CVS Unit Interactive Revision

Cardiology Clinic

Interactive Revision

Outpatient Cardiology Clinic

In this interactive session, you are a final year medical student on their Cardiology rotation. You are attached to the outpatient Cardiology clinic. You have been asked to see some of the patients from the clinic list independantly and to present your findings after review.

You double check the list before calling in your first patient...

Mr John Zenon

• An 85-year-old man presenting with fatigue and episodes during which he feels he is going to pass out. He has no known heart disease. 

• An ECG was requested and the nurse attached this to his file.

Interpret this ECG...

Multiple Choice

What does the ECG demonstrate?

• Atrial fibrillation

• Normal sinus rhythm

• Sinus bradycardia

• First degree heart block

Sinus bradycardia

• HR <50/60bpm, even if transient

• Sinus node dysfunction or conduction system disease

• Causes - intrinsic sinus node, AV nodal, and His-Purkinje disease, or extrinsic influences

• Symptoms - syncope, fatigue, and dizziness

• Complications - cardiovascular collapse and death

Atropine

Muscarinic antagonist

Increases ventricular rate

Used in severe bradycardia or heart block

Mr Dennis Kyalo

• A 78-year-old man with a history of hypertension presents to his primary care physician with 1 episode of dizziness while watching television. On physical examination, his heart rate is measured at about 40 bpm.

• A 12-lead ECG is obtained.

Interpret this ECG...

Multiple Choice

What does the ECG demonstrate?

• Sinus bradycardia

• Atrial fibrillation

• 2:1 heart block

• Complete heart block

Complete heart block

• Impaired (delayed or absent) conduction from the atria to the ventricles

• Causes -  fibrosis and calcification of the conduction system, CAD, and medication

• Symptoms - syncope/pre-syncope, fatigue, dyspnoea

• Permanent pacing improves survival in patients with third-degree AV block, especially if syncope has occurred

Open Ended

Can you name a drug that can cause heart block?

Side effects may include...

• beta-blocker - glucagon

• calcium channel blocker - calcium chloride

• digoxin - digibind (digoxin immune Fab)

Mrs Sara Valerio

• A 30-year-old woman complaining of recurrent palpitations during exercise. She had previously been healthy and was on no medications. She described a long history of 'skipped heart beats'.

• She attends the clinic for a treadmill exercise test, which demonstrated good effort tolerance and no evidence of ischaemia.

• Mrs Opoku then collapses in the recovery area and the emergency alarm is pulled.

An ECG monitor is attached...

Multiple Choice

What does the ECG demonstrate?

• Pulseless electrical activity (PEA)

• Ventricular fibrillation

• Ventricular tachycardia

• Torsades de pointes

VT (Monophasic)

• Ventricular rhythm faster than 100 bpm

• Causes - ischaemic heart disease, structural heart disease, idiopathic

• RVOT tachycardia - stress, exercise, catecholamine excess

• Symptoms - tachycardia, hypotension, syncope, airway compromise

• Complications - VF, sudden cardiac death

Multiple Select

What are the shockable rhythms? (Select all)

• Asystole

• Pulsesless electrical activity

• Pulseless ventricular tachycardia

• Ventricular fibrillation

• Ventricular tachycardia

Mr Juan Doe

• A 35-year-old man previously presented to accident and emergency department with palpitations, shortness of breath, dizziness, and chest pain of 4 hours' duration.

• His symptoms self-resolved and he was referred to the Cardiology clinic for further assessment.

Multiple Choice

What does the ECG demonstrate?

• NSTEMI

• Right bundle branch block

• Atrioventricular Reentry Tachycardia

• Wolff-Parkinson-White Syndrome

Wolff-Parkinson-White Syndrome

• Accessory pathway from the atrium to the ipsilateral ventricle across the mitral or tricuspid annulus - pre-excite the ventricle

• Causes - Defect in the atrioventricular (AV) electrical insulation 

• Symptoms - palpitations, dizziness, SOB, chest pain

• Complications - sudden cardiac death

Valsalva Maneuver

Increase vagal tone

Increase intrathoracic pressure

Reduce preload

Reduce heart rate

Diagnose pre-excitation

Can be used to terminate SVT

Mr Horacio Lopez-Garcia

• A 50-year-old man presents to the emergency department and referred to cardiology clinic with worsening left-sided chest pain for 2 days. The pain is worse on taking a deep breath. He describes shortness of breath due to the pain. His examination is unremarkable except for tenderness on palpation of the left fourth and fifth costochondral joints.

Open Ended

What is the most common condition in patients presenting with chest pain to the emergency department?

Costochondritis

• Inflammation of ≥1 costal cartilages

• Causes - idiopathic, repetitive microtrauma, infective

• Symptoms - Insidious onset of anterior chest-wall pain exacerbated by certain movements of the chest and deep inspiration

• Treatment - NSAIDS (+PPI), surgical drainage or debridement

Multiple Choice

Which rib articulates with the sternal angle/manubriosternal joint?

• I

• II

• III

• IV

Intercostal Neurovascular bundle

• Found between layers of intercostal muscle

• Lies immediately at the lower border each rib

• In order of vein, artery, nerve (Mneumonic - VAN)

Open Ended

Can you think of any clinical reasons why knowing the location of intercostal neurovascular bundle is important?

Intercostal nerve block

Indicated in analgesia for chest trauma, thoracotomy, mastectomy, upper abdominal surgical procedure.

Needle insertion above rib to avoid damage to neurovascular bundle

References

• https://cdn.pixabay.com/photo/2016/11/06/10/35/hospital-1802679_1280.jpg

• https://upload.wikimedia.org/wikipedia/commons/thumb/e/e2/GNU_Health_patient_tree_view.png/800px-GNU_Health_patient_tree_view.png

• https://litfl.com/wp-content/uploads/2018/08/ECG-Sin-us-bradycardia-768x302.jpg

• https://litfl.com/wp-content/uploads/2018/08/ECG-Strip-II-CHB-Complete-heart-block-768x379.jpg

References

• https://litfl.com/pre-excitation-syndromes-ecg-library/

• https://upload.wikimedia.org/wikipedia/commons/7/73/Costal_cartilages_frontal.png

• https://www.resus.org.uk/sites/default/files/inline-images/G2015_Adult_ALS.jpg

• https://litfl.com/wp-content/uploads/2018/08/ECG-RVOT-VT-LBBB-Inferior-axis-2-768x424.jpg

• https://commons.wikimedia.org/wiki/File:Endothoracic_fascia.svg