Cardiology for Finals

Andrew C Rankin

• What do you need for Finals?

• The knowledge and skills required to be a FY doctor

• History, examination, investigations, treatments

• Common conditions

Cardiology for Finals

• Clinical skills–History

–Examination• Clinical Skills Website

• ECG

Cardiology for Finals OSCE

Heart Failure

Cardiology for Finals

• A 65 yr old man is admitted with heart failure

• What 5 investigations would you do, and why?• ECG• CXR• Troponin• Full blood count• U&E’s• Echo

Heart Failure

• A 65 yr old man is admitted with heart failure

• Name 4 drugs which should be prescribed at discharge from hospital

• For each drug, state:– Mechanisms of action?– Why it is prescribed?– Adverse effects?– Drug class?

Heart Failure

1. Furosemide (frusemide)

2. Ramipril (and / or candesartan)

3. Carvedilol (or bisoprolol)

4. Spironolactone (or eplerenone)

5. Digoxin

Drugs for Heart Failure

Diuretics

Disease Modifying Therapy

Renin-Angiotensin-Aldosterone System

Renin AT I

AT II

vasoconstriction

Aldosterone

ACE

ATII type I receptor

Na retentionK excretion

Fibrosis

Sympathetic NS

Noradrenaline

Adrenaline

1-adrenoreceptors

HRvasosconstriction

cardiotoxicity

Symptomatic Heart Failure

CONSENSUS I (NEJM 1987)

• 253 NYHA IV

• Enalapril vs placebo

• Mean FU : 188 days

1 yr Mortality1 yr Mortality Enalapril Placebo 26% 44%

P=0.002

SOLVD (T) (NEJM 1991)

• 2569 LVEF 35% + CHF

• Enalapril vs placebo

• Mean FU : 41.4 months

4 yr Mortality4 yr MortalityEnalapril Placebo 35% 40%

P=0.0036

All-cause mortality100

90

80

60

70

50

240 20161284 28

Placebo

Carvedilol

Months

% Survival

P=0.00014

Carvedilol in severe CHF

Packer et al, NEJM 2001

2289 patients; NYHA IV Heart failure

Beta Blockers in Heart Failure

“Start low, go slow”• carvedilol 3.125mg bd for 2 weeks

- double every 2 weeks until 25mg/bd • bisoprolol 1.25mg od for 2 weeks

- double every 2weeks until 10mg

• diuretics may have to be increased

15.612.4 11.9

7.8

SOLVD (1991) CIBIS-IIMERIT-HF

(1999)

Diureticdigoxin

DiureticdigoxinACEI

DiureticdigoxinACEI

Diuretic digoxinbeta-blockerACEI

15

10

5

0

% death at 1 year

Drug treatment of CHF

NICE 2010 - Heart Failure

Cardiac Resynchronisation TherapyCardiac Resynchronisation Therapy

RV pacingRV pacing

LV pacingLV pacing(via cardiac vein)(via cardiac vein)

RA pacingRA pacing

CARE-HF

Cleland et al. N Engl J Med 2005;352:1539-49.

Cardiomyopathy

Cardiology for Finals

Cardiomyopathies

From Davidson’s Principles & Practice of Medicine

Normal Hypertrophic Dilated

Coronary Artery Disease

Cardiology for Finals

• A 55 yr old man is admitted with severe central chest pain

• What investigation would you do first, and why?• ECG• CXR• Troponin• Full blood count• U&E’s• Echo

Coronary Artery Disease

ST elevationST elevation

ENHANCED REPERFUSION THERAPY FOR STEMIPatients presenting to SAS/DGH 2008

Return to local DGH within 24hrs or when stable

Primary PCI

PCI Centre

Call to balloon time <90 min*

Thrombolysis contraindicated

Shock

STEMI/Posterior MI

Primary PCI

PCI Centre

Cath/PCI within 24hrs

No reperfusion

Rescue PCI

PCI Centre

Thrombolysis

Call to balloon time >90 min

Reperfusion

No Shock

*Maximum journey time 40 min*

ISIS-2.Lancet 1988

Left anterior descending coronary artery in a patient with STEMI

Widimsky P Eur Heart J 2010;31:634-636

a b

c

a. Occluded LAD

b. Post-thrombolysis

c. Post-PCI

Thrombolysis Thrombolysis vsvs Angioplasty for STEMI Angioplasty for STEMI

Danami-2 Study; 1572 patients with STEMI

Busk et al, Eur Heart J 2008

Myocardial infarction redefined

WHO definition: (2 of 3)• Typical symptoms (chest pain)• Typical ECG changes (Q waves)• Enzyme rise

ESC/ACC redefinition 2000• Troponin rise, with one of:• Chest pain• ECG changes (Q waves or ST segment)• PCI

Acute coronary syndrome

No ST elevationST elevation

Chest painPresentation

WorkingDiagnosis

Myocardial Infarction

STEMI NSTEMI+

+

Unstable Angina

-

ECG

Troponin

Final diagnosis

Acute Coronary Syndrome

Evidence based medicine

Cardiology for Finals

• Why do we use a treatment?

• Because it saves lives!

• Evidence of improved outcome

Evidence based Cardiology

Smith & Pell 2003BMJ 327:1459-61

Parachutes: Evidence Base

Arrhythmias

Cardiology for Finals

Cardiac ArrhythmiasCardiac Arrhythmias

““Supraventricular”Supraventricular”

VentricularVentricular

AtrialAtrial

JunctionalJunctional

Narrow or wide QRS?

Adenosine

Irregular?

P waves?

TerminatesAV block

SVT Atrial

AF

AV reentry tachycardia

Accessory pathway

Supraventricular Tachycardia

AdenosineAdenosine

Termination of AVRT

Adenosine and SVT

Accessory pathway

Carotid Sinus Massage

Atrial Flutter

Atrial Flutter

AdenosineAdenosine

Adenosine and Atrial Flutter

Accessory pathway

Ablation catheter

Radiofrequency ablation

• AF affects 1.0-1.5% of the population in

the developed world

• Life-time risk 1-in-4 for >40 year olds

• Increased prevalence with age

– 10% >80 years

• 1% of health care budget in UK

Atrial Fibrillation – an new epidemic

Algorithm for treatment of AF!

PersistentPermanentParoxysmal

Peters N, et al. Lancet 2002

Atrial fibrillationAtrial fibrillation

Rate controlRate control

Rhythm controlRhythm controlRisk of embolismRisk of embolism

Atrial Fibrillation

“Natural” time course of AF

ESC AF Guidelines 2010

Rhythm vs Rate control in AFFIRM

AFFIRM=Atrial Fibrillation Follow-up Investigation of Rhythm ManagementThe AFFIRM Investigators. N Engl J Med 2002; 347(23): 1825–33

Cu

mu

lati

ve m

ort

alit

y (%

pat

ien

ts)

Years

All-cause death at Year 5: 23.8 versus 21.3% for rhythm versus rate control

0

30

25

20

15

10

5

Rhythm control

Rate control

0 1 2 3 4 5

(p=0.08; N=4060 )

Amiodarone vs Sotalol for AF

Singh et al (SAFE-T) NEJM 2005;352:1861

Warfarin prevents strokes in AF

• Warfarin prevents 20-30 strokes per 1000 patient years

• 6 - 8 serious bleeding episodes per 1000 patient years

CHADS2 Score for Risk Assessment

CHADS

Cardiac Failure 1Hypertension 1Age >75 1Diabetes 1Stroke 2Score Risk Anticoagulation therapy0 Low Aspirin1 Medium Aspirin or Warfarin (INR 2-3)2 High Warfarin (INR 2-3)

CHA2DS2-VASc and stroke rate

ESC AF Guidelines 2010

• Previous stroke, TIA

or systemic

embolism

• Age > 75 years

• Heart failure or moderate to severe LV SD (e.g. EF <40%)• Hypertension• Diabetes• Female sex• Age 65-74 years• Vascular disease

CHA2DS2-VASc and stroke rate

ESC AF Guidelines 2010

CHA2DS2-VASc and therapy

ESC AF Guidelines 2010

Pulmonary vein isolation for PAF

NICE Guidance – Rate Control for AF

Beta-blocker or CCB

Digoxin added

ESC AF Guidelines 2010

Management cascade for AF

Wide-complex tachycardia

SVTSVTBundle branch block

OROR VT ?VT ?

Echt et al. NEJM 1991;324:781-788.

80

85

90

95

100

0 91 182 273 364 455

Days After Randomization

Pat

ien

ts W

ith

ou

t E

ven

t (%

)

Placebo (n = 743)

Encainide or Flecainide (n = 755)

P = 0.001

Cardiac Arrhythmia Suppression Trial

Post-MI; LVSD; NSVT

Implantable Cardioverter Defibrillator

Transvenouslead

Bipolar endocardialsensing

Shockingcoils

Pectoraldevice

Meta-analysis of the ICD secondary prevention trials (AVID, CASH, CIDS)

Connolly SJ, et al. Eur Heart J 2000;21:2071

Death Arrhythmic Death

Amio

AmioICD

ICD

ICD for Secondary Prevention

%

Mo

rtal

ity

Years Years

Hypertension

Cardiology for Finals

Hypertension – NICE 2006

NICE CG127 Hypertension 2011

Hypertension – NICE 2011

NICE CG127 Hypertension 2011

NICE CG127 Hypertension 2011

Conclusions• Cardiology will come up!

• Official Revision Session

• Work hard!

• Do well!

Cardiology for Finals