Overview • Scars • Acute coronary syndromes • Valvular heart disease • Infective Endocarditis • Dextrocardia • Arrhythmias
Midline sternotomy scar What is this scar? Which 3 procedures would cause this scar? What else would you look for?
What could this be? What are the indications? Where else should you look?
“We have this patient with chest pain” 66 year old with a background of DM type 2, hypertension and a 40 pack yr smoking hx. Day 1 post inguinal hernia repair. Has been having central crushing chest pain for last 15 minutes. No relief from GTN. Hot & sweaty, vomited twice. Obs: BP- 120/60 P-75 RR- 24 Sats 98% on RA
What ECG features suggest an STEMI?? ST elevation in 2mm in 2 or more contigous limb leads ST elevation in 2 or more contigous chest leads New onset LBBB Posterior MI .What features suggest an to NSTEMI ??? ST depression and /or T wave inversion in 2 or more leads. Risk is assessed using the TIMI score.
ManagementWhat would you do as an F1?1) Assess haemodynamic stability2) oxygen(?) 3) Initiate ACS protocol4) Nitrates 5) AnalgesiaSTEMI - Primary PCI NSTEMI – Risk assessment and PCI Unstable angina – Functional Testing +/- AngiogramUniversal Secondary Prevention and Cardiac Rehabilitation
1) EXERCISE TOLLERANCE TEST 2) CT CALCIUM SCORING 4) STRESS ECHO 3) MYOCARDIAL PERFUSION SCAN FUNCTIONAL TESTING
Valvular heart disease • Common exam question • Can find lots of patients with valve replacement • Things to know are - Which valve - What the cause could have been - Clinical signs - Basic principles of management • Questions about complications of surgery
Scenario 1 “ A 72 year gentleman man presents with a history of collapse as he was rushing up a hill to catch a bus. There was no LOC. He reports no associated weakness/numbness/tingling in the limbs, visual disturbance, slurred speech, headache, chest pain, or palpitaions. This had never occurred before. He has noticed that he is increasingly SOB of late whilst gardening/ doing house-work etc. He has no previous cardiac history. He suffers from hypertension and gout.”
Aortic Stenosis Causes 1) Senile calcification 2) Biscuspid Aortic valve 3) strep associated – Rheumatic fever Symptoms Exertional : Dysponea, syncope angina Features of AS on examination ????
Features on Examination • narrow pulse pressure • slow rising pulse • LV heave • Forcefull apex beat • ESM radiating to the carotid- heard all over the precordium • Features of left ventricular dysfunction Severe Stenosis→ 1) Narrow PP 2) Quite or loss of S2 DDX for an ESM → 1) HOCM 2) VSD 3) Aortic sclerosis. Management : TAVI vs Open AVR +/- CABG? Exam tip : Which heart sound is metallic in an AVR??
Mitral Regurgitation “ A 72 year old lady presents with a history of increasing SOB, orthoponea and palpitations over a few months. She has a history of Angina, Hypertension. She is found to be in Atrial fibrillation” Causes
Mitral Regurgitation Clinical features AF small volume pulse displace apex beat loud PSM radiating to the axilla bibasal crepitations • MGX: mitral valve clip vs Open MVR +/- CABG. Discuss indication. Decision is often based on a TOE.
Mitral Regurgitation • Management • Consider patients pre-morbid state • Medical : Diuresis • Rate control • Anti coagulation • ACE inhibitors and B-blockers. • Surgical : Assessment with an TTE / TOE and angiogram. Mitral clip or an open Valve Replacement
Cause: Congenital Rheumatic Heart disease Senile Degeneration Clinical Signs Malar flush Irregular pulse Tapping apex beat – palpable 1st HS Left parasternal heave / Enlarged LA Loud 1st heart sound Opening snap Mid-diastolic murmur. Mitral Stenosis
On investigation CXR- Enlarged left atrium, calcified valves and pulmonary oedema. ECG – p-mitrale and AF
Management Medical : Rate control (digoxin) Anti-coagulate Valvuloplasty Surgical: Valve replacement Valveotomy (open / closed)
Aortic Regurgitation • Causes : Acute (inf. Endocarditis) • Chronic: Connective tissue disorders (RA), Rheumatic heart disease, syphilitic heart disease . Aortitis: Marfans / Anklysing spondylitis Clinical features: Wide PP collapsing pulse – hyperdynmaic apex beat Eponymous signs Early diastolic murmur
Aortic Regurgitation • Other causes of a collapsing pulse? • Anything that causes a high circulating volume: • Pregnancy • Anaemia • PDA • Thyrotoxicosis • Management • Valve replacement vs conservative management
Complications of Valve replacements • INFECTION : early vs late. • FAILURE OF VALVE: early vs late • DISLODGEMENT • THROMBUS FORMATION vs HAEMMOHRAGE
Management • What would you do as an F1? • ECG • CxR • Inform seniors • Echo • Conservative: if AF, rate control. Diuretics improve symptoms • Surgical: Valve repair/ replacement
“ A 54 year old lady initially presents with an abscess. • She vascular infarcts on CT and is admitted to the acute stroke unit. She has no major risk factors for a CVA. • On doing base line bloods she has CRP 300 • Urine dip show blood +++ • She’s on the stroke ward, she has some left sided weakness. Obs stable, and apyrexial so far “
What is the diagnosis??? Infective endocarditis What would you look for ???
What would you look for? • Signs of sepsis • New murmur or change in existing murmur • Microscopic haematuria, ARF, splenomegaly • Embolic features e.g. abscesses
What would you do as an FY1? • Bloods • Blood cultures • ABG • Urine dip & MCS • CxR • ECG • Echo (TOE) • Inform seniors
Common questions 1. Risk factors? Lifestyle factors (IVDU), cardiac lesions, aortic or mitral valve disease, PDA, VSD, coarctation, prosthetic valve 2. Organisms? • Strep viridans (35-50%), HACEK (Haemophilus, actinobacillus, cardiobacterium, Eikenella) • Fungi • SLE – Libman-Sachs endocarditis 3. Criteria for Diagnosis?
Duke criteria for diagnosis 2 major OR 1 major and 3 minor OR all 5 minor criteria Major • +ve blood culture typical organism in 2 separate cultures or persistently +ve blood cultures • Endocardium involved • Positive echo or new valvular regurgitation Minor • Predisposition • Fever >38C • Vascular/immunological signs • +ve blood cultures that do not meet major criteria • +ve echo that does not meet major criteria
Management • MDT decision • Conservative management: Long-term antibiotics and serial echos • Surgical management: Valve replacement
Dextrocardia A congenital defect where the heart is situated on the right side of the body 2 types: Isolated dextrocardia – heart placed further to the right in thorax, associated with other cardiac abnormalities Dextrocardia situs inversus – heart placed to the right side as a mirror image