Cardiology for Finals Andrew C Rankin. What do you need for Finals? The knowledge and skills...
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![Page 1: 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,](https://reader035.fdocuments.net/reader035/viewer/2022070417/56649e2d5503460f94b1c5d3/html5/thumbnails/1.jpg)
Cardiology for Finals
Andrew C Rankin
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• 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
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• Clinical skills–History
–Examination• Clinical Skills Website
• ECG
Cardiology for Finals OSCE
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Heart Failure
Cardiology for Finals
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• 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
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• 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
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1. Furosemide (frusemide)
2. Ramipril (and / or candesartan)
3. Carvedilol (or bisoprolol)
4. Spironolactone (or eplerenone)
5. Digoxin
Drugs for Heart Failure
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Diuretics
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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
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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
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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
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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
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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
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NICE 2010 - Heart Failure
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Cardiac Resynchronisation TherapyCardiac Resynchronisation Therapy
RV pacingRV pacing
LV pacingLV pacing(via cardiac vein)(via cardiac vein)
RA pacingRA pacing
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CARE-HF
Cleland et al. N Engl J Med 2005;352:1539-49.
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Cardiomyopathy
Cardiology for Finals
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Cardiomyopathies
From Davidson’s Principles & Practice of Medicine
Normal Hypertrophic Dilated
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Coronary Artery Disease
Cardiology for Finals
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• 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
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ST elevationST elevation
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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*
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ISIS-2.Lancet 1988
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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
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Thrombolysis Thrombolysis vsvs Angioplasty for STEMI Angioplasty for STEMI
Danami-2 Study; 1572 patients with STEMI
Busk et al, Eur Heart J 2008
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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
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Acute coronary syndrome
No ST elevationST elevation
Chest painPresentation
WorkingDiagnosis
Myocardial Infarction
STEMI NSTEMI+
+
Unstable Angina
-
ECG
Troponin
Final diagnosis
Acute Coronary Syndrome
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Evidence based medicine
Cardiology for Finals
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• Why do we use a treatment?
• Because it saves lives!
• Evidence of improved outcome
Evidence based Cardiology
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Smith & Pell 2003BMJ 327:1459-61
Parachutes: Evidence Base
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Arrhythmias
Cardiology for Finals
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Cardiac ArrhythmiasCardiac Arrhythmias
““Supraventricular”Supraventricular”
VentricularVentricular
AtrialAtrial
JunctionalJunctional
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Narrow or wide QRS?
Adenosine
Irregular?
P waves?
TerminatesAV block
SVT Atrial
AF
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AV reentry tachycardia
Accessory pathway
Supraventricular Tachycardia
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AdenosineAdenosine
Termination of AVRT
Adenosine and SVT
Accessory pathway
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Carotid Sinus Massage
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Atrial Flutter
Atrial Flutter
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AdenosineAdenosine
Adenosine and Atrial Flutter
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Accessory pathway
Ablation catheter
Radiofrequency ablation
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• 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
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Algorithm for treatment of AF!
PersistentPermanentParoxysmal
Peters N, et al. Lancet 2002
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Atrial fibrillationAtrial fibrillation
Rate controlRate control
Rhythm controlRhythm controlRisk of embolismRisk of embolism
Atrial Fibrillation
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“Natural” time course of AF
ESC AF Guidelines 2010
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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 )
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Amiodarone vs Sotalol for AF
Singh et al (SAFE-T) NEJM 2005;352:1861
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Warfarin prevents strokes in AF
• Warfarin prevents 20-30 strokes per 1000 patient years
• 6 - 8 serious bleeding episodes per 1000 patient years
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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)
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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
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CHA2DS2-VASc and stroke rate
ESC AF Guidelines 2010
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CHA2DS2-VASc and therapy
ESC AF Guidelines 2010
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Pulmonary vein isolation for PAF
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NICE Guidance – Rate Control for AF
Beta-blocker or CCB
Digoxin added
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ESC AF Guidelines 2010
Management cascade for AF
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Wide-complex tachycardia
SVTSVTBundle branch block
OROR VT ?VT ?
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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
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Implantable Cardioverter Defibrillator
Transvenouslead
Bipolar endocardialsensing
Shockingcoils
Pectoraldevice
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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
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Hypertension
Cardiology for Finals
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Hypertension – NICE 2006
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NICE CG127 Hypertension 2011
Hypertension – NICE 2011
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NICE CG127 Hypertension 2011
![Page 67: 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,](https://reader035.fdocuments.net/reader035/viewer/2022070417/56649e2d5503460f94b1c5d3/html5/thumbnails/67.jpg)
NICE CG127 Hypertension 2011
![Page 68: 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,](https://reader035.fdocuments.net/reader035/viewer/2022070417/56649e2d5503460f94b1c5d3/html5/thumbnails/68.jpg)
Conclusions• Cardiology will come up!
• Official Revision Session
• Work hard!
• Do well!
Cardiology for Finals