phase 2a sasan panbehchi & areeb mazhar the peer teaching society is not liable for false or...

Phase 2a

Sasan Panbehchi & Areeb Mazhar

The Peer Teaching Society is not liable for false or misleading information…

• Valvular disease• Hypertension• Stable vs Unstable Angina• Myocardial Infarction• Heart Failure


Aims


Heart Valves

• Congenital – biscuspid valve • Senile Calcification – most common cause,

mostly in the elderly • Autoimmune/infection: Rheumatic Fever • Others: William’s Syndrome


Aortic Stenosis – Aetiology

• Symptoms: – Usually none until AS is moderately severe (aortic orifice is ≤ 1/3 of its normal

size • Severe AS

– S – Syncope (exercise induced)– A – Angina (from LV hypertrophy) – D – Dyspnoea (due to pulmonary oedema from heart failure)

• Signs– Carotid Pulse: small volume, slow-rising, narrow pulse pressure– Thrill: systolic thrill may be palpable over aortic area – Auscultation: ejection systolic murmur radiating to the carotids


Aortic Stenosis – Clinical presentations

• ECG• CXR• Exercise testing

• ECHO!!!


Aortic Stenosis - Investigation

1. Modify atherosclerotic RF as high risk of IHD2. Digoxin, ACE-I, diuretics if symptomatic

(careful!)3. Monitoring4. AVR-mortality 4-8%5. Balloon valvuloplasty-efficacy?


Aortic Stenosis-Management

• Rheumatic heart disease• SLE• Marfans• Ehler Danlos Syndrome


Aortic Regurgitation-Aetiology

• Symptoms• LV hypertrophy-dizziness, angina on exertion (< flow

to CA), palpitations• If severe=heart failure symptoms

• Signs• Characteristic early diastolic murmur• Water hammer pulse, de musset sign• Low diastolic pressure


AR-Clinical Presentations

• Ix• Echo again

• Mx• Monitor• Treat heart failure• Valve replacement


AR-Investigation and management

• Rheumatic fever• Degenerative calcification • Congenital• Amyloid, RA etc


Mitral Stenosis-Aetiology

• Symptoms• SOBOE, orthopnea, PND, • AF and systemic emboli

• Signs• mid diastolic murmur• Malar flush• RV heave• Raised JVP• Laterally displaced apex beat


Mitral Stenosis-Clinical presentation

• Ix• Same as before!

• Mx• Monitoring• Medication-diuretics and long acting nitrates for

dysponea. Anticoagulation. • PMC-percutaneous mitral balloon valvuloplasty


Mitral Stenosis-Investigation and management

• MI• Infective endocarditis• Ehler danlos, marfan and SLE


Mitral Regurgitation-Aetiology

• Symptoms• Acute can cause life threatening pul. Oedema• Chronic usually well tolerated but can get dysponea

• Signs• Pansystolic murmur• Often not much


Mitral Regurgitation-Clinical presentation

• Investigation• Rinse and repeat

• Management• If acute give nitrates, diuretics, positive inotropes• If HF give ACE-I and spironolactone • Valve replacement


Mitral Regurgitation-Investigation and management

• If BP in GP is >140/90mmHg then offer ABPM. If high normal then continue reviewing annually.

• NICE suggests:• Stage 1 HTN: >140/90mmHg• Stage 2 HTN: >160/100mmHg• Stage 3 HTN: >180/110mmHg


Hypertension

• Essential/primary HTN (most common)

• Secondary:• HTN and pre-eclampsia in pregnancy• Cushings, conns and phaechromocytoma• Coarctation of aorta• Renal disease


Hypertension-aetiology

• Usually asymptomatic but rule out secondary causes.

• Take a full DH• Ever get headaches, palpitations, sweating episodes?• FH kidney disease? Palpable kidneys?• Cushingoid appearance?• Consider their lifestyle and contributing factors: salt,

obesity, lack of exercise, CV risk factors


Hypertension-clinical presentation

• End organ damage: urine dipstick, serum creatinine and eGFR, 12 lead ECG, echo

• CV disease prevention: fasting blood glucose and serum lipids

• Secondary causes: renin/aldosterone ratio, 24hr urinary metanephrines, MRI renal arteries etc


Hypertension-Investigations

• Lifestyle interventions-lose weight, reduce salt, encourage exercise, stop smoking


Hypertension-Management

• Smoking• Diabetes • Obesity• Sedentary lifestyle• Metabolic syndrome


Stable angina-aetiology

• 3 factors:• 1. constricting pain in chest, may radiate to back,

shoulders or neck• 2. exercise is the precipitant• 3. relieved by rest or GTN spray

• Typical, atypical and non-anginal pain• If prolonged, worse on inspiration, not related to

exercise etc then not likely to be angina


Stable angina-Clinical presentation

• 12 lead ECG• FBC?• TFT• Cardiac enzymes• Echo

• Diagnosis is clinical


Stable angina-Investigations

• 1st line-BB or CCB• If symptoms do not improve then use both or if one

is contraindicated then add in a long acting nitrate, nicorandil or ivabradine.

• Only add a 3rd anti angina drug if symptoms still not adequately controlled

• Also all patients should be on aspirin and statins


Stable angina-Management (NICE)

• Definition: angina of increasing frequency or severity; occurs on minimal exertion or at rest; associated with increased risk of MI.


Unstable Angina

• Conservative: Modify risk factors, i.e. Stop smoking, exercise, weight loss and control hypertension and DM.

• Medical: Aspirin, beta-blockers, Ca2+ channel blockers, GTN for symptomatic relief.

• Surgical: Percutaneous transluminal coronary angioplasty (PTCA) involves balloon dilatation of the stenotic vessel(s). Indications: poor response to medical treatment or not suitable for CABG etc.


Unstable Angina- Management

• Includes: 1. Unstable Angina2. STEMI (i.e. acute MI)3. NSTEMI


Acute Coronary Syndromes

Risk Factors:


ACS

Modifiable:

•Smoking•Hypertension•DM•Hyperlipidaemia•Obesity•Sedentary life-style

Non-modifiable:

•Age•Gender•Family history

Controversial Risk factors: stress, type A personality, hyperinsulinaemia, ACE genotype, etc.

• Incidence 5/1000 per annum (UK) for ST-segment elevation (declining in UK)

• Several diagnostic criteria exist. Most common one is a symptomatic patient + initially increasing and then decreasing cardiac biomarkers as well as ECG changes etc.


ACS


ACS- Signs and Symptoms• Signs: Distress, anxiety, pallor, sweatiness,

pulse increased or decreased, BP high or low, 4th heart sound. There may be signs of heart failure (raised JVP, 3rd heart sound, basal crepitation) or a pansystolic murmur (papillary muscle dysfunction/rupture, VSD). Low-grade fever may be present. Later, a pericardial friction rub or peripheral oedema may develop.

• Symptoms:1. Acute central chest pain, lasting

>20min, which radiates to left side of the jaw and left arm, often associated with nausea, sweatiness, dyspnoea, palpitations.

2. BUT, BE CAREFUL!!!!

May present without chest pain specially in the very elderly or diabetics.

1. MONA2. Attach ECG monitor and record a 12-lead ECG3. IV access and Bloods incl. FBC, U&Es, Glucose and

specially Cardiac enzymes. Cardiac troponin levels (T and I) are the most sensitive and specific markers of myocardial necrosis. Serum levels increase within 3–12h from the on- set of chest pain, peak at 24–48h, and decrease to baseline over 5–14 days.

4. B-blockers5. Primary PCI or thrombolysis (Streptokinase or

Alteplase)


Management of Acute MI

• Start Regular Aspirin, B-blocker, ACE-I, Statin and address the modifiable risk factors.

• Review regularly- VERY IMPORTANT!!!• Complications can be devastating….• Examples include:


Long term management

• Cardiac arrest• Pericarditis• Cardiac tamponade • Heart failure

Definition:


Heart failure

Cardiac output is inadequate to meet body’s metabolic demands.

• Different ways of classifying it such as systolic vs diastolic, acute vs chronic, low-output vs high out-put but the most common is LEFT sided vs RIGHT sided heart failure.

• Prevalence is 1-3% of general population and prognosis is not great. If hospital admission is required there is a 5yr mortality of 75%.


HF- Basic concepts

• May occur independently or together as CCF.


Left Vs Right

Right sided heart failure: Left sided heart failure:

Symptoms: Symptoms:

Dyspnea, poor exercise tolerance, fatigue,

orthopnoea, paroxysmal nocturnal dyspnoea

(PND), nocturnal cough (±pink frothy sputum),

wheeze (cardiac ‘asthma’), nocturia, cold

peripheries, weight loss, muscle wasting.

Peripheral oedema (up to thighs, sacrum,

abdominal wall), ascites, nausea,

anorexia, facial engorgement, pulsation in

neck and face (tricuspid regurgitation)

Causes: LVF, pulmonary stenosis, lung

disease. (cor pulmonale)

• Diagnosis can be made using Framingham criteria (see BOX).65 Other signs: exhaustion, cool peripheries, cyanosis, High BP, narrow pulse pressure, pulsus alternans, displaced apex (LV dilatation), RV heave (pulmonary hypertension), murmurs of mitral or aortic valve disease, wheeze.


Signs:


Diagnostic Criteria:• Don’t

forget BNP!!!

• Once again, conservative, medical and surgical interventions to offer.


Management:

• Treat the underlying cause such as vacuities, hypertension and cardiomyopathy • Medical treatment (Next slide).• Surgical interventions such as valve replacement etc.

• Medications are divided into ones that improve prognosis and ones that help with the symptoms.

• What medications are given to people with HF?1. Diuretics (Furosemide +/- Spironolactone) 2. ACE-i (if intolerant because of side effects for

example use Vasodilators)3. B-blockers4. Digoxin 5. Aspirin


Medical management

phase 2a sasan panbehchi & areeb mazhar the peer teaching society is not liable for false or...

Documents

misleading information

peer teaching society

severe aortic orifice

aortic area auscultation

symptoms soboe

ejection systolic murmur

low diastolic pressure

narrow pulse pressure