Countdown to Finals: Cardiology
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