1. Cardiology in a heartbeat
Your hosts: Malik ‘heart throb’ Fleet and
Thomas ‘heart ache’ McLeod
2. Objectives
Be able to perform in a cardio related osce.
Describe the key features and management
of:
Atrial Fibrillation
Acute Coronary Syndrome
Answer SBAs related to this week’s teaching
3. Outline of session
20 minutes OSCE and debrief
40 minutes tutorial
20 minutes SBAs
Answer any questions
4. Notes from the OSCE scenario
DR ABCDE: (Before ‘D’!)
Ask examiner for observations
Does patient meet PERT criteria? They
always do so call for help!
(PERT criteria=
5. Notes from the OSCE scenario
D - anger
R - esponse
A -irway
B- reathing
C - irculation
D - isability (AVPU)
E - xposure
LOOK
FEEL
LISTEN
MEASURE
TREAT
6. Notes from the OSCE scenario
A - irway:
Look
Feel
Listen
Measure
Treat
Often patient is breathing
so able to say airway is
patent. If not, suggest
ensuring airway e.g Guedel
airway
7. Notes from the OSCE scenario
B- reathing
Look: cyanosed? Trachea central? Chest expansion?
Feel: symmetrical chest movement? Percussion?
Listen: auscultate chest (ask examiner for findings)
Measure:
a. Resp rate
B. O2 sats on air
Treat:
Give oxygen: high flow (e.g. 15L/min) - non
rebreathe mask (unless C/I e.g COPD)
8. Notes from the OSCE scenario
C- irculation
Look: cyanosed? General appearance? JVP? Pain?
Feel: Peripheries- cool? Clammy?; Pulse
Listen: heart sounds
Measure:
Heart rate
Blood pressure
Cap refill
Urine output
Temp.
ECG
Treat:
IV access (“two wide bore cannulae”)
Bloods (FBC/ U and E)
Fluid Challenge
(MONA if acute coronary syndrome)
9. Notes from the OSCE scenario
D- isability: AVPU + BM
Patient responds to:
A - lert
V - oice
P - ain
U - nresponsive
Ask examiner for BM
10. Notes from the OSCE scenario
E- xposure:
Expose patient from head to toe looking for
any other clue for deterioration.
+ “ending exam”: write notes, hand over to
team etc.
11. Notes from the OSCE scenario:
8 Reversible causes of VT: The 4 ‘H’s and 4 T’s.
4 T’s:
T-hrombosis (coronary or
pulmonary)
T-amponade
T-oxins
T-ension pneumothorax
4 H’s:
H-ypoxia
H-ypovolaemia
H-ypo/er kalaemia (metabolic)
H-ypothermia
12. Notes from the OSCE scenario:
2 shockable rhythms:
Pulseless Ventricular Tachycardia
Ventricular Fibrillation
2 non shock:
-Pulseless electrical activity
-Asystole
15. AF: Objectives
By the end of this session you should be able to:
Identify how AF presents and establish an appropriate differential
Suggest sensible investigations as relating to your differential
Recognise and describe the classic ECG findings and the pathophysiology of AF.
Classify AF as according to its pattern and amenability to cardioversion (‘the 3 P’s)
Describe the management options in terms of Rate and Rhythm control and list
suitable examples of patients and medications accordingly.
17. “Joe”
Joe is a 45 year old professional clown.
He has recently returned from a boozy working
holiday in Magaluf.
He has the biggest performance of his career at the
Brent Cross circus tomorrow. He feels terribly
unprepared and begins to sweat when talking about it.
He presents to you in A and E complaining of being
aware that his heart is doing ‘funny things’ and feels
short of breath.
18. Differential Diagnosis at this
stage?
Anxiety induced palpitations (panic attack)
Atrial Fibrillation
(hyperthyroidism)
21. AF: ECG findings and
pathophysiology
ECG findings:
Absent p waves ~ no identifiable p waves throughout trace.
Narrow QRS (AV conduction in tact)
25. Case development
History: diagnosed with hypertension 10 years ago. Stopped taking ‘useless
tablets’ after 6 months. Father died at 60 from hypertensive heart
disease/failure.
Ix:
No echo done
Bloods: TFTs: negative
Troponin: negative
Joe begins to feel worse, his heart rate increases to 150 bpm and he has
slight pain. No ST elevation on ECG.
27. AF: Management: Acute Onset
If HAEMODYNAMIC INSTABILITY:
Non Life threatening:
-RATE (if major contributor to haemodynamic
instability):
-Beta Blocker / Ca Channel Blocker
-Amiodarone
-RHYTHM:
-PCV* (or ECV if available)
*Pharmacological Cardioversion:
I.V Amiodarone
-ANTICOAGULATION:
-start heparin
- commence oral warfarin depending on outcome
of CV/ onset of AF.
Life threatening:
-RHYTHM:
Emergency electrical cardioversion
-(Anticoagulation should not
delay intervention).
29. AF: Rhythm: Cardioversion:
WARNING!
AF = clot generator
Normal rhythm (cardiac output restored)
clots disseminated to brain etc.
CARDIOVERSION
30. AF: Rhythm: Cardioversion: VTE
prophylaxis
<48 hours
-Heparin
-PCV (or ECV)
-Confirm onset of AF:
-If definitely <48hours: no need for further
anticoagulation.
-If unsure: warfarin for 4 weeks
>48hours
a. ANTI COAGULATE (3 weeks)
or
b. TRANS OESOPHAGEAL ECHO (TOE)
-detects whether a thrombus is present or not.
-If not: heparin + cardioversion
-If present: warfarin for 3 weeks and repeat TOE.
* Continue warfarin for 4 weeks post
cardioversion
33. AF: Rhythm: Cardioversion:
ELECTRICAL
>48 hours
ECV (= low grade shock to heart):
1st line: > 48 hours
If doubts over success (e.g. previous failure to cardiovert; early recurrence of AF):
Give AMIODARONE or SOTALOL for 4 weeks prior to ECV.
Improves rates of cardioversion
34. Atrial fibrillation: “3 p’s”
Classification
Paroxysmal:
Spontaneous self termination
<7 days (often <48hours)
Persistent:
Lasts > 7 days
NOT self terminating
Permanent
Does not terminate
Not amenable to cardioversion
(NOTE: can return to sinus rhythm if cure underlying pathology e.g.
hyperthyroidism)
35. AF: Management: Paroxysmal
Classified as…
Therapeutic objective: SUPPRESSION OF
PAROXYSMS
Paroxysm defined as…
From the Greek…
36. AF: Management: Paroxysmal
Classified as…
Spontaneous self termination
<7 days (often <48hours)
Paroxysm defined as…"sudden attack, outburst"
From the Greek… (παροξυσμός paroxusmos), "irritation,
exasperation".[
37. AF: Management: Paroxysmal
Suppression of paroxysms:
CONSERVATIVE:
1.there is a known precipitant of paroxysm
E.g. Alcohol; caffeine.
2. the patient asymptomatic/few symptoms
3. No history of left ventricular dysfunction/ ischaemic heart disease
Rx: -drug free / “pill in the pocket” strategy:
Pill in a pocket= “Flecainide” (or other Class 1c agent)
38. AF: Management: Paroxysmal
Suppression of paroxysms:
MEDICAL/ PHARMACOLOGICAL:
-If patient is symptomatic
-Frequent paroxysms
-No known precipitant
1st Line: Beta Blocker
2nd line (symptoms not controlled): Sotalol
3rd line/ if poor left ventricular function: Amiodarone
41. AF: Management: Persistent:
RATE
RATE control strategy should be preferred 1st line option in:
Over 65s
Coronary artery disease
C/I to antiarrhthymic drugs
Not suitable for cardioversion
No heart failure
42. AF: Management: Persistent:
RATE
RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker
Monotherapy:
Beta blocker
Ca Channel Blocker
(Digoxin ~ if sedentary)
If require more than monotherapy:
Beta blocker/ Ca channel blocker + Digoxin
43. AF: Management: Persistent:
RHYTHM
RHYTHM control strategy should be preferred 1st line option in:
Younger patients
Symptomatic
AF secondary to treated/ corrected precipitant (e.g. chest infection)
With heart failure
44. AF: Management: Persistent:
RHYTHM
RHYTHM control strategy 1st line option is:
Cardioversion + Anticoagulation
If recurrence/ unsuccessful/ requires drug to maintain sinus rhythm:
1st line:
Beta Blocker
2nd Line (I.e. not effective/ contraindicated):
+ structural heart disease :AMIODARONE
- NO structural heart disease: FLECAINIDE (or Sotalol)
45. AF: Management: Permanent
Classified as…
Therapeutic objective: think blender: control rate as rhythm functions are
broken!
47. AF: Management: Permanent:
RATE
RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker
Monotherapy:
Beta blocker
Ca Channel Blocker
(Digoxin ~ if sedentary)
If require more than monotherapy:
Beta blocker/ Ca channel blocker + Digoxin
48. AF: Management:
ANTICOAGULATION
Acute:
Commence heparin until full risk assessment of emboli has been performed.
>48 hours- 3 weeks of oral anticoagulation (warfarin) prior to cardioversion
NO anticoagulation if:
Stable sinus rhythm has been restored
<48 hours
No risk factors for emboli
Chronic:
Discuss with patient risks and benefits of anticoagulation.
CHADS 2 = predictor of stroke.
C= congestive cardiac failure (1)
H= hypertension (1)
A = age (>75) (1)
D= Diabetes (1)
S= stroke/ previous TIA (2)
Warfarin : aim for therapeutic INR 2 -3
(If warfarin C/I : Aspirin 300 mg/day)
CHADS 2 score of: % risk of stroke
0: 1.9%
6: 18.2%
49. AF: Summary
You should now be able to:
Identify how AF presents and establish an appropriate differential
Suggest sensible investigations as relating to your differential
Recognise and describe the classic ECG findings and the pathophysiology of AF.
Classify AF as according to its pattern and amenability to cardioversion (‘the 3 P’s)
Describe the management options in terms of Rate and Rhythm control and list
suitable examples of patients and medications accordingly.
75. ST: Elevation
Mechanism behind ECG changes:
Complete occlusion of coronary vessel leads to ischaemia/infarction which
is seen as ST elevation.
The mechanism is, however, poorly understood.
Injury wave hypothesis= abnormal currents are generated between normal
and infarcted tissue and detected as an ‘injury wave’.
Localisation:
Right Coronary Artery (Post. Descending/ Marginal): Inferior STEMI: Leads II, III, avF
Left Anterior Descending: Anterior STEMI: V1-V4
Left circumflex: Lateral STEMI: I, aVL, V5, V6
82. A 45 year old man suffers sudden central
chest pain while at rest. It spreads across
his chest and up to his neck. After 20 mins,
the pain has not eased and he is
increasingly sweaty and short of breath.
This is the third such episode in the last 3
months
12hr Troponin I <0.05 ug/L
83. What is the single most accurate classification of
this event?
A. Acute Coronary Syndrome
B. Non-ST elevation myocardial infarction
C. ST elevation myocardial infarction
D. Stable angina
E. Unstable angina
84. What is the single most accurate classification of
this event?
A. Acute Coronary Syndrome
B. Non-ST elevation myocardial infarction
C. ST elevation myocardial infarction
D. Stable angina
E. Unstable angina
85. A 55 year-old woman has noticed her heart
beating fast. It happens infrequently and is not
assosciated with any other symptoms. She is
anxious about the cause of these attacks as she
has no other medical problems.
HR 80bpm, BP 115/75mmHg
After a normal ECG, a 24hr tape is performed
86.
87. Which is the single most appropriate
treatment?
A. Amiodarone 100mg PO once daily
B. Digoxin 62.5mcg PO once daily
C. Flecainide 150mg PO as required
D. Metoprolol 25mg PO twice daily
E. Sotalol 40mg PO twice daily
88. Which is the single most appropriate
treatment?
A. Amiodarone 100mg PO once daily
B. Digoxin 62.5mcg PO once daily
C. Flecainide 150mg PO as required
D. Metoprolol 25mg PO twice daily
E. Sotalol 40mg PO twice daily
89. SBAs:
Which of the following is not a reversible
cause of cardiac arrest?
Hypoxia
Hypo/Hyperkalaemia
Tension Pneumothorax
Hyperthyroidism
Tamponade
90. SBAs:
Which of the following is not a reversible
cause of cardiac arrest?
Hypoxia
Hypo/Hyperkalaemia
Tension Pneumothorax
Hyperthyroidism
Tamponade
91. SBAs:
A 67 year old lady has just been diagnosed with persistent AF.
Cardioversion has previously failed. She is symptomatic, has
coronary artery disease but no heart failure. What1st line treatment
would you prescribe?
Paracetamol
Beta Blocker
Flecainide
Sotalol
Amiodarone
92. SBAs:
A 67 year old lady has just been diagnosed with persistent AF.
Cardioversion has previously failed. She is symptomatic, has
coronary artery disease but no heart failure. What1st line treatment
would you prescribe?
Paracetamol
Beta Blocker
Flecainide
Sotalol
Amiodarone
93. A 48-year old patient gives a 5 day history of dyspnoea.
He is found to be in atrial fibrillation. Which is the most
appropriate management plan?
A. Chemical cardioversion with IV amiodarone
B. Chemical cardioversion with IV flecainide
C. Anticoagulation with warfarin and rate control
D. Transthoracic echocardiogram to exclude thrombus
followed by DC cardioversion
E. Anticoagulation with warfarin then initiation of oral
amiodarone
94. A 48-year old patient gives a 5 day history of dyspnoea.
He is found to be in atrial fibrillation. Which is the most
appropriate management plan?
A. Chemical cardioversion with IV amiodarone
B. Chemical cardioversion with IV flecainide
C. Anticoagulation with warfarin and rate control
D. Transthoracic echocardiogram to exclude thrombus
followed by DC cardioversion
E. Anticoagulation with warfarin then initiation of oral
amiodarone
Editor's Notes
Risk factors:
Modifiable: Smoking; obesity; hyperlipidaemial; diabetes mellitus, sedentary lifestyle
Non-modifiable:Age; gender (males are at greater risk), family history of IHD
group of symptoms attributed to obstruction of the coronary arteries.
Ischaemia: reduced perfusion to cells. NOTE: purely symptomatic (angina). No cell death.
Infarction: reduced perfusion (ischaemia) exceeds tolerance of cells resulting in cell death. Partial (NSTEMI) and total (STEMI) occlusion.
STEMI: myocardial infarction with ST elevation seen in ECG.
Non -STEMI- infarction (positive troponin) but no ST elevation seen.
How do we Differentiate
STEMI – ST elevation
New onset LBBB
NSTEMI/UA – Partial occlusion.
ECG may be : NORMAL
ST Depression (most common)
T-wave inversion
Angina
Ischaemia caused by dynamic obstruction of a coronary artery due to plaque rupture with superimposed thrombosis and spasm
Presentation features:
Chest pain: new onset; at rest or deterioration of angina (unstable?); crushing, central; lasting longer than 20mins
S.O.B
Palpitations
Anxious/ Distressed
Sweaty
Pallor
Vomiting
Examine:
Haemodynamic status
Signs of complications eg. pulmonary oedema,
cardiogenic shock
Non-coronary causes of acute chest pain, such as aortic dissection