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CARDIOLOGY UNIT PRESENTATION Nwalozie J.C. 17/03/2014

Nwalozie J.C. 17/03/2014. Question A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom. Discuss 3 differential

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Page 1: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

CARDIOLOGY UNIT PRESENTATION

Nwalozie J.C. 17/03/2014

Page 2: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Question A 50 year old man presents with sudden-

onset breathlessness & feeling of impending doom.

Discuss 3 differential diagnoses & describe the management of Acute Left Ventricular Failure.

Page 3: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Answers

3 differential diagnoses: 1. Acute Severe asthma

2. Pulmonary Embolism

3.Acute exacerbation of COPD

Page 4: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential
Page 5: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential
Page 6: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential
Page 7: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

MANAGEMENT OF ACUTE LEFT VENTRICULAR FAILURE

Page 8: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Outline Introduction Precipitating factors Pathophysiology Clinical features Investigations Management Treatment Prognosis & Monitoring Follow-up Conclusion

Page 9: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Introduction Inability of the left ventricle to effectively

handle its pulmonary venous return with leakage of fluid from the pulmonary capillaries & venules into the alveolar space (secondary to increased hydrostatic pressure) leading to rapid onset of breathlessness.

It is a medical emergency .

It can arise de novo or on a background of chronic left ventricular failure.

Page 10: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

PRECIPITATING FACTORS

Dietary indiscretion Uncontrolled hypertension Non adherence to drugs Myocardial ischaemia or infarction Arrhythmias Thyrotoxicosis Fluid overload Anaemia Pulmonary & other infections Inappropriate medications- -ve inotropes,

NSAIDS Acute valvular insufficiency

Page 11: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

PATHOPHYSIOLOGY

↓ CARDIAC OUTPUTINCREASED PCWP

ACTIVATION OF RENIN ANGIOTENSINSYSTEM

ACTIVATION OF S/S SYSTEM

INCREASED HEART RATEINCREASED SYSTEMIC VASCULAR RESISTANCE

INCREASED PRELOAD

CARDIAC ISCHAEMIA↓ LEFT VENTRICULAR

FUNCTION

SYMPTOMATICDECOMPENSATION

Page 12: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

CLINICAL FEATURES Extreme SOB with use of accessory muscles of

respiration

Sensation of drowning, chest pain, palpitations

Cough(with pink , frothy sputum)

Previous history: Of cardiac disease

Restlessness, Profuse sweating

Page 13: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

CLINICAL FEATURES Orthopnoea(patient noticed to be sitting up in bed) - sensitivity 5% - specificity 77%

PND

Pulse(Tachycardia, Pulsus Alternans)

BP

S3

Wheezing (Cardiac ‘asthma’) – sensitivity 22% - specificity 58%

Crepitations - sensitivity 6% - specificity 78%

Page 14: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Other features:

-Cyanosis

-Cold skin

-Features of underlying heart disease/precipitating factor

-Features of right heart failure

Page 15: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

INVESTIGATIONS 1.Pulse oximetry

2. Blood

3. Electrocardiography

4. Radiologic

5.Others- eg. Pulmonary arterial catheterisation

Page 16: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

BLOOD INVESTIGATIONS ABG

FBC – anaemia, infection

U & Es

CARDIAC MARKERS

Page 17: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

CARDIAC MARKERS

CARDIAC ENZYMES

OTHER CARDIAC MARKERS

Page 18: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

IMPORTANCE OF BNP IN HF

1. Useful in Diagnosis

2. Assessing Severity

3. Predicting short & long-term CVS mortality

Page 19: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

WHAT LEVELS ? NO HEART FAILURE-BNP < 100pg / dl-NT PRO-BNP < 300pg / dl

HEART FAILURE-BNP >500pg / dl-NT PRO-BNP > 1000pg / dl*80% Sensitivity for heart failure

Page 20: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

ELECTROCARDIOGRAM Ischaemia / infarction

Arrhythmia – A fib

LVH

Prolonged QRS

Page 21: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

CHEST RADIOGRAPH FINDINGS IN HEART FAILURE Cardiomegaly – 74% sensitive, 78%

specific

Vascular redistribution

Interstitial oedema

Alveolar oedema

Pleural effusions (right sided/bilateral)

Page 22: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential
Page 23: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Others Echocardiography 1.Identify reversible cause eg MI,

valvular insufficiency ,tamponade 2.Distinguish between systolic and

diastolic dysfunction

• Monitor urine output

Page 24: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Treatment A medical emergency

Begin treatment before investigations

ABC of resuscitation , Patient to sit up

Treatment can be medical, radiological/surgical

Page 25: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential
Page 26: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

TREATMENT AIMS OF IMMEDIATE MANAGEMENTOverall aim- Redistribute fluid out of lungs!

-Decrease Preload (right-sided filling) eg loop diuretics,morphine,tolvaptan

-Increase left-sided emptying eg ACE-I,NTG,nitroprusside

↓ Afterload, Cardiac output

-± improve LV contractility – inotropes eg dopamine,dobutamine,milrinone,levosimendan

Page 27: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential
Page 28: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential
Page 29: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Other measures-diet , fluid restriction , ultrafiltration , treat precipitating cause eg infection

Radiological-IABP,LV assist device , CRT

Surgical-Valve repairs , transplantation

Page 30: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Prognosis & monitoring Poor prognostic factors include: -Underlying heart

disease/precipitating factor -BNP>500 pg/dl -K <3mmol/l -Na < 133mmol/l -Frequent ventricular extrasystoles

Monitoring for vital signs, other signs , symptoms ,urine output ,renal function ,electrolytes.

Page 31: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Follow Up

Page 32: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

Conclusion ALVF is a life-threatening medical emergency

that is as a result of LV compromise leading to accumulation of fluid in the lungs with resultant acute onset of symptoms.

It is essential to make a diagnosis( ie differentiate it from similar conditions) so that necessary interventions can be instituted as soon as possible

Management is multidisciplinary and should be individualised according to how each patient presents.

Page 33: Nwalozie J.C. 17/03/2014. Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential

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