

usingtheHR.

Digoxintoxicity