cardiology unit presentation
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Nwalozie J.C. 17/03/2014. CARDIOLOGY UNIT PRESENTATION. Question. A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom. - PowerPoint PPT PresentationTRANSCRIPT
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CARDIOLOGY UNIT PRESENTATION
Nwalozie J.C. 17/03/2014
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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.
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Answers 3 differential diagnoses: 1. Acute Severe asthma
2. Pulmonary Embolism
3.Acute exacerbation of COPD
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MANAGEMENT OF ACUTE LEFT VENTRICULAR FAILURE
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Outline Introduction Precipitating factors Pathophysiology Clinical features Investigations Management Treatment Prognosis & Monitoring Follow-up Conclusion
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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.
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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
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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
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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
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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%
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Other features:
-Cyanosis
-Cold skin
-Features of underlying heart disease/precipitating factor
-Features of right heart failure
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INVESTIGATIONS 1.Pulse oximetry
2. Blood
3. Electrocardiography
4. Radiologic
5.Others- eg. Pulmonary arterial catheterisation
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BLOOD INVESTIGATIONS ABG
FBC – anaemia, infection
U & Es
CARDIAC MARKERS
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CARDIAC MARKERS
CARDIAC ENZYMES
OTHER CARDIAC MARKERS
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IMPORTANCE OF BNP IN HF
1. Useful in Diagnosis
2. Assessing Severity
3. Predicting short & long-term CVS mortality
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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
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ELECTROCARDIOGRAM Ischaemia / infarction
Arrhythmia – A fib
LVH
Prolonged QRS
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CHEST RADIOGRAPH FINDINGS IN HEART FAILURE Cardiomegaly – 74% sensitive, 78% specific
Vascular redistribution
Interstitial oedema
Alveolar oedema
Pleural effusions (right sided/bilateral)
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Others Echocardiography 1.Identify reversible cause eg MI,
valvular insufficiency ,tamponade 2.Distinguish between systolic and
diastolic dysfunction
• Monitor urine output
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Treatment A medical emergency
Begin treatment before investigations
ABC of resuscitation , Patient to sit up
Treatment can be medical, radiological/surgical
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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
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Other measures-diet , fluid restriction , ultrafiltration , treat precipitating cause eg infection
Radiological-IABP,LV assist device , CRT
Surgical-Valve repairs , transplantation
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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.
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Follow Up
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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.
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