020216 acs and heart failure.pptx
TRANSCRIPT
7/25/2019 020216 ACS and heart failure.pptx
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C2F- ACS and HF
FY1 Grace McKay
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Pre lecture quiz
You are the FY1 on general medical on call You are !lee"edto re&ie' Mr #hite( a )% year old male in !ed $ com"lainin"ain
the nur+e hand+ o&er the *ollo'ing in*ormation
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S- )% yo "t Mr #hite +udden on+et o* che+t "ain ,1% min+
B- day $ "o+t o" K. +econdary to /A
A- 0e'+ % increa+ed ..( H. and +lightly hy"erten+i&e( ta
"aracetamol !ut no im"ro&ement
R- Plea+e come and re&ie' him3
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You go to +ee the "atient
He i+ com"laining o* a +e&ere che+t tightne++and a "ain in hi+ throat( he ee"+ hiccu"ingand !elching during the con&er+ation andrelay+ that he *eel+ quite +ic Mr #hite loo+
!reathle++ and "ale 'ith a +'eaty *orehead he nur+e in*orm+ you that Mr #hite ha+ 24M diet controlled( hy"erchole+terolemiaand u+ually +moe+ 15 cigarette+ a day
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Medication+
Sim&a+tatin 65mg P/ /4
.ami"ril 2%mg P/ /4
Paracetamol 1g P/ 74S4ihydrocodeine $5mg 88
Senna 1%ml P/ /4
inza"arin 6%55 unit+ SC /4
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71 #here i+ the in*arct8
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72
1#hich "art o* the heart i+ re"re+ented !y 9CG lead+ :1
a. anterior
b. lateralc. inferior
d. septal
e. high lateral
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7$
#hich +erum !iochemical marer 'ill mo+t a
in the diagno+i+ *or thi+ "atient8
a. Calcium
b. D-dimer
c. Troponin
d. Creatinine kinase
e. Lactate
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76
Sugge+t 2 alternati&e diagno+e+ *or thi+ "atiacute che+t "ain- other than ACS
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7%
#hat i+ the a""ro"riate ultimate managemethi+ "atient8
a. Aspirin 300mg
b. Primary PC
c. Thrombolysis
d. ! unfractionated heparin
e. "C lo# molecular #eight heparin
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7)<=
#hat com"licationha+ occurred inthi+ "atient8
Ho' 'ould youmanage it8
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7>
?ucily your attendance at thi+ lecture mean+ that you manage to "atient He i+ +cheduled to !e di+charged home 2 'ee+ a*ter all t#hat $ additional medication+ 'ould !e most im"ortant to contindi+charging the "atient8
a a+"irin( clo"idogrel( !eta-!locer
! clo"idogrel( met*ormin and ator&a+tatin
c i+o+or!ide monotitrate( !endro@umathiazide and !eta-!locer
d a+"irin( 'ar*arin and *ru+omide
e a+"irin( tinza"arin and G0
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7
Fa+t *or'ard 2 year+( you ha""en to !e on a GP rotation 'hmeet Mr #hite again3 He ha+ come to the "racti+e com"lainocturnal cough( reduced eBerci+e tolerance and anle +'e#hat "o+t M com"lication ha+ Mr #hite mo+t liely de&elo
a Pulmonary em!oli+m
! Pericardial eDu+ion
c Heart *ailure
d .educed re+"on+e to ACS medication
e :entral +e"tal de*ect
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715
You request an Xray toinvestigate thesesymptoms further, whichfeatures of this imagesupport your initialdiagnosis?
( points availa!le"
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Ho' did you do8
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71 #here i+ the in*arct8
$ "T ele%ation in Leads &' 3 and A
inferior infarct. )b also reciprocal
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72
1#hich "art o* the heart i+ re"re+ented !y 9CG lead+ :1
$ "eptum
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7$
#hich !iochemical marer 'ill aid you in the
diagno+i+ *or thi+ "atient8
$ "erum troponin- *& hours
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76
Sugge+t 2 alternati&e diagno+e+ *or thi+ "atiacute che+t "ain- other than ACS
*. Pericarditis
&. Dissecting aortic aneurysm3. Pulmonary embolism
+. ,esphageal reflu' spasm or rupture
. /iliary tract disease
. Perforated peptic ulcer
1. Pancreatitis
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7%
#hat i+ the a""ro"riate ultimate managemethi+ "atient8
$ Percutaneous coronary inter%ention
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7)<=
#hat com"licationha+ occurred inthi+ "atient8 :F
Ho' 'ould youmanage it8 "ut out a
cra+h call( +tart CP.( a+"er A?S "rotocol
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7>
?ucily your attendance at thi+ lecture mean+ that you ma+a&e thi+ "atient He i+ +cheduled to !e di+charged home 2a*ter all the drama #hat $ additional medication+ might ycon+ider continuing !e*ore di+charging thi+ "atient8 E0 h
already on a +tatin and an AC9
a a+"irin( clo"idogrel( !eta-!locer
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7
Fa+t *or'ard 2 year+( you ha""en to !e on a GP rotation 'hmeet Mr #hite again3 He ha+ come to the "racti+e com"lanocturnal cough( reduced eBerci+e tolerance and anle +'e#hat "o+t M com"lication ha+ Mr #hite mo+t liely de&elo
c Heart *ailure
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715
You reque+t an ray to in&e+tigatethe+e +ym"tom+ *urther( 'hich*eature+ o* thi+ image +u""ort yourinitial diagno+i+8
#$Al&eolar oedema E!at 'ing+
%$B line+ -Kerley
&$'ardiomegaly
$)ilated "rominent I? &e++el+
$*Du+ion+-"leural
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A'S
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#hat i+ ACS- acute coronary+yndrome8
he cla++icL
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he cla++ic"re+entation
Hx: Central chest pain or discomfort #ith a tightness or ac
to throat' arm' back and epigastrium. Can be accompanied
and indigestion.
O/E: (rom the end of the bed2 Pale' ",/' s#eating' ani
eneral- #hy bother4
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he great mimic+ o* A
*. Pericarditis
&. Dissecting aortic aneurysm
3. Pulmonary embolism
+. ,esphageal reflu' spasm or rupture
. /iliary tract disease. Perforated peptic ulcer
1. Pancreatitis
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Some 9M7+- match the "ain
1Aortic di++ection
2Pericarditi+
$.e@uB
6Myocarditi+
a. Patient presents #ith chest pain de%eloping o%er a fe# d
include pyreia' dyspnoea' fatigue and tachycardia.
b. Patient presents #ith continuous abdominal pain #hich back5 there are asymmetric pulses in the upper limbs an
hypotensi%e.
c. Patient presents #ith a sharp chest pain' slightly relie%e
,n auscultation' a rubbing noise is audible.
d. Patient presents #ith a burning retrosternal chest pain'
stooping do#n or straining. other symptoms include #at
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Some 9M7+- match the "ain
1Aortic di++ection
2Pericarditi+
$.e@uB
6Myocarditi+
a. Patient presents #ith chest pain de%eloping o%er a fe# d
include pyreia' dyspnoea' fatigue and tachycardia.
b. Patient presents #ith continuous abdominal pain #hich back5 there are asymmetric pulses in the upper limbs an
hypotensi%e.
c. Patient presents #ith a sharp chest pain' slightly relie%e
,n auscultation' a rubbing noise is audible.
d. Patient presents #ith a burning retrosternal chest pain'
stooping do#n or straining. other symptoms include #at
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n&e+tigation+ -9CG
eBam"le+ B $
6hat
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S9M
,2mm in che+t
,1mm in lim!+
n e+tigation+ -iochemical
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n&e+tigation+ -iochemicalmarer+
Myocardial necro+i+ relea+e o* tro"onin
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ro"onin
#hat other "athologie+ can cau+ri+e in tro"onin8
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n&e+tigation+-9cho < C.
SG0 guideline"orta!le C. to a++cardiac +ize and oe
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Cla++i*ying ACS
)"T789A
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treatment
M orphine :diamorphine &.-*0mg ; 8etoclopramid
O ygen <if hypoic= aim >+->?@ sats
N itroglycerine- & puffs T)
A spirin 300mg
C lopidogrel 300mg
L m#h therapeutic dose
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S9M treatment
#$+-A' (."/gi&en in catheter la!
2 Primary Percutaneou+ Coronarynter&ention
$ Fi!rinoly+i+
Contraindication+ to
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Contraindication+ toO!rinoly+i+
Absolute
*. Pre% haemorrhagic stroke
&. schaemic stroke mo
3. C)" damage:neoplasm
+. 8aBor surgery' head inBury or maBor
trauma 3 #eeks
. Acti%e internal: bleeding *mo
<not mense=
. no#n:suspected aortic dissection
1. no#n bleeding disorder
elati%e
*. efractory hypertensio
&. TA mo
3. P, anticoags
+. Pregnant: * #eek post
. Li%er or renal dysfnc
. LP *mo
1. E*0 mins cpr
?. )on compressible %asc
>. Acti%e peptic ulcer dise
*0.Ad%anced li%er disease
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ACS
!( and sudden death
HF
Cardiogenic shock
!"D
8
Arrhythmia
Pericarditis
Pseudo-anyeursm and f
rupture
Pericardial effusion
,ngoing chest pain and
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Heart Failure
Ma++i&e to"ic *or $5 minute+3
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9++entially
#hat - inadequate cardiac out"ut to "er*u+e !ody
#hy
Pre+entation
4iagno+i+
Se&erity
Progno+i+
Management
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9++entially
#hat
#hy
Pre+entation
4iagno+i+
Se&erity
Progno+i+
Management
Pre pump Pump Post
Too much bloodeg thyrotoicosis
8Cardiomyopathy!al%ular diseaseDrugs
Arrhythmia8yocarditisCongenital structuralChemo agents
Fyperten AtherosclCoarctati
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9++entially
#hat
#hy
Pre+entation
4iagno+i+
Se&erity
Progno+i+
Management
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9++entially
#hat
#hy
Pre+entation
4iagno+i+
Se&erity
Progno+i+
Management
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9++entially
#hat
#hy
Pre+entation
4iagno+i+
Se&erity
Progno+i+
Management
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9++entially
#hat
#hy
Pre+entation
4iagno+i+
Se&erity
Progno+i+ 01 mortality within years
Management
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9++entially
#hat
#hy
Pre+entation
4iagno+i+
Se&erity
Progno+i+
Management
A t H t * il P l
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Acute Heart *ailure- Pulmonaryoedema
You are the FY1 on cardiology You ha&e Qu+t !een !lee"ed Mr+ Pott+ a )6 year old *emale 'ho had "rimary PC thi+ a*a S9M he nur+e hand+ o&er that Mr+ Pott+ i+ !reathle++u" a "in *rothy +"utum and tachy"noeic 0e'+ %
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The patient is sat up in
bed leaning for#ards'
she is pale and s#eaty
#ith tachypnoea and she
seems distressed.
Fer chest has fine lung
crackles on auscultation.
G!P is raised.
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#hat do you do8
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P/4MA0 -hel"
2- o+itionJ u"right i* not already 'ith "illo'+
- BygenJ 155R i* no "re eBi+ting lung di+ea+e
)- iuretic+J Furo+emide 65mg : +lo'ly
+- or"hineNdiamor"hine 2%-%mg : +lo'ly
A- ntiemetic
-- itrate+ G0 +"ray to nitrate in*u+ion i+o+or!ide nitrate
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Hel" ho"e*ully'ill ha&e come!y then mayneed an 0:
deci+ion
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HF
1 riad to diagno+e ACS
2 reatment acronym M/0A?C- PCNhrom!
$ Com"lication+ o* M -including Heart *ailu6 Acute Heart *ailure - "ulmonary oedema
emergency
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Fin