Cardiovascular

1. Cardiology Cases
Dr Aqib Chaudry

2. Disclaimer
This lecture series has been designed and produced by
doctors and students. We have made every effort to
ensure that the information contained is accurate and in
line with Learning Objectives featured on SOFIA, however
this guide should not be used to replace formal ICSM
teaching and educational materials.

3. Cardiology Schedule
 Chest Pain – STEMI, NSTEMI, Angina
 Shortness of Breath – Heart Failure
 Atrial Fibrillation

4. A 72 year old gentleman attends the Emergency
Department complaining of chest pain…

5. What could it be?

6. Chest Pain Differentials

7. Understand the Pain

8. Understand the Pain
S – central/sided
O – sudden/very sudden/gradual
C – pressure/stabbing/tearing
R - left arm/jaw/shoulders
A – nausea/vomiting/sweating/fear
T – last longer than 30 mins
E – exertion/position/GTN/morphine
S – out of 10

9. Presenting Complaint
 72 year old gentleman
 Sudden onset, 1 hour ago at rest
 Central
 Crushing
 Nausea, no vomiting
 Sweatiness
 Worse when trying to walk towards his front door
 Improved with GTN spray
 Sometimes gets chest pain on climbing stairs

10. Past Medical History

11. Past Medical History
 Hypertension
 Type 2 Diabetes
 Raised cholesterol
 Psoriasis

12. Drug History
 Amlodipine 5mg
 Atorvastatin 20mg
 GTN spray
 Allergies - Penicillin

13. Family History
 Mother had a head attack aged 62
 Nil other

14. Social History
 Lives with wife
 Accountant
 30 pack year smoking history
 Occasional alcohol

15. Examination
 Looks distressed, sweaty, clammy
 BP 150/75, HR 110 + regular, Sats 94% on air
 HS I+II+0
 Lungs clear
 Vomits during examination

16. Investigations

17. Investigations
 Full set of observations
 ECG
 Routine Bloods – FBC, U&Es, LFTs, CRP,
 Lipids, HbA1c, BNP, Troponin
 Chest X-Ray

18. Stable Angina
Chest pain resulting from myocardial ischaemia that is
precipitated by exertion and relieved by rest.
 CAUSES:
 MOST COMMON – Atherosclerosis
 RARE TYPES OF ANGINGA –
 Decubitus Angina – symptoms occur when lying down
 Prinzmetal Angina – symptoms caused by coronary vasospasm
 Coronary Syndrome X – symptoms of angina with normal
exercise tolerance and normal coronary angiograms

19. Stable Angina - Management
 Conservative
 Medical
 Surgical

20. Stable Angina - Management
 Conservative
 Diet Modification
 Exercise
 Stop smoking
 Medical
 Symptomatic Relief – GTN Spray
 Beta Blockers / Calcium Channel Blockers
 Risk Factor Modification – Statins
 Surgical
 Coronary Stent, Bypass

21. Acute Coronary Syndrome
 Cardiac symptoms caused by a sudden reduced blood
flow to the heart muscle.
 Unstable Angina
 NSTEMI
 STEMI

22. Key Investigations
 ECG
 STEMI
 ST elevation
 New onset LBBB
 Hyper acute T waves
 NSTEMI/UA
 ST depression,
 T wave inversion
 Troponin
 STEMI or NSTEMI
 A raised troponin suggests myocardial infarction
 Unstable Angina
 Does not have an elevated troponin

23. ST Elevation

24. ST Depression

25. Where is the infarct?

26. Where is the infarct?
 Inferior (right coronary artery): II, III, aVF
 Anterior (left anterior descending): V1-V4
 Lateral (left circumflex): I, aVL, V5/6
 Posterior (posterior descending): tall R wave + ST
depression in V1-3

27. STEMI Management
Immediately:
Morphine & Metoclopramide
Oxygen
Nitrates
Aspirin 300mg STAT
Clopiodgrel 300mg STAT or Ticagrelor 180mg STAT
AIM OF STEMI TREATMENT: Coronary reperfusion either by PCI or fibrinolysis
Patient presenting < 12 hours from onset of symptoms
• Send to cathlab for PCI if it can happen within 120 mins of the time that
fibrinolysis could have been administered
Patient presenting > 12 hours from onset of symptoms
• Coronary angiography followed by PCI if indicated

28. Acute Coronary Syndrome
 Long term management of STEMI
A – ACE Inhibitor
B – Beta blocker
C – Cholesterol lowering agent
D – Dual antiplatelet therapy
E – Echo to assess heart function

29. NSTEMI/UA Management
 Immediately:
 Morphine & Metoclopramide
 Oxygen
 Nitrates
 Aspirin 300mg STAT
 Clopiodgrel 300mg STAT or Ticagrelor 180mg STAT
 PLUS Fondaparinux 2.5mg daily – if low bleeding risk
unless coronary angiography planned

30. NSTEMI/UA Management
 Risk stratify using GRACE score
 High Risk
 Coronary angiography within 72 hours
 Low Risk
 Conservative management and outpatient investigations (e.g.
angiography, echo, exercise ECG)

31. Complications of ACS
 Sudden Death on PRAED Street

32. Complications of ACS
 Sudden Death on PRAED Street
 P – Pump Failure
 R – Rupture of papillary muscle or septum
 A – Aneurysm and arrhythmias
 E – Embolism
 D – Dressler’s Syndrome

33. OSCE Station: Midline Sternotomy

34. OSCE Station: Midline Sternotomy
 Valve Replacement (Tissue or Metallic)
 Valve Repair
 Coronary Artery Bypass Graft
 Repair of a congenital defect
 Heart transplant

35. A 72 year old lady attends the Emergency Department
complaining of breathlessness…

36. Presenting Complaint
 2 day history of shortness of breath
 Wheezy
 Has had to sleep in her armchair
 Woke up in middle of night feeling breathless
 Reduced exercise tolerance

37. Past Medical Hx
 Hypertension
 T2DM
 Raised cholesterol
 MI 2015 – stent inserted
 MI 2018 – coronary artery bypass graft

38. Drug Hx
 Aspirin 75mg
 Atorvastatin 20mg
 Bisoprolol 5mg
 Amlodipine 10mg
 Furosemide 20mg recently started by GP

39. Family Hx
 Unremarkable

40. Social History
 Lives with her son’s family
 Stair lift
 No carers
 No smoking, no alcohol

41. Examination
 Raised JVP (5cm)
 Third heart sound
 Peripheral oedema to the mid shin
 Bilateral crackles to the midzone

42. Heart Failure
 Failure of the heart to adequately meet the cardiac
output required to meet the body’s physiological
requirements
 Acute v Chronic

43. Causes of LHF
Heart Muscle
 Ischemic heart disease
 Myocardial infarction
 Cardiomyopathy
Heart Valves
 AS, AR, MS, MR
Arrhythmias
Systemic – e.g. HTN

44. Causes of RHF
Secondary to left Heart Failure
Lungs
 Pulmonary HTN
 Pulmonary Embolus
 Pulmonary valve disease
 Chronic lung disease
Heart Muscle
Heart Valves
 PS, PR, TS, TR

45. LHF – Signs & Symptoms
 RESPIRATORY SYMPTOMS
 Dyspnoea
 Orthopnoea
 Paroxysmal Nocturnal Dyspnoea
 Cough +/- pink sputum
 Wheeze
 Fatigue

46. LHF – Signs & Symptoms
 Heart
 Inc HR/RR
 3rd heart sound
 Murmur
 Displaced apex beat
 Lungs
 Bilateral crackles
 Wheeze

47. RHF – Signs & Symptoms
 Swelling – ankles, abdomen, face
 Weight gain
 Fatigue
 Decreased mobility

48. RHF – Signs & Symptoms
 Heart
 Inc HR/RR
 Murmur
 Head and Neck
 Raised JVP
 Facial oedema
 Abdomen
 Distension – ascites / hepatomegaly
 Peripheries
 Pitting oedema

49. Investigations
 Bloods
 FBC, U&E, LFT, Lipids, Glucose
 BNP
 Troponin
 ECG
 Chest X-Ray
 Echocardiogram

50. Heart Failure CXR
 A – Alveolar Shadowing
 B – Kerley B Lines
 C – Cardiomegaly
 D – Upper lobe diversion
 E – Pleural effusions

51. Management of Heart Failure

52. Acute Heart Failure
 Sit patient up
 High flow oxygen 15L/min via non-rebreathe mask
 IV Diuretics - Furosemide 40mg IV
 If systolic > 90mmHg consider IV vasodilators such as GTN
 If systolic < 90mmHg consider inotropes
 Analgesia if required (e.g. small dose opiates)

53. Chronic Heart Failure
 Optimise CV risk
 Statin, anti-HTN, DM, anti-platelet
 Specific
 1st – ACEi, Beta Blocker, Loop Diuretic
 2nd – Add Spironolactone
 3rd – Consider Digoxin
 4th Consider cardiac resynchronisation therapy
 Annual influenza vaccine + one off pneumococcal
vaccine

54. Thanks for coming along