More acute cardiology

Transcription

1 Case 1 RC 86, Male More acute cardiology Dr John Chambers Consultant Cardiologist A&E: SOB at rest. No chest pain. Exertional SOB for 6/12. PMHx: HT Rx: Ramipril 5mg od Examination: Afebrile, HR = 105, RR=27, BP 158/86, SaO 2 =86%, bibasal crackles, loud ESM aortic area. Bloods: Troponin=0.08 (ULN 0.04). Others normal Diagnosis? Acute coronary syndrome Valvular heart disease Hypertensive heart disease Cardiomyopathy eg HCM Non-cardiac 86 yrs old, pulmonary oedema, loud ESM, ischaemic ECG, raised troponin Acute management What will you give him at 2am? Aspirin, Clopidogrel, Enoxaparin? Frusemide? GTN infusion? Ramipril continue or stop? Spironolactone? Metoprolol? Anything else?

2 Vasodilators are contraindicated in aortic stenosis ACE ARB ISMN Hydralazine Nitroprusside SVR, BP Cardiac output 25 patients with severe AS and heart failure IV nitroprusside on ITU No placebo group Angiotensin trials Shavelle. Heart 2005 Vasodilators in Aortic stenosis Acute management Vasodilator therapy in heart failure due to aortic stenosis can be safe and improve cardiac performance Consider using, but very cautiously CCU / ITU only Start low Monitor BP and clinical state very closely Seek advice What would I give him at 2am? Aspirin, Clopidogrel, Enoxaparin Frusemide GTN infusion Ramipril Spironolactone Metoprolol YES YES Maybe YES No Not yet

3 Diagnosis? Echo Acute coronary syndrome Hypertensive heart disease Valvular heart disease Cardiomyopathy eg HCM Tests: coronary angiogram and Echo Aortic stenosis - outcomes Medical Rx: 90% 2 year mortality Surgical mortality predictable from comorbidities **Age Gender Coronary disease Renal disease Heart failure Etc Typical risk age 80+: >20% What s HOT! 358 people with critical AS Unsuitable for AVR, Mean age 82yrs Randomised TAVI vs Medical Rx

4 Results Case 2 Survival Function 61 year old lady with 3 month history SOB Very breathless last 48 hours No relevant PMH; obese Sinus tachycardia; BP 95/60; SaO 2 96%, normal heart sounds and clear chest; JVP probably elevated; Urea 13, creatinine 146, WC 9.6, CRP 32 Differential diagnosis Poor LV function Valvular heart disease Pulmonary embolus Chronic severe PHT Pericardial effusion Acute management What will you give her at 2am? Enoxaparin? Frusemide? IV fluids? GTN infusion? Spironolactone? Metoprolol? Anything else? Diagnosis? Poor LV function Valvular heart disease Pulmonary embolus Chronic severe PHT Pericardial effusion Tests: ECG, Echo and CT

5 ECGs Right heart pathology Left heart pathology Pericardial pathology

6 Pericardial effusion Our patient what is this, what will you do? Suspect in patient with history malignancy,tb, ESRD, cardiac trauma, recent complex EP procedure, CABG or PPM, hypothyroidism, CT disorders Rate of accumulation of fluid more important than size of effusion Emergency pericardial drain associated with high mortality (25%) in inexperienced hands so refer to cardiologist and only drain out of hours if clear signs of tamponade What s HOT? > 100,000 ~ 5,000 Emergency echo Pericardial effusion Pulseless electrical activity Severe LV dysfunction Vegetations Right heart pathology Case 3 SM 42yrs, Female A&E: confused + poor speech ODQ: Intermittent pain in left flank last 1/12 PMHx: Nil Rx: codydramol, voltarol T=37.8C, HR 87, BP110/70. MMTS 3/10,?expressive dysphasia Systolic murmur (?PSM) Nothing else abnormal found Immediate investigations CXR - Normal ECG Normal FBC: WC 13.2, Hb 10.6, MCV 80, PLT 544 U&Es: Normal CRP: 78 Urinalysis: +1 protein, +2 blood, nil else

7 Initial diagnoses / management Diagnosis UTI? Cerebrovascular event Rx: CT Brain: Amoxycillin Normal Progress: Confusion / speech recovered. CRP 41. T=37.5 Home for OP echo, carotid doppler Good grief! MSU: Not done Blood cultures: Not done Abdo / spine imaging: Not done MRI Brain Not done Neuro review: Not done Cardiology review: Not done Echo / carotids as an outpatient?! What next? 2 weeks later, back in A&E Feeling unwell New rash on palms Ongoing flank pain Husband thinks intermittently confused CRP: 64 Sent home: Has medical OPA due soon (2 weeks) GP to refer to dermatology What next - part 2 3 weeks later general medical clinic Sees SpR, no consultant discussion Feeling unwell, rash on palms, flank pain, intermittent confusion PSM present. Echo / carotids: Not done (!) Sent home (!!) for oupatient: Bloods: the usual + CRP + AutoAbs Echo / carotids CT abdomen Emerging results Bloods WC = 13.4, Hb = 9.2, CRP=89 Na = 125 AutoAbs: CT abdomen: Echo / carotids: Negative Splenic infarct Appointments in ~6 weeks What next part 3 2 weeks later A&E Confused, cant talk (expressive aphasia) Inflammatory markers raised PSM present Haematuria present Finally, the penny drops.. No action taken!!!!

8 Additional results / progress Blood cultures: MR brain: Strep viridans MCA territory infarct Neuro, cardio, cardiothoracic MDT Try to treat with Abs initially, Markers don t settle Emergency MVR Does really well Home, partial resolution of neurologic deficit Learning points Fever + murmur: consider SBE Cultures, Urinalysis, ECG and Echo = mandatory When to get an urgent echo Persistent fever Embolic phenomena ECG abnormalities Heart failure Haematuria +ve cultures Beware out-patient strategies: out of sight = out of mind Get results, act on results