Overview of

Cardiovascular
System
CVS
Common presentations

● Chest pain SOCRATES!

● Palpitations
Differentials
● Dyspnoea ● Cardiac
● Orthopnoea ● Lung
● Paroxysmal nocturnal dyspnoea ● GI
● Oedema ● Musculoskeletal
● Dizziness/syncope ● Mental health
● Functional
Heart Peripheral vessels
Endocardium Pressure
● Infective endocarditis ● Hypertension
● Rheumatic heart disease

Myocardium Narrowing/blockage
● Myocarditis ● Peripheral vascular disease
● Ischaemic heart disease
● Heart failure Aneurysm
● AAA
Pericardium
● Pericarditis Dissection
● Aortic dissection
Conducting pathways
● Arrhythmias

Valves
● Valvular heart diseases
Ischaemic heart disease
Prevention of CVD
● Lifestyle modification
○ Cardioprotective diet- ↓ saturated fat, ↓ cholesterol
○ Physical activity
○ Weight control
○ ↓ alcohol
○ X smoking

● Pharmacological
Stable angina Investigations

No previously 64-slice CT coronary

Pathophysiology confirmed CAD angiography
● Atherosclerosis of coronary arteries
Previously Non-invasive functional testing
confirmed CAD Exercise ECG
Features
● Constricting discomfort in the front of
chest/neck/shoulder/jaws/arm Management
● Precipitated by exertion
● Acute Short-acting nitrate e.g. GTN
Relieved by rest/GTN within ~5min
Long term 1st line- BB or CCB
3/3 - typical angina Long-acting nitrate
2/3 - atypical angina Ivabradine
Nicorandil
1/3 - non-anginal chest pain Ranolazine
Lifestyle management
Acute coronary syndrome
Unstable angina NSTEMI STEMI

Pathophysiology Plaque rupture leads to thrombus formation

Partial occlusion- Partial occlusion- Total occlusion-

ischaemia subendocardial infarction transmural infarction

Features Chest pain occurs at rest, lasting >15-20min, not relieved with rest/GTN
+/- nausea, diaphoresis, SOB, palpitations

ECG changes Non-specific ST ST depression ST elevation

segment and T wave T waves inversion
changes

Cardiac markers Normal Raised Raised

Investigations
Management- STEMI
AB CDE
M O N A C/T/P
Management- NSTEMI/unstable angina
AB CDE
MONA
Fondaparinux
Management- secondary prevention
Dual antiplatelet therapy
What if the pt also needs to take
● Aspirin 75mg- continue indefinitely anticoagulant?
● 2nd antiplatelet- continue what is taken in acute stage ● If PCI not done- aspirin, 12m
● If PCI done- clopidogrel, 12m
ACEI
● Continue indefinitely
DVLA!
BB
Group 1 Group 2
● At least 12m, continue indefinitely if reduced LVEF
No need to inform Must inform
Statin PCI successful Stop at least
- stop 1w 6w
PCI not
done/unsuccessful
- stop 4w
Complications of MI
Complications of MI
Arrhythmias
 SA node
● Sinus tachycardia
Conduction pathway ●
●
Sinus bradycardia
Sick sinus syndrome

Atrium
● SVT
● Atrial fibrillation
● Atrial flutter

AV node
● 1st degree AV block
● 2nd degree AV block-
Mobitz Type I, Type II
● 3rd degree AV block

Bundle of His, Purkinje fibres

● LBBB
● RBBB

Ventricle
● VT, Torsades de Pointes
● VF
General principles
Tachycardia ABCDE Bradycardia

Unstable features Atropine

Synchronized DC ● Shock
Yes Yes Transcutaneous pacing
shock ● Syncope Transvenous pacing
● Myocardial ischaemia
● Heart failure

No No

Manage accordingly
● SVT- vagal manoeuvres, adenosine Rule out risk of asystole
● AF- rate/rhythm control Observe
● VT- amiodarone
● Torsades de Pointes- magnesium sulphate
Recognize these ECGs
Cardiac arrest

1. Call for help

2. CPR 30:2
3. Attach defibrillator- assess rhythm
○ Shockable- deliver 1 shock,
resume CPR
○ Non-shockable- resume CPR

Remember reversible causes 4H and 4T

 Investigations
Atrial fibrillation
Bedside Bloods Imaging

Causes ECG FBC CXR

BP U&E Echocardiogram
Cardiac TFT
● IHD
● HTN
● Heart failure Management
● Valvular heart disease
Rate control
Non-cardiac ● BB
● Hyperthyroidism ● CCB
● Caffeine ● Digoxin*
● Alcohol
Rhythm control
● Electrolyte imbalance ● Amiodarone
● Flecainide*
● DC cardioversion

Anticoagulation
 Chronic AF
Management
Rate control Rhythm control
Acute AF

1st line 1st line when

Unstable Stable
● New onset AF
● Reversible cause
If not controlled, consider ● Heart failure caused by AF
● Combine 2 drugs ● Atrial flutter suitable for
DC ● Rhythm control ablation
cardioversion ● Rhythm control more suitable
Ablation
Persistent AF
Onset <48h Onset >48h Paroxysmal AF

Rate👌 Rate👌 Long term drug/

Rhythm👌 Rhythm👌(but need Duration <48h Duration >48h Pill-in-pocket
3w of anticoagulation strategy
first, with rate control
Treat as Anticoagulated- DC cardioversion
during this period)
acute Not anticoagulated- TOE-guided
cardioversion/anticoagulate for 3/52
before DC cardioversion
Management- stroke prevention
Assess stroke risk- CHA2DS2-VASc score
● Offer oral anticoagulation when- ≥1 (male), ≥2 (female)
● 1st line DOAC

Assess bleeding risk- ORBIT score

Heart failure
Classification of heart failure
SYMPTOMATIC SEVERITY
CAUSES OF HF
● MYOCARDIAL DISEASE : CAD, HTN, Cardiomyopathies
● VHD
● Pericardial : constrictive pericarditis, pericardial effusion
● Congential
● Arrhythmias
● High output status : anemia, thyrotoxicosis, septiciemia, liver failure, pagets, vit B12
def
● Volume overload : end stage CKD, nephrotic syndrome
● Obesity
● Drugs, alcohol, cocaine, NSAIDs, BB, CCB
Think backwards…

Right heart failure Left heart failure

Portal/ systemic manifestations Pulmonary manifestations

1. Hepatosplenomegaly
2. Raised JVP
3. Peripheral edema
4. Ascites
 Right heart failure Left heart failure

Portal/ systemic manifestations Pulmonary manifestations

1. Hepatosplenomegaly 1. 3rd heart sound

2. Raised JVP 2. Cough with pink, frothy sputum
3. Peripheral edema 3. Cardiogenic wheeze
4. Ascites 4. Bibasal crackles
5. Dyspnea
Valvular heart
disease
Valvular heart disease
Quick summary
Systolic murmur Diastolic murmur

1. Aortic stenosis 1. Aortic regurgitation

2. Aortic sclerosis 2. Mitral stenosis
3. Mitral regurgitation 3. Tricuspid stenosis
4. Mitral valve prolapse 4. Pulmonary regurgitation
5. Ventricular septal defect (VSD)
6. Tricuspid regurgitation
7. Pulmonary stenosis
References

NICE guidelines
Resus Council UK
Life in the Fastlane ECG
OSCEStop