Phase2 Karl Wild and Rowena Speak

Phase2Karl Wild and Rowena Speak

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Stable Angina• Stable Angina - A retrosternal chest tightness or heaviness which is brought on by

exertion and relieved by rest.

• Symptoms – constricting discomfort in the front of the chest, arms, neck and jaw, Provoked by physical exertion, especially after meals and in cold, windy weather or excessive

emotion Relieved (within minutes) with rest or glyceryl trinitrite.

• Causes – Mostly Atheroma. Anaemia, Aortic Stenosis, Tachyarrhythmia, Hypertrophic Cardiomyopathy Arteritis.

Unstable Angina – Angina of recent onset (<24hr) or a deterioration in stable angina with symptoms occurring at rest.

Refractory Angina – Refers to patients with severe coronary artery disease in whom revascularization is not possible and whose angina is not controlled by medical therapy.

Angina Examination

Signs – AnaemiaThyrotoxicosisHyperlipidaemiaAortic Stenosis (Ejection Systolic murmur radiating to neck)Check blood pressure

Angina Investigation

• 12 lead ECG -During an attack – Transient ST depression & T

wave inversion.• Cardiac Catheterization, CT Coronary

Angiography• Exclude anaemia, diabetes, hyperlipidaemia,

thyrotoxicosis and arteritis

Angina Management

• Address risk factors• Aspirin 75mg daily• B-blocker/ Ca2+ – Atenolol/AmlodipineBoth if uncontrolled on one• Nitrates – GTN, Isosorbide Mononitrate bd• Ivabradine/Nicorandil

Revascularisation

• PCI –Single vessel CAD and normal LV function

• CABG –Triple vessel disease and abnormal LV function

Acute Coronary Syndromes

• ST Elevation Myocardial Infarction (STEMI)• Non ST Elevation Myocardial Infarction (NSTEMI)• Unstable Angina

• Causes –Plaque rupture Coronary SpasmThrombosis VasculitisEmboli

NSTEMI

ECG changes -ST depressionT Wave inversion

Could be normal

STEMI

• ECG changes –Tall T wavesST elevationNew LBBB

Later –T wave inversionPathological Q waves

ACS symptoms -

• Acute central chest pain• Radiates neck and arm• Lasting >20 minutes• Nausea• Dyspnoea• Palpitations

ACS Signs -

• Distress, anxiety, pallor, sweatiness• Tachy/bradycardia• Hyper/hypotension• 4th heart sound• Signs of HF and murmur• Later - Pericardial friction rub & peripheral

oedema

ACS Investigations

• ECG• Bloods• Cardiac Enzymes –Cardiac Troponin (T & I) ^ 3 hours after onset

and peak at 24-48hrCreatine Kinase (CK-MB) ^ 3 hours after onset,

peak within 24hr

ACS ManagementNSTEMI

OxygenMorphineGTNAspirin 300mg POClopidogrel 300mg POAtenolol PO / Verapamil POEnoxaparin

More Nitrate if in pain.High risk – GPIIb/Iia antagonist (tirofiban)Low risk – Discharge if 12hr Trop -ve

STEMIOxygenAspirin 300mg POMorphineGTN

PRIMARY PCI / ThrombolysisAtenolol

ACS Pathology Cause ECG changes Cardiac enzymes

(Stable angina) (Narrowing lumen)

Unstable angina

Ischaemia Non-occlusive thrombus

No ST elevation

-ve troponin

NSTEMI Ischaemia/Infarction

Non-occlusive thrombus

No ST elevation

+ve troponin

STEMI Transmural infarction

Occlusive thrombus

ST elevation +ve troponin



Hypertension (HTN)• Essential (primary) HTN

= idiopathic• Secondary HTN =

something is causing it


HTN: causes of secondary• Renal disease: intrinsic, renovascular • Endocrine: Cushing’s, Conn’s, Phaeochromocytoma,

Acromegaly, Hyperparathyroidism• Coarctation of the aorta• Pre-eclampsia and HTN in pregnancy• Drugs and toxins: alcohol, cocaine, ciclosporin,

decongestants, adrenergic medications, oral contraceptives, corticosteroids, liquorice


HTN: symptoms• Usually asymptomatic• Headaches, paroxysmal sweats or palpitations

= think phaeochromocytoma (tumour of the adrenal medulla)

http://www.google.co.uk/url?sa=i&rct=j&q=pheochromocytoma&source=images&cd=&cad=rja&uact=8&docid=Q8Pm2TE8F7qCnM&tbnid=vXIgO1NYuJt3iM:&ved=0CAcQjRw&url=http://library.med.utah.edu/WebPath/ENDOHTML/ENDO076.html&ei=Ud4eVJftKMWUauj7gbAM&bvm=bv.75775273,d.d2s&psig=AFQjCNHBq5W_tLRzycSwebbdbRc0uOLh3A&ust=1411395504963489


HTN: diagnosis• GP surgery BP measurements of adults at least every 5 yearsWhite coat syndrome = patients have elevated BP in a clinical setting but not

in other settings due to anxiety experienced during a clinic visit.

• ABPM = ambulatory blood pressure monitoring• HBPM = home blood pressure monitoring• Cardiovascular risk assessment• HTN retinopathy screening• ECG to look for LVH• Bloods: electrolytes, creatinine, eGFR, fasting glucose, lipids• Urinalysis: albuminuria, proteinuria or haematuria ± albumin:creatinine

ratio.


HTN: stages• Stage 1 - BP in surgery/clinic is ≥140/90 mm

Hg and ABPM or HBPM is ≥135/85 mm Hg.

• Stage 2 - BP in surgery/clinic is ≥160/100 mm Hg and ABPM or HBPM is ≥150/95 mm Hg.

• Severe - BP in surgery/clinic is ≥180/110 mm Hg or higher.


HTN: lifestyle interventions• Lower salt intake• Reduce alcohol consumption • Stop smoking• Do more exercise• Be less stressed


HTN: initiation of treatment• Offer step 1 treatment to

people aged under 80 with stage 1 hypertension and one or more of:

a) target organ damageb) established cardiovascular

diseasec) renal diseased) diabetese) 10-year cardiovascular risk

equivalent to 20%

• Offer step 1 treatment to people of any age with stage 2 hypertension


HTN: treatment


Heart failure• A complex syndrome that can result from any

structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation.


HF: aetiology• Ischaemic heart disease• Cardiomyopathy• HTN• Diseases of the heart

valves• Pericardial disease• Arrhythmias

• Alcohol• Cocaine• Chemo• Severe anaemia• Thyroid disease• Idiopathic


HF: symptomsLeft• Exertional dyspnoea• Orthopnoea• Paroxysmal nocturnal

dyspnoea (PND)• Fatigue

Right• Swollen ankles• Fatigue• Anorexia


HF: signsLeft• Cardiomegaly• Third and fourth heart

sounds• Tachycardia• Crepitations in lung bases

Right• Raised JVP• Hepatomegaly• Pitting oedema• Ascites

HF Investigations

• Chest X ray• Bloods• B-type Natriuretic Peptide• ECG• Transthoracic echocardiogram

Chronic HF Management

• Diuretics – Furosemide• ACE-I – Ramipril / ARB – Candesartan• B-Blocker – Atenolol• Spironolactone• Digoxin• Vasodilators – Hydralazine & Isosorbide

Dinitrate

Acute HF Management

• Oxygen• Diamorphine IV• Furosemide IV• GTN spray• If systolic BP >100mmHg IV nitrate

HF Question

A 75 year-old woman is brought to the Emergency Department by ambulance following an emergency call at 4 am. She is pain-free but very breathless. She has previously been diagnosed with congestive cardiac failure and is receiving drug treatment from her General Practitioner.

GOOD LUCK!!!

Phase2 Karl Wild and Rowena Speak

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