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Phase 2a Sasan Panbehchi & Areeb Mazhar

Cardiovascular Disease. Phase 2a Sasan Panbehchi & Areeb Mazhar. The Peer Teaching Society is not liable for false or misleading information…. Aims. Valvular disease Hypertension Stable vs Unstable Angina Myocardial Infarction Heart Failure.

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Phase 2a Sasan Panbehchi & Areeb Mazhar

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  1. Cardiovascular Disease Phase 2a Sasan Panbehchi & Areeb Mazhar The Peer Teaching Society is not liable for false or misleading information…

  2. Aims • Valvular disease • Hypertension • Stable vs Unstable Angina • Myocardial Infarction • Heart Failure The Peer Teaching Society is not liable for false or misleading information…

  3. Heart Valves The Peer Teaching Society is not liable for false or misleading information…

  4. Aortic Stenosis – Aetiology • Congenital – biscuspid valve • Senile Calcification – most common cause, mostly in the elderly • Autoimmune/infection: Rheumatic Fever • Others: William’s Syndrome The Peer Teaching Society is not liable for false or misleading information…

  5. Aortic Stenosis – Clinical presentations • Symptoms: • Usually none until AS is moderately severe (aortic orifice is ≤ 1/3 of its normal size • Severe AS • S – Syncope (exercise induced) • A – Angina (from LV hypertrophy) • D – Dyspnoea (due to pulmonary oedema from heart failure) • Signs • Carotid Pulse: small volume, slow-rising, narrow pulse pressure • Thrill: systolic thrill may be palpable over aortic area • Auscultation: ejection systolic murmur radiating to the carotids The Peer Teaching Society is not liable for false or misleading information…

  6. Aortic Stenosis - Investigation • ECG • CXR • Exercise testing • ECHO!!! The Peer Teaching Society is not liable for false or misleading information…

  7. Aortic Stenosis-Management • Modify atherosclerotic RF as high risk of IHD • Digoxin, ACE-I, diuretics if symptomatic (careful!) • Monitoring 4. AVR-mortality 4-8% 5. Balloon valvuloplasty-efficacy? The Peer Teaching Society is not liable for false or misleading information…

  8. Aortic Regurgitation-Aetiology • Rheumatic heart disease • SLE • Marfans • Ehler Danlos Syndrome The Peer Teaching Society is not liable for false or misleading information…

  9. AR-Clinical Presentations • Symptoms • LV hypertrophy-dizziness, angina on exertion (< flow to CA), palpitations • If severe=heart failure symptoms • Signs • Characteristic early diastolic murmur • Water hammer pulse, de musset sign • Low diastolic pressure The Peer Teaching Society is not liable for false or misleading information…

  10. AR-Investigation and management • Ix • Echo again • Mx • Monitor • Treat heart failure • Valve replacement The Peer Teaching Society is not liable for false or misleading information…

  11. Mitral Stenosis-Aetiology • Rheumatic fever • Degenerative calcification • Congenital • Amyloid, RA etc The Peer Teaching Society is not liable for false or misleading information…

  12. Mitral Stenosis-Clinical presentation • Symptoms • SOBOE, orthopnea, PND, • AF and systemic emboli • Signs • mid diastolic murmur • Malar flush • RV heave • Raised JVP • Laterally displaced apex beat The Peer Teaching Society is not liable for false or misleading information…

  13. Mitral Stenosis-Investigation and management • Ix • Same as before! • Mx • Monitoring • Medication-diuretics and long acting nitrates for dysponea. Anticoagulation. • PMC-percutaneous mitral balloon valvuloplasty The Peer Teaching Society is not liable for false or misleading information…

  14. Mitral Regurgitation-Aetiology • MI • Infective endocarditis • Ehler danlos, marfan and SLE The Peer Teaching Society is not liable for false or misleading information…

  15. Mitral Regurgitation-Clinical presentation • Symptoms • Acute can cause life threatening pul. Oedema • Chronic usually well tolerated but can get dysponea • Signs • Pansystolic murmur • Often not much The Peer Teaching Society is not liable for false or misleading information…

  16. Mitral Regurgitation-Investigation and management • Investigation • Rinse and repeat • Management • If acute give nitrates, diuretics, positive inotropes • If HF give ACE-I and spironolactone • Valve replacement The Peer Teaching Society is not liable for false or misleading information…

  17. Hypertension • If BP in GP is >140/90mmHg then offer ABPM. If high normal then continue reviewing annually. • NICE suggests: • Stage 1 HTN: >140/90mmHg • Stage 2 HTN: >160/100mmHg • Stage 3 HTN: >180/110mmHg The Peer Teaching Society is not liable for false or misleading information…

  18. Hypertension-aetiology • Essential/primary HTN (most common) • Secondary: • HTN and pre-eclampsia in pregnancy • Cushings, conns and phaechromocytoma • Coarctation of aorta • Renal disease The Peer Teaching Society is not liable for false or misleading information…

  19. Hypertension-clinical presentation • Usually asymptomatic but rule out secondary causes. • Take a full DH • Ever get headaches, palpitations, sweating episodes? • FH kidney disease? Palpable kidneys? • Cushingoid appearance? • Consider their lifestyle and contributing factors: salt, obesity, lack of exercise, CV risk factors The Peer Teaching Society is not liable for false or misleading information…

  20. Hypertension-Investigations • End organ damage: urine dipstick, serum creatinine and eGFR, 12 lead ECG, echo • CV disease prevention: fasting blood glucose and serum lipids • Secondary causes: renin/aldosterone ratio, 24hr urinary metanephrines, MRI renal arteries etc The Peer Teaching Society is not liable for false or misleading information…

  21. Hypertension-Management • Lifestyle interventions-lose weight, reduce salt, encourage exercise, stop smoking The Peer Teaching Society is not liable for false or misleading information…

  22. Stable angina-aetiology • Smoking • Diabetes • Obesity • Sedentary lifestyle • Metabolic syndrome The Peer Teaching Society is not liable for false or misleading information…

  23. Stable angina-Clinical presentation • 3 factors: • 1. constricting pain in chest, may radiate to back, shoulders or neck • 2. exercise is the precipitant • 3. relieved by rest or GTN spray • Typical, atypical and non-anginal pain • If prolonged, worse on inspiration, not related to exercise etc then not likely to be angina The Peer Teaching Society is not liable for false or misleading information…

  24. Stable angina-Investigations • 12 lead ECG • FBC? • TFT • Cardiac enzymes • Echo • Diagnosis is clinical The Peer Teaching Society is not liable for false or misleading information…

  25. Stable angina-Management (NICE) • 1st line-BB or CCB • If symptoms do not improve then use both or if one is contraindicated then add in a long acting nitrate, nicorandil or ivabradine. • Only add a 3rd anti angina drug if symptoms still not adequately controlled • Also all patients should be on aspirin and statins The Peer Teaching Society is not liable for false or misleading information…

  26. Unstable Angina • Definition: angina of increasing frequency or severity; occurs on minimal exertion or at rest; associated with increased risk of MI. The Peer Teaching Society is not liable for false or misleading information…

  27. Unstable Angina- Management • Conservative: Modify risk factors, i.e. Stop smoking, exercise, weight loss and control hypertension and DM. • Medical: Aspirin, beta-blockers, Ca2+ channel blockers, GTN for symptomatic relief. • Surgical: Percutaneous transluminal coronary angioplasty (PTCA) involves balloon dilatation of the stenotic vessel(s). Indications: poor response to medical treatment or not suitable for CABG etc. The Peer Teaching Society is not liable for false or misleading information…

  28. Acute Coronary Syndromes • Includes: • Unstable Angina • STEMI (i.e. acute MI) • NSTEMI The Peer Teaching Society is not liable for false or misleading information…

  29. ACS Risk Factors: • Non-modifiable: • Age • Gender • Family history • Modifiable: • Smoking • Hypertension • DM • Hyperlipidaemia • Obesity • Sedentary life-style Controversial Risk factors: stress, type A personality, hyperinsulinaemia, ACE genotype, etc. The Peer Teaching Society is not liable for false or misleading information…

  30. ACS • Incidence 5/1000 per annum (UK) for ST-segment elevation (declining in UK) • Several diagnostic criteria exist. Most common one is a symptomatic patient + initially increasing and then decreasing cardiac biomarkers as well as ECG changes etc. The Peer Teaching Society is not liable for false or misleading information…

  31. ACS- Signs and Symptoms • Signs: Distress, anxiety, pallor, sweatiness, pulse increased or decreased, BP high or low, 4th heart sound. There may be signs of heart failure (raised JVP, 3rd heart sound, basal crepitation) or a pansystolic murmur (papillary muscle dysfunction/rupture, VSD). Low-grade fever may be present. Later, a pericardial friction rub or peripheral oedema may develop. • Symptoms: • Acute central chest pain, lasting >20min, which radiates to left side of the jaw and left arm, often associated with nausea, sweatiness, dyspnoea, palpitations. • BUT, BE CAREFUL!!!! May present without chest pain specially in the very elderly or diabetics. The Peer Teaching Society is not liable for false or misleading information…

  32. Management of Acute MI • MONA • Attach ECG monitor and record a 12-lead ECG • IV access and Bloods incl. FBC, U&Es, Glucose and specially Cardiac enzymes.Cardiac troponin levels (T and I) are the most sensitive and specific markers of myocardial necrosis. Serum levels increase within 3–12h from the on- set of chest pain, peak at 24–48h, and decrease to baseline over 5–14 days. • B-blockers • Primary PCI or thrombolysis (Streptokinase or Alteplase) The Peer Teaching Society is not liable for false or misleading information…

  33. Long term management • Start Regular Aspirin, B-blocker, ACE-I, Statin and address the modifiable risk factors. • Review regularly- VERY IMPORTANT!!! • Complications can be devastating…. • Examples include: • Cardiac arrest • Pericarditis • Cardiac tamponade • Heart failure The Peer Teaching Society is not liable for false or misleading information…

  34. Heart failure Definition: Cardiac output is inadequate to meet body’s metabolic demands. The Peer Teaching Society is not liable for false or misleading information…

  35. HF- Basic concepts • Different ways of classifying it such as systolic vs diastolic, acute vs chronic, low-output vs high out-put but the most common is LEFT sided vs RIGHT sided heart failure. • Prevalence is 1-3% of general population and prognosis is not great. If hospital admission is required there is a 5yr mortality of 75%. The Peer Teaching Society is not liable for false or misleading information…

  36. Left Vs Right • May occur independently or together as CCF. Right sided heart failure: Left sided heart failure: Symptoms: Symptoms: Peripheral oedema (up to thighs, sacrum, abdominal wall), ascites, nausea, anorexia, facial engorgement, pulsation in neck and face (tricuspid regurgitation) Causes: LVF, pulmonary stenosis, lung disease. (cor pulmonale) Dyspnea, poor exercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea (PND), nocturnal cough (±pink frothy sputum), wheeze (cardiac ‘asthma’), nocturia, cold peripheries, weight loss, muscle wasting. The Peer Teaching Society is not liable for false or misleading information…

  37. Signs: • Diagnosis can be made using Framingham criteria (see BOX).65 Other signs: exhaustion, cool peripheries, cyanosis, High BP, narrow pulse pressure, pulsus alternans, displaced apex (LV dilatation), RV heave (pulmonary hypertension), murmurs of mitral or aortic valve disease, wheeze. The Peer Teaching Society is not liable for false or misleading information…

  38. Diagnostic Criteria: • Don’t forget BNP!!! The Peer Teaching Society is not liable for false or misleading information…

  39. Management: • Once again, conservative, medical and surgical interventions to offer. • Treat the underlying cause such as vacuities, hypertension and cardiomyopathy • Medical treatment (Next slide). • Surgical interventions such as valve replacement etc. The Peer Teaching Society is not liable for false or misleading information…

  40. Medical management • Medications are divided into ones that improve prognosis and ones that help with the symptoms. • What medications are given to people with HF? • Diuretics (Furosemide +/- Spironolactone) • ACE-i (if intolerant because of side effects for example use Vasodilators) • B-blockers • Digoxin • Aspirin The Peer Teaching Society is not liable for false or misleading information…

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