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Cardiology Finals Revision Andrew Degnan PALI Wednesday 12 th September 2012 Slide 2 Why Cardiology? Slide 3 2005 Paper 1-Heart failure Paper 2-Unstable angina Resit 1-Aortic stenosis Resit 2-Infective endocarditis and pericarditis 2006 Paper 1-Heart failure Paper 2-Primary prevention 2007 Paper 1-Heart failure and pericarditis Paper 2-None 2010 Paper 1-None Paper 2-Postural hypotension Resit 1-Aortic stenosis Resit 2-Infective endocarditis 2011 Mock-Heart failure Paper 1-None Paper 2-Infective endocarditis and heart failure Resit 1-Acute MI Resit 2-Postural hypotension 2012 Paper 1-None Paper 2-Unstable angina and postural hypotension Slide 4 Slide 5 2012 Mock Paper Unstable Angina Slide 6 MEQ 1.8 A 39 year old Asian man was admitted to the medical admissions unit with pains in his chest and neck. He admitted to smoking 20 cigarettes per day and a blood cholesterol had been measured at 7.2mmol/L (reference range 3.5- 5.0mmol/L). His average HR on admission was 90 bpm and his blood pressure was 170/100mmHg. An initial diagnosis of unstable angina was made. (a) What are his risk factors for coronary artery disease? (2 marks) Slide 7 MEQ 1.8 A 39 year old Asian man was admitted to the medical admissions unit with pains in his chest and neck. He admitted to smoking 20 cigarettes per day and a blood cholesterol had been measured at 7.2mmol/L (reference range 3.5-5.0mmol/L). His average HR on admission was 90 bpm and his blood pressure was 170/100mmHg. An initial diagnosis of unstable angina was made. Slide 8 Risk Factors for CVD Unmodifiable Factors Male Increasing age Asian decent Post-menopause Family History Modifiable Risk Factors Smoking Hyperlipidaemia Obesity (diet and exercise) Diabetes Hypertension Stress Slide 9 (b) You decide to admit him to hospital. What drug therapy could he be started on? List 4 potentially beneficial drugs (2 marks) and give a reason for prescribing each (2 marks). Slide 10 Immediate Treatment of NSTEMI and UA Anti-ischaemic therapy (decrease myocardial oxygen demand) Nitrates (GTN IV), venodilation, decrease venous return Beta-blockers, decrease sympathetic drive and so decrease O2 demand Anti-thrombotic therapy (prevent further development of partially occluded thrombus) Aspirin, prevents platelet aggregation and activation Clopidogrel, alternative action on platelets. Can be used in combitaion with or in place of aspirin Heparin, usually LMWH, breaks down any clots Slide 11 Results of blood tests revealed a Troponin T of 0.35ng/ml (normal=unrecordable), peak CK was 180iu/ml (reference range: 25-200iu/ml) on day 2 (c) List the 2 cardinal ECG features of an acute full thickness anterior myocardial infarction and outline their electrophysiological cause (4 marks) Slide 12 The Easy Bit http://en.wikipedia.org/wiki/File:12_Lead_EKG_ST_Elevation_tracing_color_coded.jpg Slide 13 The Hard Bit Is it enough to answer with It just does? Slide 14 ST Elevation Changes in the action potentials produced by necrotic tissue Abnormal firing of action potentials leads to early repolarisation secondary to ischaemia, causing this abnormal wave Pathological Q Waves Any initial downward movement of the QRS is a Q wave. Pathological Q waves are Q waves developing after MI which have a width of 1 small box and a depth > 25% of the total QRS height Develop from living tissue behind the infarct which is picked up by the ECG as a downward movement as impulses move away from the anterior leads Slide 15 Cardiac Enzymes http://en.wikipedia.org/wiki/File:AMI_bloodtests_engl.png Slide 16 Discussion Points? Slide 17 2005 Paper 1 Left Ventricular Failure Slide 18 MEQ 1.2 A 78 year old man had a large anterior myocardial infarction three years ago. Initially he made a good recovery, but has had to take a diuretic for ankle swelling since. In the last 2 months he has become short of breath on exertion. You suspect that he has developed left ventricular failure (a) Give 2 additional symptoms that would support this diagnosis (2 marks) Slide 19 MEQ 1.2 A 78 year old man had a large anterior myocardial infarction three years ago. Initially he made a good recovery, but has had to take a diuretic for ankle swelling since. In the last 2 months he has become short of breath on exertion. You suspect that he has developed left ventricular failure (a) Give 2 additional symptoms that would support this diagnosis (2 marks) Slide 20 Left Heart Failure Exertional dyspnoea Orthopnoea Paraxysmal nocturnal dyspnoea Fatigue and weakness Poor exercise tolerance Cardiac wheeze Nocturnal cough with frothy pink sputum Impaired urine output during the day and nocturia at night Impaired metal status Cold peripheries Right Heart Failure Peripheral oedema Abdominal discomfort Weight gain Anorexia and nausea Slide 21 Left Heart Failure Exertional dyspnoea Orthopnoea Paraxysmal nocturnal dyspnoea Fatigue and weakness Poor exercise tolerance Cardiac wheeze Nocturnal cough with frothy pink sputum Impaired urine output during the day and nocturia at night Impaired mental status Cold peripheries Right Heart Failure Peripheral oedema Abdominal discomfort Weight gain Anorexia and nausea Slide 22 Left Heart Failure Cachexia Cyanosis Sweating Tachopnoea Tachycardia Pulses alternans Bilateral basal crackles Displaced apex beat Extra heart sounds and murmurs (depends on cause) Right Heart Failure Cachexia Oedema Increased JVP with positive hepatojugular reflex RV heave Hepatomegaly Ankle oedema Sacral oedema Ascities Slide 23 (b) You arrange for a chest X-ray. Give four features that would support the diagnosis of left ventricular failure (4 marks) Slide 24 Adapted from http://www.e-radiography.net/technique/chest/chest_eval.htm Slide 25 Adapted from http://www.learningradiology.com/archives2007/COW%20267- Pulmonary%20edema-CHF/caseoftheweek267page.html Slide 26 Adapted from http://en.wikipedia.org/wiki/Kerley_lines Slide 27 Adapted from http://www.radiologysingapore.com/lectures/plain-films-with- diagnosis-6/ Slide 28 (c) Give 2 neurohormonal mechanisms which may be activated in heart failure (2 marks) Slide 29 4 Neurohormonal Mechanisms 1.Sympathetic Nervous System Activity Fall in CO detected by baroreceptors, sympathetic drive increases, HR and BP 2. RAAS Decreasing renal perfusion activates RAAS which PVR (angiotensin II) and blood volume (aldosterone) which both play a role in BP 3. ADH Released in response to low BP and release of angiotensin II. blood volume and hence BP 4. Natriuretic Peptides Both ANP and BNP. Both inhibit RAAS and so blood volume and BP. Beneficial effect, but not released in sufficient enough quantities. BNP=prognostic marker Slide 30 These all have an effect on? Frank Starling Mechanism Improved venous return improves LV contraction Preload vs. afterload And this combination leads to Symptoms of LV HF Hypertrophy Slide 31 (d) If starting this patient on an ACE inhibitor, what precautions would you take? (3 marks) Slide 32 Side-effects First dose hypotension Persistent cough Hyperkalaemia Renal impairment Headache Dizziness Fatigue Nausea Contra-indications and Cautions Hypersensitivity Bilateral renal artery stenosis Pregnancy Impaired renal function Aortic stenosis Cardiac outflow obstruction Hypovolaemia Haemodialysis Slide 33 Other Precautions Check baseline BP (first dose hypotension) and Us+Es (hyperkalaemia, renal dysfunction) Start low, tritrate dose up Continue to monitor Us+Es Drug interactions Slide 34 Discussion Points? Slide 35 2011 Paper 2 (also 2005 Resit 1 and 2010 Paper 2) Infective Endocarditis Slide 36 MEQ 2.6 A 32 year old woman, who is a known alcoholic and abuser of intravenous drugs, presents to A+E complaining of gradual onset malaise, fever, weight loss and night sweats. She is pyrexial (38.5). She has a pansystolic murmur which is thought to be a new finding and you suspect she has a diagnosis of infective endocarditis (a) Name 4 additional clinical signs that may be found on examination in this patient (2 marks) Slide 37 MEQ 2.6 A 32 year old woman, who is a known alcoholic and abuser of intravenous drugs, presents to A+E complaining of gradual onset malaise, fever, weight loss and night sweats. She is pyrexial (38.5). She has a pansystolic murmur which is thought to be a new finding and you suspect she has a diagnosis of infective endocarditis (a) Name 4 additional clinical signs that may be found on examination in this patient (2 marks) Slide 38 http://en.wikipedia.org/wiki/File:Acopaquia.jpg http://en.wikipedia.org/wiki/File:Splinter_hem orrhage.jpg http://en.wikipedia.org/wiki/File:Osler_Nodules_Hand.jpg http://medicalpicturesinfo.com/janeway-lesion/ Slide 39 Signs of Infective Endocarditis Hands Splinter haemorrhages Janeway lesions Oslers nodes Clubbing Slide 40 Signs of Infective Endocarditis Hands Splinter haemorrhages Janeway lesions Oslers nodes Clubbing Eyes Roth Spots Slide 41 http://www.aao.org/theeyeshaveit/optic-fundus/roth-spot.cfm Slide 42 Signs of Infective Endocarditis Hands Splinter haemorrhages Janeway lesions Oslers nodes Clubbing Eyes Roth Spots Heart New murmur Signs of HF Others Abscess Splenomegaly Petechia Slide 43 AgentRoute Strep. ViridansDental procedures Staph. aureusIVDU/Thoracotomy/Peripheral lines EnterococciUTI CandidaPeripheral lines/catheters Strep. BovisColorectal carcinoma (b) Name the 2 most likely organisms likely to be implicated in infective endocarditis (2 marks) Slide 44 Blood (microhaematuria) Pathology Micro-emboli from vegetation on heart valve Can block vessels in the glomerulus, causing glomerularnephritis and ARF. Micro-emboli cause other clinical signs (c) Your FY2 asks you to dip the urine. What would you expect to find and what is the pathology behind this abnormality? (2 marks) Slide 45 (d) Name two investigations that are mandatory to confirm your diagnosis (1 mark) Slide 46 Blood Cultures 3 sets Different times Different places Major Criteria (x2) Positive blood culture Typical organism in 2 separate cultures Persistently +ve over time Echo evidence of valvular involvement New valvular regurgitation (murmur) Echo Trans-oesophageal more sensitive >2mm for trans-thoracic Minor Criteria (x5) Risk factors Fever Vascular phenomenon Immunological phenomenon Positive blood cultures not meeting requirement for major criteria Echo evidence not meeting requirement for major requirement Dukes Criteria 1 Major + 3 Minor Slide 47 Environment favourable to Infection IVDU Dental surgery Thoracotomy Catheterisation Peripheral/central lines Immunosuppression Allow Implantations and Growth of Organism Prosthetic heart valve Pre-existing valvular disease Rheumatic Acquired Congenital (e) Other than IVDU, name 4 risk factors for this condition (2 marks) Slide 48 On further examination you can also hear the pansystolic murmur. This is loudest at the left sternal edge and you demonstrate the JVP is elevated with giant v waves. In addition she also has tender pulsatile hepatomegaly. (f) What is the most likely cardiac lesion to be responsible for this, given the above history and examination? (1 mark) Slide 49 On further examination you can also hear the pansystolic murmur. This is loudest at the left sternal edge and you demonstrate the JVP is elevated with giant v waves. In addition she also has tender pulsatile hepatomegaly. (f) What is the most likely cardiac lesion to be responsible for this, given the above history and examination? (1 mark) Tricuspid Regurgitation Slide 50 Murmurs Systolic Loud Radiate Ejection Systolic Aortic Stenosis Pansystolic Mitral Regurge Diastolic Quiet Accentuated by manoeuvres Early-mid diastolic Aortic regurge Late diastolic Mitral stenosis Remember DARMS Slide 51 Discussion Points? Slide 52 Thank You!