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