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Phase2 Karl Wild and Rowena Speak

Cardiology Revision. Phase2 Karl Wild and Rowena Speak. The Peer Teaching Society is not liable for false or misleading information…. Stable Angina. Stable Angina - A retrosternal chest tightness or heaviness which is brought on by exertion and relieved by rest. Symptoms –

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Phase2 Karl Wild and Rowena Speak

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  1. Cardiology Revision Phase2 Karl Wild and Rowena Speak The Peer Teaching Society is not liable for false or misleading information…

  2. Stable Angina • Stable Angina - A retrosternal chest tightness or heaviness which is brought on by exertion and relieved by rest. • Symptoms – • constricting discomfort in the front of the chest, arms, neck and jaw, • Provoked by physical exertion, especially after meals and in cold, windy weather or excessive emotion • Relieved (within minutes) with rest or glyceryl trinitrite. • Causes – Mostly Atheroma. Anaemia, Aortic Stenosis, Tachyarrhythmia, Hypertrophic Cardiomyopathy Arteritis.

  3. Unstable Angina – Angina of recent onset (<24hr) or a deterioration in stable angina with symptoms occurring at rest. Refractory Angina – Refers to patients with severe coronary artery disease in whom revascularization is not possible and whose angina is not controlled by medical therapy.

  4. Angina Examination Signs – • Anaemia • Thyrotoxicosis • Hyperlipidaemia • Aortic Stenosis (Ejection Systolic murmur radiating to neck) • Check blood pressure

  5. Angina Investigation • 12 lead ECG -During an attack – Transient ST depression & T wave inversion. • Cardiac Catheterization, CT Coronary Angiography • Exclude anaemia, diabetes, hyperlipidaemia, thyrotoxicosis and arteritis

  6. Angina Management • Address risk factors • Aspirin 75mg daily • B-blocker/ Ca2+ – Atenolol/Amlodipine Both if uncontrolled on one • Nitrates – GTN, Isosorbide Mononitrate bd • Ivabradine/Nicorandil

  7. Revascularisation • PCI – Single vessel CAD and normal LV function • CABG – Triple vessel disease and abnormal LV function

  8. Acute Coronary Syndromes • ST Elevation Myocardial Infarction (STEMI) • Non ST Elevation Myocardial Infarction (NSTEMI) • Unstable Angina • Causes – Plaque rupture Coronary Spasm Thrombosis Vasculitis Emboli

  9. NSTEMI ECG changes - • ST depression • T Wave inversion • Could be normal

  10. STEMI • ECG changes – Tall T waves ST elevation New LBBB Later – T wave inversion Pathological Q waves

  11. ACS symptoms - • Acute central chest pain • Radiates neck and arm • Lasting >20 minutes • Nausea • Dyspnoea • Palpitations

  12. ACS Signs - • Distress, anxiety, pallor, sweatiness • Tachy/bradycardia • Hyper/hypotension • 4th heart sound • Signs of HF and murmur • Later - Pericardial friction rub & peripheral oedema

  13. ACS Investigations • ECG • Bloods • Cardiac Enzymes – Cardiac Troponin (T & I) ^ 3 hours after onset and peak at 24-48hr Creatine Kinase (CK-MB) ^ 3 hours after onset, peak within 24hr

  14. ACS Management NSTEMI Oxygen Morphine GTN Aspirin 300mg PO Clopidogrel 300mg PO Atenolol PO / Verapamil PO Enoxaparin More Nitrate if in pain. High risk – GPIIb/Iia antagonist (tirofiban) Low risk – Discharge if 12hr Trop -ve STEMI Oxygen Aspirin 300mg PO Morphine GTN PRIMARY PCI / Thrombolysis Atenolol

  15. The Peer Teaching Society is not liable for false or misleading information…

  16. Hypertension (HTN) • Essential (primary) HTN = idiopathic • SecondaryHTN= something is causing it The Peer Teaching Society is not liable for false or misleading information…

  17. HTN: causes of secondary • Renal disease: intrinsic, renovascular • Endocrine: Cushing’s, Conn’s, Phaeochromocytoma, Acromegaly, Hyperparathyroidism • Coarctation of the aorta • Pre-eclampsia and HTN in pregnancy • Drugs and toxins: alcohol, cocaine, ciclosporin, decongestants, adrenergic medications, oral contraceptives, corticosteroids, liquorice The Peer Teaching Society is not liable for false or misleading information…

  18. HTN: symptoms • Usually asymptomatic • Headaches, paroxysmal sweats or palpitations = think phaeochromocytoma (tumour of the adrenal medulla) The Peer Teaching Society is not liable for false or misleading information…

  19. HTN: diagnosis • GP surgery BP measurements of adults at least every 5 years White coat syndrome = patients have elevated BP in a clinical setting but not in other settings due to anxiety experienced during a clinic visit. • ABPM = ambulatory blood pressure monitoring • HBPM = home blood pressure monitoring • Cardiovascular risk assessment • HTN retinopathy screening • ECG to look for LVH • Bloods: electrolytes, creatinine, eGFR, fasting glucose, lipids • Urinalysis: albuminuria, proteinuria or haematuria ± albumin:creatinine ratio. The Peer Teaching Society is not liable for false or misleading information…

  20. HTN: stages • Stage 1  - BP in surgery/clinic is ≥140/90 mm Hg and ABPM or HBPM is ≥135/85 mm Hg. • Stage 2 - BP in surgery/clinic  is ≥160/100 mm Hg and ABPM or HBPM is ≥150/95 mm Hg. • Severe - BP in surgery/clinic is ≥180/110 mm Hg or higher. The Peer Teaching Society is not liable for false or misleading information…

  21. HTN: lifestyle interventions • Lower salt intake • Reduce alcohol consumption • Stop smoking • Do more exercise • Be less stressed The Peer Teaching Society is not liable for false or misleading information…

  22. HTN: initiation of treatment • Offer step 1 treatment to people aged under 80 with stage 1 hypertension and one or more of: • target organ damage • established cardiovascular disease • renal disease • diabetes • 10-year cardiovascular risk equivalent to 20% • Offer step 1 treatment to people of any age with stage 2 hypertension The Peer Teaching Society is not liable for false or misleading information…

  23. HTN: treatment The Peer Teaching Society is not liable for false or misleading information…

  24. Heart failure • A complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation. The Peer Teaching Society is not liable for false or misleading information…

  25. HF: aetiology • Ischaemic heart disease • Cardiomyopathy • HTN • Diseases of the heart valves • Pericardial disease • Arrhythmias • Alcohol • Cocaine • Chemo • Severe anaemia • Thyroid disease • Idiopathic The Peer Teaching Society is not liable for false or misleading information…

  26. HF: symptoms Left Right Swollen ankles Fatigue Anorexia • Exertional dyspnoea • Orthopnoea • Paroxysmal nocturnal dyspnoea (PND) • Fatigue The Peer Teaching Society is not liable for false or misleading information…

  27. HF: signs Left Right Raised JVP Hepatomegaly Pitting oedema Ascites • Cardiomegaly • Third and fourth heart sounds • Tachycardia • Crepitations in lung bases The Peer Teaching Society is not liable for false or misleading information…

  28. The Peer Teaching Society is not liable for false or misleading information…

  29. HF Investigations • Chest X ray • Bloods • B-type Natriuretic Peptide • ECG • Transthoracic echocardiogram

  30. Chronic HF Management • Diuretics – Furosemide • ACE-I – Ramipril / ARB – Candesartan • B-Blocker – Atenolol • Spironolactone • Digoxin • Vasodilators – Hydralazine & Isosorbide Dinitrate

  31. Acute HF Management • Oxygen • Diamorphine IV • Furosemide IV • GTN spray • If systolic BP >100mmHg IV nitrate

  32. HF Question A 75 year-old woman is brought to the Emergency Department by ambulance following an emergency call at 4 am. She is pain-free but very breathless. She has previously been diagnosed with congestive cardiac failure and is receiving drug treatment from her General Practitioner.

  33. GOOD LUCK!!!

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