SEMINAR GROUP 5

CARDIOVASCULAR

Presenter:
Izzat Hafizudin 1120529
Nadia Amilin 1120506
Aliya Shukri 1120498
Farah Liyana 1120515
Aimi Nazihah 1120508

Lecturer : Dr Hilmi Lockman

SCENARIO
A 50 year old gentleman complained of chest pain for one day and leg swelling for
one month.
CHEST PAIN
Cardiovascular  Acute coronary syndrome, pericarditis

Respiratory  Pulmonary embolism, pneumothorax

Gastrointestinal  Reflux oesophagitis

Vascular  Aortic dissection

HISTORY TAKING FOR CHEST PAIN
1. When did the chest pain start?
Why: to determine acute or chronic.
Acute  MI, pulmonary embolism, pneumothorax, pericarditis.
Chronic  angina and oesophagitis.

2. Is the chest pain constant or intermittent?

Why: Constant pain suggest MI, dissecting aneurysm and pneumonia.
Intermittent pain suggest angina.

3. Where exactly is the chest pain?

Why: MI and angina is typically behind the sternum.
HISTORY TAKING FOR CHEST PAIN
4. Does the pain travel anywhere else?
Why: MI and angina may radiate to neck, jaw and down left side of
arm. Esophageal pain may radiate to throat or back. Dissecting
aneurysm may radiate between the scapula, abdomen or legs.

5. Can you describe the nature of the chest pain?

Why: MI may be described as heavy and crushing. Esophageal pain is
usually burning, dissecting aneurysm is tearing.

6. What makes the pain better?

Why: if the pain relieved by antacid considered esophagitis. If relieved
by gylceryl trinitrate or rest suggest angina. Pericarditis improves on
leaning foward.
HISTORY TAKING FOR CHEST PAIN
7. What makes the pain worse?
Why: if the pain precipitated or increased by breathing consider
pneumothorax ; if aggravated by movement suggest pericarditis;
if the pain precipitated by activity suspect angina; prepicitated by
certains foods can consider esophageal reflux.

8. Any trauma to chest or back?

 HISTORY TAKING FOR CHEST PAIN

9. Associated symptoms
Coughing up blood? Why: consider pulmonary embolism
Fever and pus like sputum? Why: should consider pneumonia
Shortness of breath?Why: consider pneumothorax, pulmonary embolism, pneumonia congestive
heart failure due to MI
Acid or bitter taste in mouth?Why: may suggest reflux esophagitis

10. Past medical history : DM, HPT, obesity, high cholestrol, heart surgery.

11. Family history

12. Symptoms of anxiety ( palpitation, shortness of breath, rapid breathing, tremor)
LEG EDEMA
Heart failure

Liver cirrhosis

Chronic renal failure

Deep vein thrombosis

Nephrotic syndrome

Hypothyroidism
 HISTORY TAKING FOR LEG EDEMA

1. How long have you had the leg swelling?

Why: to determine if acute or chronic

2. Is it unilateral or bilateral?
Why: unilateral  DVT

3. Are there other areas of the body that are swollen?

HISTORY TAKING FOR LEG EDEMA
4. Are you pregnant?

5. Associated symptoms
Sx of cardiac failure? SOB, bilateral ankle swelling etc.
Sx of dvt? Diffuse leg swelling, leg warmth, ankle pitting edema
Sx of hypothyroidism? Cold intolerance, weight gain, constipation, non
pitting lower limb swelling.
HISTORY TAKING FOR LEG EDEMA
6. Past medical hx?
Why: cardiac failure, liver cirrhosis, renal disease, hypothyroidism.

7. Medications?
Why: NSAID, calcium channel blocker, progesterone, estrogen.

8. Alcohol history?
Why: risk of liver cirrhosis

9. Risk factor for DVT?

Why: prolonged bed rest, period of immobility, CHF.
PHYSICAL EXAMINATION
General examination
 Altered mental status
 Body habitus
 Pallor
 Jaundice
 Scratch marks due to pruritus
 Clubbing
 Splinter haemorrhage
 Cyanosis
 Vital signs

Cardiovascular system examination

 Raised JVP
 Cardiomegaly
 Heaves and thrills
 3rd and 4th heart sound
 Murmurs
 Pleural rub
Respiratory system examination
 Tachypnoeic
 Bibasal crepitation
 Pleural effusion

Abdominal examination
 Abdominal distension and ascites
 Tender hepatomegaly
 Bilateral ankle oedema
 INVESTIGATION

Electrocardiogram (ECG)
Cardiac biomarkers
Other blood investigations
Chest x-ray
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 1. ECG

To differentiate between STEMI and NSTEMI

Features that suggesting for unstable angina or NSTEMI are :
- ST depression (more than/equal to 0.5mm in 2 or more contagious lead)
- T inversion
Need to review with cardiac biomarkers to distinguish with unstable angina
Serial ECG should be done as ST changes my evolve
Features that suggesting for STEMI are :
- ST elevation (>1mm in 2 contagious lead)
- New LBBB
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ECG PATTERNS OF VARIOUS STEMI LOCATIONS

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 Use ECG to rule out pericarditis.
Features :
- Widespread concave ST elevation and PR depression throughout
most of the limb leads (I, II, III, aVL, aVF) and precordial leads
(V2-6).
- Reciprocal ST depression and PR elevation in lead aVR.

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 Use ECG to rule out pulmonary embolism.
Features : (S1Q3T3 sign)
- Prominent S wave in lead I
- With Q wave and T wave inversion in lead III
- With inverted T waves in lead V1-V6.

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 2. CARDIAC BIOMARKERS

A) Cardiac Troponin (Troponin T or I)

Highly specific and sensitive for myocardial injury or necrosis.
May not elevated if done early (<6 hours), need to repeat test 6-12 hours
after.
May persist for 5-14 days.
B) Creatinine Kinase (CK-MB)
Less sensitive and specific but useful in diagnosed reinfarction.
C) Myoglobin
• Not specific but negative test within 4-8 hours of chest pain can rule out myocardial necrosis.

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 3. BLOOD INVESTIGATION

Full blood count

Renal profile
Random blood sugar
Coagulation profile
Lipid profile

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 4. CHEST X-RAY

Look for cardiomegaly, pulmonary oedema.

Widened mediastinum (to rule out aortic dissection)

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 ACS

MANAGEMENT
UNSTABLE ANGINA/NSTEMI
MANAGEMENT
1. RISK STRATIFICATION
For prognosis and management strategies.
Score commonly used for prognosis  TIMI Score

Low Risk:
<2
Moderate
Risk: 3-4
points
High Risk :
>5 points
MANAGEMENT BASED ON RISK STRATIFICATION:
2. MANAGEMENT
(ACUTE, IN-WARD, UPON DISCHARGE)
The goals of management are:
Immediate relief of ongoing ischemia and angina
Prevention of recurrent ischemia and angina
Prevention of serious adverse cardiac events
(I) ACUTE - ED
If history suggestive ACS

- Aspirin 300mg crushed

stat
- Sublingual GTN

ECG, cardiac
biomarkers

Suggestive Inconclusive
Low risk  outpatient
Clopidogrel 300 mg stat High risk  CCU/HDU with
continuous ECG monitoring
 (II) WARD

1. General measures
-Supplemental oxygen, keep SpO2 > 90%
-Pain relief  morphine (IV 2 mg to 5 mg) + anti-emetic
2. MEDICATION
Medications Examples

Anti-platelet • ASA (T. Aspirin)

- Loading dose: 300mg
- Maintenance: 75-150mg OD
• ADP receptor antagonist
(T. Clopidogrel)
- Loading dose: 300-600mg
- Maintenance: 75mg OD

Anti- • Clexane (enoxaparin) • Arixtra (fondaparinux)

coagulant - Initial 30 mg IV bolus - 2.5 mg s/c OD for 8 days or
- Then 15 minutes later by: duration of hospitalization
s/c 1.0 mg/kg BD if age < 75
years
s/c 0.75 mg/kg BD if age 75
years and above
Duration of therapy : 2-8 days

OR
 Anti ischemic • Nitrates • Ongoing chest pain  give
drug therapy - S/L GTN 0.5mg every 5 minutes for a total of
3 doses.
• If symptoms still persist  IV
GTN
• B-blocker

• Ca channel blocker

Lipid • Atorvastatin – 80 mg od
modifying • Simvastatin – 40 mg od
drug

ACE-I • Captopril
• Enalapril

3. Revascularization
 (III) UPON DISCHARGE

Important discharge instructions should include:

Education on medication
- medication on discharge (aspirin, clopidogrel, B- blocker, ACE-I,
Statin, + anti angina)
Patients given sublingual nitrates should be instructed in its proper and safe use.
Lifestyle change and CV risk factors modification
Scheduling of timely follow-up appointment and dates for further investigations
Referral to a cardiac rehabilitation program where appropriate
 STEMI
MANAGEMENT
INITIAL
• Secure ABC
• Sublingual GTN if chest pain persists (avoid if SBP < 90 mmHg).
• Continuous ECG monitoring.
• Aspirin 300mg chewed and swallowed.
• Clopidogrel 300 mg
• Alternatively, ticagrelor at a loading dose of 180 mg may be given
if primary PCI is being considered.
• Oxygen by nasal prongs/facemask if SpO2 is less than 95%.
• Set 2 IV line and blood taken for cardiac biomarkers,
full blood count, renal profile, glucose and lipid profile.
• Pain relief - morphine IV at 2-5 mg by slow bolus injection every 5-15 minutes as
necessary + anti-emetic (IV metoclopromide 10 mg and 8-hourly as needed)
• Intramuscular injections should be avoided.
• Assessment for reperfusion strategy.
All patient with chest pain
must get
R = Resus (Triage to resus
/red zone)
A = Aspirin 300mg crushed
H = Heart score
M = Morphine
A = Anti platelet
N = Nitrates
 REPERFUSSION STRATEGY
1. FIBRINOLYTIC THERAPY
2. PRIMARY PCI

*primary PCI is superior to fibrinolytic except for early presentation

*In majority of our hospitals, fibrinolytic therapy is more readily
available and constitutes the main reperfusion strategy.
Important considerations:
• Time from symptom onset to FMC.
• Time to PCI (time from hospital arrival to balloon dilatation
i.e. DBT).
• Time to hospital fibrinolysis (time from hospital arrival to
administration of fibrinolytic therapy i.e. DNT).
• Contraindications to fibrinolytic therapy.
• High risk patients
 Time from onset of symptoms to FMC
Early (within 3 Late presentation (3-12 hrs of Very late presentation
hrs of onset) onset) (> 12 hrs)

Both Persistent
reperfusion Asymptomatic ischaemic
strategies are Primary PCI is preferred and symptoms,
equally haemodynamic haemodynamic or
ally stable: electrical
effective instability:

PCI is more
If transferred
preferred when: If at PCI from a centre
capable with no PCI
• Fibrinolytic facility: facility:
therapy is Both
contraindicated DBT within 90 DBT < 2 hrs reperfusion not PCI is
• High-risk minutes including routinely preferred
patient transfer delay
recommended
• PCI time delay
(DBT-(minus)DNT
>60 minutes) If delay to PCI longer: fibrinolytic
& transfer to PCI capable centre
for pharmacoinvasive
 Contraindications in fibrinolytic therapy

Absolute Relative

Risk of Risk of
intracranial Risk of bleeding intracranial Risk of bleeding Others
haemorrhage haemorrhage

•Risk of intracranial Current use of

bleeding anticoagulant in
Severe uncontrolled
•History of ischemic Active bleeding or therapeutic dose Pregnancy
hypertension on
stroke within 3/12 bleeding diastheses (INR>2)
presentation (BP > Prior exposure
•Known structural (excluding menses) Recent major
180/110 mmHg) (>5 days and
cerebral vascular Significant head surgery <3/12
Ischaemic stroke > within 12 months
lesion (ex. AV trauma within 3/12 Traumatic or
3/12 of first usage) to
malformation) Suspected aortic prolongedCPR > 10
History of chronic, streptokinase (if
•Known intracranial dissection minutes
severe uncontrolled planning to use
neoplasm hypertension Recent internal
bleeding within same agent)
4/52
Non-compressible
vascular puncture
Active peptic ulcer
 Large
infarcts

Post-infarct Anterior
angina infarcts

High-
Post- risk
Hypotension
revasculariz patients and
ation (Post- cardiogenic
CABG and shock
post-PCI)

Elderly Significant
patients arryhthmias
1. FIBRINOLYTIC
Streptokinase Tenecteplase

Most widely used TNK-Tpa

Not fibrin specific agent
Single IV bolus:
1.5 mega unit in 100 ml normal saline 30 mg if < 60 kg
or 5% dextrose over 1 hour 35 mg if 60 to < 70 kg
40 mg if 70 to < 80 kg
45 mg if 80 to < 90 kg
50 mg if > 90 kg

*Heparin or enoxaparin should be given immediately after the completion of fibrinolysis

and needs to be given for 48 hours. Subcutaneous (SC) fondaparinux 2.5 mg daily may
be given as an alternative for 8 days or till discharge.
INDICATORS OF SUCCESSFUL REPERFUSION

Resolution of chest pain

Early return of ST segment elevation to isoelectric line or a
decrease in the height of the ST elevation by 50% (in the lead
that records the highest ST elevation) within 60-90 minutes of
initiation of fibrinolytic therapy
Early peaking of CK and CK-MB levels
Restoration and/or maintenance of haemodynamic and/or
electrical stability
FAILED FIBRINOLYSIS
Manifested as 1 or more of the following:
 continuing chest pain
 persistent ST segment elevation
 haemodynamic instability.

More likely to develop complications such as heart failure (HF) and

arrhythmias
Treatment  rescue PCI
 2. PCI
Primary PCI Facilitated PCI Rescue PCI

• Refer to a strategy of
• Preferred reperfusion planned immediate PCI • Rescue PCI may be
strategy in patients with (< 1 hour) after an considered in patients
ischaemic symptoms initial pharmacologic who have failed
< 12 hours when it can regimen - fibrinolytic fibrinolytic therapy or
be performed in; agent - have recurrent chest
• A timely manner glycoprotein (Gp) pain and/or ischaemic
• By experienced IIb/IIIa inhibitor complications
operators - or a combination of
these
• In centres performing
a sufficient number of
primary PCI • The purpose 
procedures to achieve earlier
reperfusion but retain
the benefits of primary
PCI
• However, it is
associated with higher
mortality and bleeding
rates. It is therefore not
recommended
 CONCOMITANT THERAPY
I. Oxygen Therapy
In the presence of hypoxaemia (spo2 < 95%)
Within the first 6 hours
II. Antiplatelet Agents
ASPIRIN CLOPIDOGREL TICAGRELOR PRASUGREL

• All patients unless • In patients less than • Loading dose is 180 • Particularly diabetics.
contra indicated 75 years of age mg • Loading dose is 60
• Initial dose of 100- given fibrinolysis • Maintenance dose is mg
300 mg  loading dose of 90 mg bd. • Maintenance dose is
• Maintenance dose : 300 mg • Short acting 10 mg/day.
75 – 150 mg daily.  maintenance  In patients who may
dose of 75 mg daily need surgery without
increasing the risk of
• In patients bleeding.
considered for
primary PCI
 dose of 300-600
mg
III. Antithrombotic Therapy

UFH
LMWH – enoxaparin
Anti Xa inhibitor – fondaparinux
Gp IIb/IIIa inhibitors
In patients > 75 years of age and with
renal impairment
In patients treated medically to reduce
reinfarction without increasing bleeding
In the setting of primary or emergency PCI

IV. B- blocker
• Use oral ß-blockers in all stable patients without specific contraindication
V. ACE-I and ARB
 ACE-I (within 24 hours) following STEMI
 Started when BP is stable and SBP remains above 100 mmHga.nd SBP remains above
100 mmHg.
 Contraindication to ACE-I and ARB therapy:
 SBP < 100 mmHg.
 Established contraindications e.g. bilateral renal artery stenosis.

VI. Nitrates
 In patient with
 Continuing chest pain and / or ischaemia.
 HF
 Hypertension.

VII. Calcium channel blockers

 Adjunctive therapy in patients with hypertension who cannot tolerate ß-blockers
 Avoided in patients with LV dysfunction and pulmonary congestion
HEART FAILURE
MANAGEMENT
Oxygen - Aim to achieve oxygen saturation of more than 95% in order to maximize tissue
oxygenation and to prevent end organ dysfunction or multi organ failure.
Frusemide – Intravenous frusemide 40 - 100mg or infusion 5-20mg/hour
Nitrates - If the BP is adequate (SBP > 100 mmHg), IV nitrates hould be considered and
closely monitored for hypotension. This commonly occurs with concomitant diuretic therapy.
 Nitroglycerin Infusion 5 – 200mcg/min
 Isosorbide dinitrate Infusion 1 – 10mg/hr
 Nitroprusside Infusion 0.1 – 5mcg/kg/min

Morphine sulphate - IV 1- 3 mg bolus (repeated if necessary, up to a maximum of 10mg). It

reduces pulmonary venous congestion as well as reduces anxiety and is most useful in
patients who are dyspnoeic and restless. Intravenous anti-emetics (metoclopramide 10mg or
prochlorperazine 12.5mg) should be administered concomitantly.
Sympathomimetics
 Dobutamine Infusion 2 – 20mcg/kg/min
 Dopamine Infusion <2 – 3mcg/kg/min - renal arterial vasodilation to promote
diuresis
2 – 5mcg/kg/min - inotropic doses
5 – 15mcg/kg/min - peripheral vasoconstriction
 Noradrenaline Infusion 0.02 – 1mcg/kg/min till desired blood
If the blood pressure is low at initial presentation (SBP <100mmHg) or drops during treatment :

Noradrenaline infusion
Dopamine infusion
Avoid vasodilators (nitrates, nitroprusside) and morphine until the blood pressure has stabilized
Correct over diuresis or hypovolaemia
In Right Ventricular (RV) Infarction, the hypotension may respond to volume loading.

Other Measures
Intubation and mechanical ventilation
Correction of acidosis
Invasive haemodynamic
Intra-aortic balloon counterpulsation (IABP)
Ventricular Assist Devices (VAD)
Monitor
 symptoms and signs
 vital signs
 - oxygen saturation
 - heart rate
 - blood pressure
 - respiratory rate
 - urine output
 - body weight

• Investigations
 - renal function tests
 - Serum potassium, sodium and magnesium
 - Invasive haemodynamic monitoring (if necessary)
 - pulmonary capillary wedge pressure, cardiac index
LONG TERM MANAGEMENT
Education
 Education and counseling about the heart failure syndrome, its signs and symptoms, its prognosis and drug
treatments
 Educate patients on their drug regime and the need for compliance. Stress on the potential befits and side
effects of the drugs
 Warn against self medication and the possible drug interactions

Diet & Nutrition

 Advice on weight reduction.
 Salt restriction diet
 Fluid restriction 1-1.5 liter/day if HF symptoms are still not well controlled with medications

Lifestyle
 Abstain from alcohol and smoking
 Patients with severe should be advised against pregnancy and have good contraception method
Exercise
 Dynamic exercise 3 to 5 times a week for 20 to 30 min

Sleep Disorders
 Treatment will include weight loss and CPAP in those with sleep apnoea

Social Support
 From family or support groups