Investigation and management of the cardiac patient

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Investigation and management of the cardiac
patient
Andrew C Rankin Glasgow Royal Infirmary
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Limb leads
Bipolar
Unipolar
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Chest leads
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ECG leads the heart

• II, III, aVF Inferior
• V1-V6 Anterior
• I, aVL, V6 Lateral

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Causes of Atrial Fibrillation

• Which is not associated with AF?
• Heart failure
• Alcohol excess
• Hypothyroidism
• Hypertension
• Acute Myocardial Infarction

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Atrial fibrillation
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Case 1

• 43 year old man
• Brought to AE as an Emergency
• Woke at 3.00am with severe chest pain
• Cold sweat nausea
• Smoker Family history of CA

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First ECG - 0436
What is the heart rate?
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• What is the heart rate?
• 30 bpm
• 40 bpm
• 50 bpm
• 60 bpm
• 70 bpm
• 80 bpm

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Reading ECG Squares
Intervals and Timing

• Paper speed 25mm/sec
• 25 small squares per second
• 5 large squares per second
• Each large square 0.2 s
• Each small square 0.04 s

5 large squares 1 second RR 1 second 60 bpm
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Rate
300 divided by the number of large squares
between each QRS complex
1 square - 300/min 2 squares - 150/min 3
squares - 100/min 4 squares - 75/min 5 squares -
60/min 6 squares - 50/min
OR - 1500 divided by the number of small squares
between each QRS complex
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First ECG - 0436
What is the diagnosis?
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• What is the diagnosis?
• Acute Anterior MI
• Acute Inferior MI
• Old Inferior MI
• Old Anterior MI
• Pericarditis

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Inferior ST elevation
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Acute Myocardial Infarction
Current of injury
ST elevation
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First ECG - 0436
What should you do now?
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• What should you do now?
• Give thrombolysis
• Admit to CCU
• Dial 999
• Dont know

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ENHANCED REPERFUSION THERAPY FOR STEMIPatients
presenting to SAS/DGH 2008
STEMI/Posterior MI
Shock
No Shock
Call to balloon time lt90 min
Thrombolysis contraindicated
PCI Centre
PCI Centre
Primary PCI
Primary PCI
Reperfusion
Maximum journey time 40 min
Return to local DGH within 24hrs or when stable
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Contraindications to thrombolysis?

• Absolute contraindications    ACC/AHA
  Guidelines 2004
• Any prior ICH
• Known structural cerebral vascular lesion (eg,
  AVM) or malignant intracranial neoplasm (primary
  or metastatic)
• Ischemic stroke within 3 months EXCEPT acute
  ischemic stroke within 3 hours
• Suspected aortic dissection
• Active bleeding or bleeding diathesis
  (excluding menses)
• Significant closed head or facial trauma within
  3 months

Relative contraindications History of chronic
severe, poorly controlled hypertension Severe
uncontrolled hypertension on presentation (SBP
greater than 180 mm Hg or DBP greater than 110 mm
Hg) History of prior ischemic stroke greater
than 3 months, dementia, or other known
intracranial pathology Traumatic or prolonged
(greater than 10 minutes) CPR or major surgery
(less than 3 weeks) Recent (within 2 to 4
weeks) internal bleeding Noncompressible
vascular punctures For streptokinase prior
exposure (more than 5 days ago) or prior allergic
reaction to these agents Pregnancy Active
peptic ulcer Current use of anticoagulants the
higher the INR, the higher the risk of bleeding
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Repeat ECG - 0450
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Monitor tracing - 0451
Successfully defibrillated
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Post-VF management?

• Amiodarone
• Implantable Cardioverter Defibrillator
• Beta-blocker
• Flecainide
• Observe

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Implantable Cardioverter Defibrillator
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Transferred for Primary PCI
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• Stent insertion during angioplasty.

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The next day - 0900
Is there evidence of myocardial damage?
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• Is there evidence of myocardial damage?
• T wave inversion
• Q waves
• ST segment elevation
• Peaked T waves

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Q waves T wave inversion
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Old Myocardial Infarction
Myocardial window
Q wave
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Further investigations

• What investigation is now appropriate?
• Troponin-I (or T)
• Cholesterol
• Glucose
• Echocardiogram
• Exercise test (pre-discharge)

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Drugs at Discharge

• What drugs should he be sent home on?
• Aspirin
• Clopidogrel
• Statin
• Beta-blocker
• ACE inhibitor
• All of the above

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Case 2

• 42 year old woman
• Single, 2 teenage children, non-smoker
• Active e.g. skiing
• PMH of knee injury
• O/E Systolic murmur noted
• Pan-systolic murmur at apex

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Pan-systolic murmur

• What is the likely diagnosis?
• Mitral stenosis
• Mitral regurgitation
• Aortic stenosis
• Aortic regurgitation
• Ventricular septal defect

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Pan-systolic murmur

• Which physical sign indicates severity of chronic
  MR?
• Prominent V wave (raised JVP)
• Displaced apex beat
• Systolic thrill
• Opening snap
• Loudness of systolic murmur

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Pan-systolic murmur

• What investigation do you most want now?
• ECG
• Chest X-ray
• Echocardiogram
• Cardiac catheterisation

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Chest X-Ray

• Which diagnosis can we make from a CXR?
• Left ventricular hypertrophy
• Left ventricular dilation
• Aortic stenosis
• Mitral regurgitation
• Myocardial infarction
• None of the above

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Chest X-Ray
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Echocardiography - Long Axis View
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Mitral Regurgitation
Ao
LV
LA
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Echocardiography - Four-chamber View
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Case 2 6 months later

• Fatigue lethargy
• Weight loss of 1.5 stones
• Drenching night sweats
• Antibiotics from GP
• O/E Febrile
• PSM EDM

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Systolic murmur with pyrexia

• Which investigation is most important now?
• Full blood count
• ESR
• CRP
• Blood cultures
• Repeat trans-thoracic echo
• Trans-oesophageal echo
• Cardiac catheterisation

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Admission to Oban hospital

• Results
• CRP 112
• ESR 74
• Hb 9.2, WCC 12, Platelets 43.
• Urinalysis blood protein
• Echo showed MR, AR vegetations on mitral valve
• 6 ve cultures for Streptococcus mutans

• Diagnosis of infective endocarditis (SBE)
• IV ceftriaxone gentamicin for 4 weeks

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Admission to Oban hospital

• Results
• CRP 112
• ESR 74
• Hb 9.2, WCC 12, Platelets 43.
• Urinalysis blood protein
• Echo showed MR, AR vegetations on mitral valve
• 6 ve cultures for Streptococcus mutans

• Diagnosis of infective endocarditis (SBE)
• IV ceftriaxone gentamicin for 4 weeks

• Repeat echo new vegetations on AV

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Transfer to GRI

• Trans-oesophageal echo (TOE)
• Vegetations on MV and AV
• Severe MR AR
• Dilated LV

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Trans-oesophageal echo
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Aortic regurgitation
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LA
Aorta
LV
Vegetation in LVOT
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Further progress

• Intermittent pyrexia
• Vegetations on MV and AV
• Severe valve regurgitation
• Accepted for surgery (MVR AVR)

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Final question?

• What kind of valve replacements should she have?
• Mechanical (tilting disc)
• Bioprosthetic (tissue valve)
• Factors to consider
• Need for anticoagulation child-bearing
  potential time to valve failure fitness for
  future surgery

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Type of Valve?
Mechanical
Tissue
Illustrations from BHF Health Information Series
Number 11 Valvular Heart Disease (2005)
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Mechanical v Tissue
Decision of INFORMED PATIENT
No survival difference when age and RFs were
taken into consideration (Meta-analysis 2006)
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The end