Cardiology PTL

for the quiz: goto WiFi and join dlink goto webpage 192.168.0.191:8080

Dr Justin Ghosh

Clinical Lead for Cardiology

Pacemakers

In a patient with a pacemaker : A) This looks OK

B) This doesn’t look right!!!

C) Errr, what does a pacemaker do again?

Questions

• Sacubatril / valsartan is indicated in patients with severe symptomatic heart failure due to any cause, irrespective of cause once an ACEi or ARB has been tried.

• A)True

• B)False

Hypertension requiring treatment is defined as BP >160/90 on repeated office testing.

A)True

B)False

• Stage 1 HT : 135/85 to 149/94

• Stage 2 HT 150/95 on ABPM or HBPM

Rate control for atrial fibrillation should NOT involve:

• A)Verapamil

• B)Digoxin

• C)Diltiazem

• D)Amiodarone

• E)Carvedilol

Cholesterol & risk • In a patient with a previous TIA, and an elevated cardiovascular risk

estimate, a QRISK2 score can help inform patients by showing a graphical representation of their 10year risk more accurately:

• A)True

• B)False

Valves

• In patients with a systolic murmur and a severe valve lesion, the onset of symptoms define the time to move toward surgical intervention:

• A)True

• B)False

Heart failure

• Detection / treatment / life time management

• Pro BNP cut point of 400 and 2000

• AF increases the BNP often 1000-2000 (also LVH or valve disease)

• Obesity or HF medications can lower BNP

Drugs to be used in CCF

• Beta blockers (carvedilol best evidence, bisoprolol also used)

• ACE inhibitors (Enalapril 1st choice or Lisinopril, little / no evidence for Ramipril). Entresto should be used instead if LVEF 35% or less and still symptomatic.

• Spironolactone (or Eplerenone)

• Furosemide of bumetanide used as needed to control fluid overload.

• Dapagliflozsin in CCF (DAPA-HF)

Case 65 year old man

• Hx Alcohol xs. Severe LVD EF20%. NYHA IV

• AF Creat 120

• Management??

Stable Chest pain assessment

• Presence of three of the features below is defined as typical angina. • Presence of two of the three features below is defined as atypical angina. • Presence of one or none of the features below is defined as non-anginal

chest pain.

• Anginal pain is: • constricting discomfort in the front of the chest, or in the neck, shoulders,

jaw or arms • precipitated by physical exertion • relieved by rest or GTN within about 5 minute

Acute chest pain assessment (ACS)

• Chest pain within 12 hours (refer to hospital urgently for assessment)

• Chest pain in the last 12-72 hours (refer to hospital for same day assessment)

• If over 72 hours, perform clinical assessment using ECG +/- troponin to guide further assessment.

Investigations and Management of Arrhythmia

Clinical history is key

• What are “Palpitations”?

• Onset and offset.

• Associated features...look for Red Flags

• Presence of other cardiac disease.

1

7

Red Flags

• Chest pain

• Sweating

• Syncope or pre-syncope

• Family history of sudden death

• Known structural heart disease / MI

1

8

Sinus Rhythm

RA LA

RV

LV

Ectopic focus

Atrial Fibrillation - AF

Atrial Flutter

AV nodal re-entrant tacycardia - AVNRT

AV re-entrant tachycardia AVRT

Typical benign palpitations - ectopy

• Described as a normal rhythm

• Followed by heart stopping

• Then starts with a "bang"

2

6

2

7

3

0

Anticoagulation Rate (BB / Ca2+ blockers ) Rhythm control (Flecainide/ sotalol / ablation)

31

Case……

• 80 year old lady admitted with SOB and palpitations.

• ECG showed Atrial flutter rate 150.

• CRF creat 140. Asthmatic

• Management………?

ECGs – A structured approach to assessment

• Identify: patient, time taken and circumstance

• Rate

• Rhythm

• Axis

• P waves / PR

• QRS appearance & duration

• ST segments

• T waves

Break then……

• Pacemaker

• Cholesterol

• Hypertension

• Echocardiograms

• Quiz

Pacemakers

Drugs and AF Anticoagulation : Can be with either Warfarin or NOACs. General shift toward NOACs due to the ease of use, low complication profile, esp ICH

Possible regional arrangement

Amiodarone not routinely indicated in patients with AF : specialist management only.

Sotalol also not routinely indicated for AF therapy due to QT prolongation and toxicity.

Cholesterol

• No new guidelines for general management since 2016

• New FH focus

• Systematically search primary care records for people:

• younger than 30 years old, with a total cholesterol concentration greater than 7.5 mmol/l and

• 30 years or older, with a total cholesterol concentration greater than 9.0 mmol/l

• as these are the people who are at highest risk of FH

Diagnosis of FH- Simon Broome Criteria

Total cholesterol LDL-C

Child/young person > 6.7 mmol/l > 4.0 mmol/l

Adults > 7.5 mmol/l > 4.9 mmol/l

Table 1 Cholesterol levels to be used as diagnostic criteria for the index individual1

1 levels either pre-treatment or highest on treatment. LDL-C, low-density lipoprotein cholesterol.

Diagnose a person with definite familial hypercholesterolaemia (FH) if they have: cholesterol concentrations as defined in table 1 and tendon xanthomas, or evidence of these signs in first- or second-degree relative or DNA-based evidence of an LDL-receptor mutation, familial defective apo B- 100, or a PCSK9 mutation. Diagnose a person with possible FH if they have cholesterol concentrations as defined in table 1 and at least one of the following.

Family history of myocardial infarction: aged younger than 50 years in second-degree relative or aged younger than 60 years in first-degree relative. Family history of raised total cholesterol: greater than 7.5 mmol/l in adult first- or second-degree relative or greater than 6.7 mmol/l in child, brother or sister aged younger than 16 years.

Hypertension Update

• 1.2.3 If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. See section 1.5 for people with a clinic blood pressure 180/ 120 mmHg or higher. [2019]

• 1.2.8 Confirm diagnosis of hypertension in people with a:

• clinic blood pressure of 140/90 mmHg or higher and

• ABPM daytime average or HBPM average of 135/85 mmHg or higher. [2019]

• 1.4.10 Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

• target organ damage

• established cardiovascular disease

• renal disease diabetes an estimated 10-year risk of cardiovascular disease of 10% or more.

• Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity). [2019]

Case 30 yo woman….BP 210/110

• Substance misuse. Smoker

• Headaches lethargy admitted from A&E

• Investigations? Management?

Questions

• Sacubatril / valsartan is associated with better outcomes but worse renal dysfunction, when compared with Enalapril.

• A) True

• B)False

3rd line hypertension management suggests:

A) Triple therapy of ACEi/ARB, Thiazide, beta blocker

B) Adding spironolactone to prescription

C) Adding a beta blocker

D) Triple therapy with ACEi/ARB, CCB and Thiazide

In PAF, which of the following are NOT effective in helping hold sinus rhythm? A)Weight loss

B)BP control

C)CPAP

D)Digoxin

E)Flecainide

Valves

• Patients with a murmur due to a bicuspid aortic valve can be reassured that they have no significant abnormality and nothing further needs to be done:

• A)True

• B)False

Chest pain associated with widespread ST elevation on the ECG is a medical emergency and indicates the need for urgent PCI.

A)True

B)False

Pacemakers

• In a patient with a pacemaker, who has a collapse:

• A)An urgent appointment with the pacemaker clinic is needed to assess for pacemaker dysfunction.

• B)A holter monitor is likely to identify the cause

• C) The heart rhythm is unlikely to be the cause.