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Cardiology Revision 2014
Dr P BanerjeeConsultant Cardiologist
University Hospitals Coventry & Warwickshire
Picture slides ECG reading How to examine the CVS Assessment of patient with breathlessness,
chest pain, palpitations, syncope
51 yr old man Admitted with pyrexia, shivering and feeling
unwell Has a heart murmur on examination
Murmur with pyrexia Positive blood cultures Splinter hge, Roth spot, Oslers nodes,
Janeway lesions, splenomegaly, microscopic haematuria
Strep Viridans, Staph Aureus, others IV antibiotics via Hickman line for 6 weeks Valve surgery Prosthetic valve endocarditis Tricuspid valve affected in IVDA
53 yr old lady Presents to clinic with SOBOE Has Hx of rheumatic fever Cardiac murmur audible on auscultation
Rheumatic almost always Loud SI and MDM Early pulmonary hypertension and
secondary TR AF common Remember that all valvular heart disease
has rheumatic fever as a cause except isolated AS.
70 yr old lady Presents to clinic Has been hypertensive for years SOBOE for 3 years- didn’t see doctors Orthopnoea and more recently PND
CCF signs: raised JVP, ankle oedema, enlarged liver
Left heart failure signs: S3 gallop, basal crackles, pulsus alternans
Ascites, bilateral pleural effusions in advanced CCF
Echocardiography, CXR, BNP Loop diuretic, ACE/ARB, B blocker,
Spironolactone/eplerenone
65 yr old Admitted with severe central CP for 2 hrs Sweaty and clammy BP 90/60, Pulse 50/min, SR
Aspirin 300mg + Prasugrel 60 mg loading IV morphine Primary PCI
49 yr old smoker CP for 30 min, improved with IV Morphine Now comfortable, normal BP and pulse Troponin T elevated
Therapeutic clexane Aspirin + clopidpgrel Atorvastatin 80 mg od Beta blocker IV Nitrates and Tirofiban if needed PCI within max 72 hrs
76 yr old man Severe CP 7 days ago for 3 hrs Admitted now with SOB, no CP
Needs coronary angio but more electively PCI may not be needed Discharge on secondary prevention drugs:
BB, aspirin, clopidogrel (1 month if no stent and missed STEMI), statin, ACE, eplerenone (if LVEF<40%)
25 yr old lady, non smoker Flu like illness for 7 days Sharp CP on inspiration for 24 hrs, better on
sitting forward
Usually viral Check viral titres, inflammatory markers
(CRP), autoimmune profile Echo to excluse pericardial effusion Treat with NSAIDS like Ibuprofen, naproxen
etc for 7 days
75 yr old man collapsed at Tesco CPR given by Tesco staff Ambulance arrives in 3 mins Man breathing spontaneously, BP 110/70,
Pulse 70 min irregular ECGS X 2 done by ambulance personnel
If haemdynamic compromise DC shock If stable IV Metoprolol/Esmolol, IV Amiodarone
via a central line followed by oral Check for QT prolongation on ECG Check electrolytes to exclude hypokalaemia,
hypomagnesaemia and hypocalcaemia Assess LV function by echo Only Amio and BB safe if LV function poor Troponin T, Coronary angio even if Trop T
normal Consider ICD
Gentleman suddenly has cardiac arrest again
Emergency DC shock Check all as for VT ICD
28 yr old lady admitted with sudden onset palpitations
No CP or SOB Has had such episodes before- usually has
them terminated by IV injection in A&E.
Carotid sinus massage, valsalva IV Adenosine, IV Verapamil DC shock-usually not required
74 yr old man Severe central CP for 2 hrs with sweating Stable BP and pulse
Treat as STEMI
63 yr old hypertensive lady Has had on and off palpitations for months This morning noticed palpitations Later developed slurred speech with
weakness on the right side
Rate control Anticoagulate (CHADS2 VASC SCORE) Consider cardioversion If onset less than 72 hrs direct cardioversion If onset>72 hrs or unclear TOE+CV or
elective CV after at least 4 weeks of anticoagulation
CHA2DS2-VASc score for stroke risk in atrial fibrillation
Feature Score
Congestive Heart Failure 1
Hypertension 1
Age >75 years 2
Age between 65 and 74 years
1
Stroke/ TI A/ TE 2
Vascular disease (previous MI , peripheral arterial disease or aortic plaque)
1
Diabetes mellitus 1
Female 1
Later her ECG changed ? Any change in management
Management same as for atrial flutter New agents for oral anticoagulation in non
valvular AF: Dabigatran, Rivaroxaban
Asymptomatic young and fit man has had these ECGs as part of his employment check
Not indications for pacing
81 yr old gentleman with recurrent cardiac sounding syncope
Not on any AV blocking drugs Clinically NAD Next 2 ECGs are taken as strips from his 4
hr tape
Indications for permanent pacing
JACCO Hands: splinter haemorrhages, Jane way
lesions, oslers nodes, clubbing Tongue and eyes; anaemia, cyanosis,
jaundice Pulse: rate, rhythm, volume, character,
pulse equality, condition of arterial wall JVP: height, waveforms- a and v waves Ankle oedema
Facies: malar, elfin, moon Corneal arcus, xanthelasma, xanthomas Pulsations Scar marks Prominent veins
Apical impulse: position, character, thrill Hyperdynamic, heaving, tapping Left parasternal heave Base of the heart palpation: palpable heart
sounds, thrill Carotid palpation Apical thrill-diastolic, base of heart thrill-
systolic Pulmonary hypertension: RV apex,
Parasternal heave, palpable P2
Heart sounds: S1, S2, Split Murmurs Added sounds; S3, opening snap
Comfortable at rest. The pulse is irregularly irregular The JVP is elevated at 5 cms above sternal
angle with a prominent V wave. There is ankle oedema and 2 finger tender
hepatomegaly which is pulsatile
The apical impulse is located in the left 5th ICS just inside the MCL. It is tapping in character and there is an apical diastolic thrill
There is a prominent left parasternal heave and palpable P2
The S1 is loud. P2 is loud. There is a mid-diastolic rumbling
murmur with an opening snap, localised to the mitral area. Best heard in left lateral and exp.
PSM at left sternal edge increasing with inspiration
This gentleman has rheumatic mitral stenosis
with pulmonary arterial hypertension, tricuspid regurgitation, right heart failure and atrial fibrillation.
Breathlessness Palpitations Chest pain Syncope Oedema Fatigue
65 year old male presents with gradually increasing breathlessness for 6 months
I am assuming that for all of these you are assessing the patient by taking a hx, examining the cvs/resp/gi systems and then investigating and treating
Orthopnoea PND Exercise tolerance- NYHA CLASS Accompanying symptoms Causes
Heart causes Lung causes Obesity Anaemia Pulmonary hypertension Detraining
Heart failure (Hx of fatigue, PND, ankle oedema, previous IHD, hyp, valve disease)
Severe valve disease- MR,MS, AS, AR (Hx of Rheumatic fever, congenital, degenerative)
Atypical angina (angina equivalent)
COPD, Asthma, Pulmonary fibrosis, obstructive sleep apnoea
Hx of wheeze, smoking, asbestos exposure, Amiodarone, snoring
Concomitant diseases like connective tissue diseases, sarcoidosis
Signs of heart failure, S3, murmurs Reduced breath sounds, obliteration of
liver/cardiac dullness, rhonchi, end- inspiratory crackles at both lung bases
Bloods,ECG, CXR, Echo, ETT,Coronary angio Full PFTs, CT chest, CTPA, V/Q scan Sleep studies
Heart Failure: Diuretics, ACE/ARBs, B-blockers, Digoxin, Spironolactone
COPD: Bronchodilators, steroid inhalers, stop smoking
Sleep apnoea: nasal CPAP, weight reduction
PPH: Nifedipine, Amlodipine, Warfarin, Prostacyclin infusion, Viagra (Sildenafil), Bosentan
A 50 year old gentleman complains of chest pain with associated flu like illness
IHD/ MI Oesophageal pain Musculoskeletal pain Pneumonia/ chest infection Pericarditis PE
Classical Hx of effort angina (chest heaviness or tightness), > 30 min constant pain =MI, RF for CAD,
Sputum, SOB, wheeze, pleuritic CP GE reflux CP worse on postural changes, constant pain,
chest tenderness Pleuritic CP which improves on sitting forward +
fever + raised ESR/CRP SOB + pleuritic pain, DVT, long flight, prev Hx
Bronchial breathing + dullness/ crackles Pericardial rub Chest wall tenderness Epigastric tenderness Signs of DVT
Bloods : wbc, ESR, CRP, viral titres CXR: pneumonia, pleural effusion,
elevated hemidiaphragm, pulmonary infarcts, loss of pul vascularity
ECG: ACS, MI, Pericarditis, PE Blood gases,V/Q scan, CTPA Gastroscopy ETT, Myocardial perfusion scan, stress
echo, coronary angiography
IHD: B Blocker, Ca blocker, oral nitrate, nicorandil, aspirin, statin
ACS/MI: Above plus LMW heparin, clopidogrel, Gp 2b-3a receptor antibodies, IV GTN, Coronary angio, Thrombolysis for STEMI, Primary PTCA
Pneumonia: antibiotics, bronchodilators, chest physio
PE: warfarin, thrombolysis GORD: PPI. NSAIDS for pericarditis Muscular: simple pain killers
80 year old man has blacked out twice in 3 months
Cardiac syncope: Sick sinus syndrome, hypersensitive carotid sinus syndrome, intermittent AV block, VT, bifacsicular or trifascicular block, obstructing cardiac tumours, HOCM, severe AS, PAF causes dizziness only.
Neurogenic syncope: TIAs, strokes, epilepsy
Massive PE Vasovagal/ neurocardiogenic syncope Cough and micturition syncope Postural hypotension
Sudden, transient, rapid recovery, pale, no warning: Stokes-Adam attack eg. known previous MI with poor LV
Aura, seizure, prolonged LOC, slow recovery: epilepsy
limb weaknesses, speech problems, Cx spine problems: TIA, strokes
? Postural, chest pain or palpitations, drugs, following fright or heat etc
HR, ?AF, LS BP, murmurs, Neck movements,
Carotid bruit, full neuro exam Carotid sinus massage
24 hr Holter monitor, cardiomemo or event recorder
Echo Tilt table test Reveal device implant Postural hypotension: short synacthen test,
drugs, 24 hr urinary catecholamines EEG, CT head
Permanent pacemaker for 2nd and 3rd degree AV block, HCSS, SSS, bi or trifascicular block with symptoms
VT with good LV function- b blockers, amiodarone. VT with poor LV- ICD. Ischaemic VT: revascularisation
AS: surgery, HOCM : Amiodarone, ICD,
Atrial and ventricular ectopics Valve disease: AR, MR Tachyarrhythmias: PAF, SVT, rarely VT Anxiety Hyperthyroidism Excessive caffeine intake
Missed beats or racing heart Syncope, presyncope Sudden onset and sudden termination Paroxysmal or constant Caffeine intake
24 hr tape TFTs Echo
No Rx for ectopics PAF: B-blocker, flecainide, disopyramide,
propafenone, amiodarone, warfarin, ablate and pace
SVT: Verapamil and all of the above, slow pathway ablation
Valve disease: surgery if severe. Otherwise ACE for MR, Hydrallazine or Nifedipine for AR
HOPE YOU DO VERY WELL