Cardiology in Finals

1. Cardiology in Finals Daniel Belete

2. Play the game!

3. How do you do a cardiovascular examination?

4. Case 1

5. Examination • Mild SOB at rest • HR 65 regular • BP 150/90 • Added third HS • Bibasal course crackles • Pitting oedema to mid-shins

6. Differential

7. Investigations • Bedside • ECG • Bloods • FBC, U+Es, TFTs, HbA1c, lipids, LFTs, TFTs, BNP • Imaging • CXR, Echo, cardiac MRI

8. Chronic HF Management • Conservative • Patient education • Diet and fluid intake advice • Cardiac rehab • Community heart failure team • Annual influenza vaccine and a pneumococcal vaccination • Medical • Titrate loop diuretic • Reduced EF • β-blocker and ACEi/ARB • Consider long term CV risk • Think antiplatelets and statins

9. How would you grade the severity? • What are the causes of Heart Failure?

10. New York Heart Association (NYHA) • Class I — no limitation of physical activity • Class II — slight limitation of physical activity on exertion • Class III — marked limitation of physical activity on exertion • Class IV — unable to carry out any physical activity without discomfort, symptoms at rest can be present

11. Most common • IDH • HTN • Other cardiac causes • Valvular pathology (AS), pericardial disease, arrhythmias (AF) • High output states • Drugs • Alcohol, NSAIDs, CCBs, some antiarrhythmics

12. Case 2

13. Examination • Gentleman – late middle age • Pulse 80 bpm irregular • BP 160/80

15. No heaves or thrills • HS present, nil added

18. What is your diagnosis?

19. This patient presents with chest pain. How would you investigate this patient? • Bedside • Serial ECGs – ischaemic changes, arrhythmias, old infarcts • Bloods • Risk factors – HbA1c, cholesterol • Troponin • Imaging • CXR - Cardiomegaly • Echocardiogram – ventricular function, valvular function • Further Ix depend on risk of having CAD (complex, NICE 2010) • Low risk – CT calcium scoring • Medium risk – functional, e.g. myocardial perfusion scan (MIBI), stress echo, cardiac MRI • High risk – coronary angiogram

20. How would you manage patients with chronic IHD? • Conservative • Education, exercise, weight loss • Smoking cessation • Medical • Aspirin, beta-blockers, Ca ant, GTN, etc, • AF – warfarin, rate control • Control risk factors – optimise T2DM, statins • Surgical • PCA – percutaneous coronary angioplasty • CABG

21. Case 3

22. Examination Comfortable at rest. SOB on exertion HR 72bpm, regular Slow rising. No stigmata of endocarditis BP = 110/90 JVP + 2 cm above sternal notch Apex beat not displaced.

23. No heaves or thrills, HS I + II + ejection systolic murmur, loudest in the aortic area in expiration, radiating to the carotids. Clear lung fields, no pedal oedema

24. Differentials

25. Bedside – ECG (LVH, possibly LBBB or complete heart block) • Imaging: • CXR – LVH, calcified aortic valve, post stenotic dilatation of aorta • Echo – • Diagnostic • Severity – severe = valve gradient >50 mmHg and valve area <0.5 cm2 • Invasive – cardiac catheter – assess gradient, LV function, CAD

26. Conservative • Follow up clinics (‘I would arrange…..’) • Patient education Medical • Essentially treatment of heart failure/angina Surgical • Valve replacement • Valvuloplasty

27. What are the causes of aortic stenosis?

28. Case 4

29. Examination • Pulse 92 • BP 130/80 • JVP elevated +6 cm above sternal notch • Crackles at lung bases

30. Apex laterally displaced in anterior axillary line, 5th ICS, with palpable thrill • Heart sounds soft S1, normal S2 • Pan-systolic murmur, 4/6, loudest in expiration radiating into axilla

32. Heart failure – oedema, raised JVP, crackles Infective endocarditis Murmur Would you like to present your findings?

33. What is your differential diagnosis of a pan-systolic murmur? • MR • TR • VSD

34. How would you investigate this patient? • Bedside • ECGs (MR  AF, p mitrale, LVH; IE  arrhythmias) • Urine dip (haematuria) • Bloods • Biochemistry – CRP, U&E, LFTs • Haematology - WCC • Blood cultures • Imaging • CXR – pulmonary oedema, mitral valve calcification, LAH, LVH • Echo - assess LV function; TOE to assess severity and suitability for repair rather than replacement; Doppler echo to assess size and site of regurg • Other • Cardiac catheterisation - confirm diagnosis, exclude other valve disease, assess CAD

35. Management of MR • Conservative • Regular follow up, educate patient • Medical • AF – rate control, anticoagulate • Diuretics improve symptoms • Surgical • Mitral valve repair • Mitral valve replacement

36. What are the causes of mitral regurgitation? Abnormal leaflets/cusps • Rh fever • Endocarditis • Myxomatous degeneration (= mitral valve prolapse) Abnormalities of tensor apparatus • Papillary muscle rupture (due to MI) or rupture of chordae tendinae Abnormal LV cavity • Functional regurg secondary to dilatation  lateral migration of papillary muscles

37. What does this picture show?

38. Modified Duke’s criteria: 2 major OR 1 major + 3 minor OR 5 minor Major Blood cultures with typical organism, multiple bottles Endocardial involvement (Positive echo – vegetation, abscess, etc) Minor Predisposition (cardiac lesion, IVDU, etc) Fever >38C Vascular/immunological signs Blood culture not met by major criteria Echo that does not meet criteria How would you diagnose infective endocarditis?

39. Case 5

40. Examination Young man, comfortable at rest. Capillary pulsations in the nailbeds. Pulse 60bpm, regular and collapsing.

41. BP 130/60 • Visible carotid pulsations • JVP not elevated. • Thrusting apex beat displaced to the mid axillary line. • Early diastolic murmur (2/4) loudest in aortic area in expiration. • Lungs clear, no pedal oedema

42. What is your differential diagnosis? Aortic Reguritation What if there is a low pitched late diastolic murmur at the apex? - This is the classic Austin Flint murmur of AR caused by the regurgitant jet hitting the anterior leaflet of the mitral valve.

43. What are the markers of severity of AR? • Wide pulse pressure • Long duration of the diastolic murmur • Austin Flint murmur • Pulmonary hypertension • Signs of decompensation (i.e. cardiac failure) • S3

44. What are the causes of AR? ACUTE CHRONIC Congenital bicuspid valve Hypertension Rheumatic fever Rheumatological disease – RA, SLE, AnkSpond, Psoriatic arthritis Connective tissue disease – Marfan’s, Ehlers Danlos, Osteogenesisimperfecta • Infective endocarditis • Aortic dissection • Failure of a synthetic valve

45. How would you manage this patient? Conservative - patient education - dietary advice and exercise Medical - Diuretics for heart failure Surgical Valve replacement is the only definitive management.