1. Cardiology in a heartbeat
Your hosts: Malik ‘heart throb’ Fleet and
Thomas ‘heart ache’ McLeod

2. Objectives
 Be able to perform in a cardio related osce.
 Describe the key features and management
of:
 Atrial Fibrillation
 Acute Coronary Syndrome
 Answer SBAs related to this week’s teaching

3. Outline of session
 20 minutes OSCE and debrief
 40 minutes tutorial
 20 minutes SBAs
 Answer any questions

4. Notes from the OSCE scenario
 DR ABCDE: (Before ‘D’!)
 Ask examiner for observations
 Does patient meet PERT criteria? They
always do so call for help!
 (PERT criteria=

5. Notes from the OSCE scenario
 D - anger
 R - esponse
 A -irway
 B- reathing
 C - irculation
 D - isability (AVPU)
 E - xposure
LOOK
FEEL
LISTEN
MEASURE
TREAT

6. Notes from the OSCE scenario
 A - irway:
 Look
 Feel
 Listen
 Measure
 Treat
Often patient is breathing
so able to say airway is
patent. If not, suggest
ensuring airway e.g Guedel
airway

7. Notes from the OSCE scenario
 B- reathing
 Look: cyanosed? Trachea central? Chest expansion?
 Feel: symmetrical chest movement? Percussion?
 Listen: auscultate chest (ask examiner for findings)
 Measure:
 a. Resp rate
 B. O2 sats on air
 Treat:
 Give oxygen: high flow (e.g. 15L/min) - non
rebreathe mask (unless C/I e.g COPD)

8. Notes from the OSCE scenario
 C- irculation
 Look: cyanosed? General appearance? JVP? Pain?
 Feel: Peripheries- cool? Clammy?; Pulse
 Listen: heart sounds
 Measure:
 Heart rate
 Blood pressure
 Cap refill
 Urine output
 Temp.
 ECG
 Treat:
 IV access (“two wide bore cannulae”)
 Bloods (FBC/ U and E)
 Fluid Challenge
 (MONA if acute coronary syndrome)

9. Notes from the OSCE scenario
 D- isability: AVPU + BM
Patient responds to:
 A - lert
 V - oice
 P - ain
 U - nresponsive
 Ask examiner for BM

10. Notes from the OSCE scenario
 E- xposure:
 Expose patient from head to toe looking for
any other clue for deterioration.
 + “ending exam”: write notes, hand over to
team etc.

11. Notes from the OSCE scenario:
 8 Reversible causes of VT: The 4 ‘H’s and 4 T’s.
4 T’s:
T-hrombosis (coronary or
pulmonary)
T-amponade
T-oxins
T-ension pneumothorax
4 H’s:
H-ypoxia
H-ypovolaemia
H-ypo/er kalaemia (metabolic)
H-ypothermia

12. Notes from the OSCE scenario:
 2 shockable rhythms:
 Pulseless Ventricular Tachycardia
 Ventricular Fibrillation
 2 non shock:
 -Pulseless electrical activity
 -Asystole

13. Notes from the OSCE scenario:

14. Tutorial: Atrial Fibrillation

15. AF: Objectives
By the end of this session you should be able to:
 Identify how AF presents and establish an appropriate differential
 Suggest sensible investigations as relating to your differential
 Recognise and describe the classic ECG findings and the pathophysiology of AF.
 Classify AF as according to its pattern and amenability to cardioversion (‘the 3 P’s)
 Describe the management options in terms of Rate and Rhythm control and list
suitable examples of patients and medications accordingly.

16. Case: “Jo-Jo”

17. “Joe”
 Joe is a 45 year old professional clown.
 He has recently returned from a boozy working
holiday in Magaluf.
 He has the biggest performance of his career at the
Brent Cross circus tomorrow. He feels terribly
unprepared and begins to sweat when talking about it.
 He presents to you in A and E complaining of being
aware that his heart is doing ‘funny things’ and feels
short of breath.

18. Differential Diagnosis at this
stage?
 Anxiety induced palpitations (panic attack)
 Atrial Fibrillation
 (hyperthyroidism)

19. Examination
“irregularly irregular”*
*NICE recognise as very ‘sensitive’ sign for dx of AF. Regular radial pulse= 96% negative
predictive value.

20. Investigations:
 ECG: (Please present)
Joseph Jackson D.O.B: 16/3/ 1967

21. AF: ECG findings and
pathophysiology
 ECG findings:
 Absent p waves ~ no identifiable p waves throughout trace.
 Narrow QRS (AV conduction in tact)

22. AF: ECG findings and
pathophysiology
 Pathophysiology:

23. Diagnosis= AF. What are you
worried about?
 AF:
 Risk of: EMBOLISM STROKE
 Haemodynamic compromise

24. Other investigations:
+/-

25. Case development
 History: diagnosed with hypertension 10 years ago. Stopped taking ‘useless
tablets’ after 6 months. Father died at 60 from hypertensive heart
disease/failure.
 Ix:
 No echo done
 Bloods: TFTs: negative
Troponin: negative
 Joe begins to feel worse, his heart rate increases to 150 bpm and he has
slight pain. No ST elevation on ECG.

26. AF: Management: “The Blender”
 “Rate” or “Rhythm” Control

27. AF: Management: Acute Onset

If HAEMODYNAMIC INSTABILITY:
Non Life threatening:
-RATE (if major contributor to haemodynamic
instability):
-Beta Blocker / Ca Channel Blocker
-Amiodarone
-RHYTHM:
-PCV* (or ECV if available)
*Pharmacological Cardioversion:
I.V Amiodarone
-ANTICOAGULATION:
-start heparin
- commence oral warfarin depending on outcome
of CV/ onset of AF.
Life threatening:
-RHYTHM:
Emergency electrical cardioversion
-(Anticoagulation should not
delay intervention).

28. AF: Rhythm Control: Cardioversion
 Pharmacological Electrical
< 48 hours > 48 hours

29. AF: Rhythm: Cardioversion:
WARNING!
 AF = clot generator
 Normal rhythm (cardiac output restored)
 clots disseminated to brain etc.
CARDIOVERSION

30. AF: Rhythm: Cardioversion: VTE
prophylaxis
<48 hours
-Heparin
-PCV (or ECV)
-Confirm onset of AF:
-If definitely <48hours: no need for further
anticoagulation.
-If unsure: warfarin for 4 weeks
>48hours
a. ANTI COAGULATE (3 weeks)
or
b. TRANS OESOPHAGEAL ECHO (TOE)
-detects whether a thrombus is present or not.
-If not: heparin + cardioversion
-If present: warfarin for 3 weeks and repeat TOE.
* Continue warfarin for 4 weeks post
cardioversion

31. AF: Rhythm: Cardioversion: VTE
prophylaxis

32. AF: Rhythm: Cardioversion:
PHARMACOLOGICAL
<48 hours
 Flecainide Amiodarone
NO structural heart disease* YES structural heart disease*
(<8 hours) (>8 hours)
*Structural heart disease defined as: “coronary artery disease or LV dysfunction”

33. AF: Rhythm: Cardioversion:
ELECTRICAL
>48 hours
 ECV (= low grade shock to heart):
 1st line: > 48 hours
 If doubts over success (e.g. previous failure to cardiovert; early recurrence of AF):
 Give AMIODARONE or SOTALOL for 4 weeks prior to ECV.
 Improves rates of cardioversion

34. Atrial fibrillation: “3 p’s”
Classification
 Paroxysmal:
 Spontaneous self termination
 <7 days (often <48hours)
 Persistent:
 Lasts > 7 days
 NOT self terminating
 Permanent
 Does not terminate
 Not amenable to cardioversion
 (NOTE: can return to sinus rhythm if cure underlying pathology e.g.
hyperthyroidism)

35. AF: Management: Paroxysmal
 Classified as…
 Therapeutic objective: SUPPRESSION OF
PAROXYSMS
 Paroxysm defined as…
 From the Greek…

36. AF: Management: Paroxysmal
 Classified as…
 Spontaneous self termination
 <7 days (often <48hours)

Paroxysm defined as…"sudden attack, outburst"

From the Greek… (παροξυσμός paroxusmos), "irritation,
exasperation".[

37. AF: Management: Paroxysmal
 Suppression of paroxysms:
CONSERVATIVE:
 1.there is a known precipitant of paroxysm
 E.g. Alcohol; caffeine.
 2. the patient asymptomatic/few symptoms
 3. No history of left ventricular dysfunction/ ischaemic heart disease
Rx: -drug free / “pill in the pocket” strategy:
Pill in a pocket= “Flecainide” (or other Class 1c agent)

38. AF: Management: Paroxysmal
 Suppression of paroxysms:
MEDICAL/ PHARMACOLOGICAL:
-If patient is symptomatic
-Frequent paroxysms
-No known precipitant
 1st Line: Beta Blocker
 2nd line (symptoms not controlled): Sotalol
 3rd line/ if poor left ventricular function: Amiodarone

39. AF: Management: Persistent
 Classified as…

Therapeutic objective: think blender: control the rate or rhythm.

40. AF: Management: Persistent
RHYTHM vs RATE

41. AF: Management: Persistent:
RATE
 RATE control strategy should be preferred 1st line option in:
 Over 65s
 Coronary artery disease
 C/I to antiarrhthymic drugs
 Not suitable for cardioversion
 No heart failure

42. AF: Management: Persistent:
RATE
 RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker
 Monotherapy:
 Beta blocker
 Ca Channel Blocker
 (Digoxin ~ if sedentary)
 If require more than monotherapy:
 Beta blocker/ Ca channel blocker + Digoxin

43. AF: Management: Persistent:
RHYTHM
 RHYTHM control strategy should be preferred 1st line option in:
 Younger patients
 Symptomatic
 AF secondary to treated/ corrected precipitant (e.g. chest infection)
 With heart failure

44. AF: Management: Persistent:
RHYTHM
 RHYTHM control strategy 1st line option is:
 Cardioversion + Anticoagulation
If recurrence/ unsuccessful/ requires drug to maintain sinus rhythm:
1st line:
 Beta Blocker
2nd Line (I.e. not effective/ contraindicated):
+ structural heart disease :AMIODARONE
- NO structural heart disease: FLECAINIDE (or Sotalol)

45. AF: Management: Permanent
 Classified as…

Therapeutic objective: think blender: control rate as rhythm functions are
broken!

46. AF: Management: Permanent
RATE only!

47. AF: Management: Permanent:
RATE
 RATE control 1st line option: Beta blocker/ rate limiting Ca channel blocker
 Monotherapy:
 Beta blocker
 Ca Channel Blocker
 (Digoxin ~ if sedentary)
 If require more than monotherapy:
 Beta blocker/ Ca channel blocker + Digoxin

48. AF: Management:
ANTICOAGULATION
 Acute:
 Commence heparin until full risk assessment of emboli has been performed.
 >48 hours- 3 weeks of oral anticoagulation (warfarin) prior to cardioversion
 NO anticoagulation if:
 Stable sinus rhythm has been restored
 <48 hours
 No risk factors for emboli
 Chronic:
 Discuss with patient risks and benefits of anticoagulation.
 CHADS 2 = predictor of stroke.
 C= congestive cardiac failure (1)
 H= hypertension (1)
 A = age (>75) (1)
 D= Diabetes (1)
 S= stroke/ previous TIA (2)
 Warfarin : aim for therapeutic INR 2 -3
 (If warfarin C/I : Aspirin 300 mg/day)
CHADS 2 score of: % risk of stroke
0: 1.9%
6: 18.2%

49. AF: Summary
You should now be able to:
 Identify how AF presents and establish an appropriate differential
 Suggest sensible investigations as relating to your differential
 Recognise and describe the classic ECG findings and the pathophysiology of AF.
 Classify AF as according to its pattern and amenability to cardioversion (‘the 3 P’s)
 Describe the management options in terms of Rate and Rhythm control and list
suitable examples of patients and medications accordingly.

50. Tutorial: Acute Coronary
Syndrome

51. Case
 57 year old Gavin stumbles into A&E
complaining of severe chest pain. He’s grey
and very sweaty.

52. Objectives
 Pathophysiology
 Definitions
 Presentation
 Investigations
 Management of STEMI

53. What causes ischaemic heart
disease?

54. Fatty streak > Simple plaque > Complicated

55. Risk Factors

56. Non-modifiable
 Age
 Gender (males are at greater risk)
 family history of IHD

57. Modifiable

58. Definitions

59. Acute Coronary Syndrome
Unstable Angina NSTEMI STEMI

60. Ischaemia
Reduced perfusion. Purely symptomatic. No cell
death
Infarction
Reduced perfusion exceeding tolerance of cells. Cell
death

61. Ischaemia
Reduced perfusion. Purely symptomatic. No cell
death
• Stable Angina
• Unstable Angina
Infarction
Reduced perfusion exceeding tolerance of cells. Cell
Death
• NSTEMI
• STEMI
Clinical Application

62. Acute Coronary Syndrome
Unstable Angina NSTEMI STEMI

63. Differentiate?

64. ECG

65. Troponin
 0Hrs
 12Hrs

66. Unstable angina
 ST elevation
 Troponin +ve

67. NSTEMI
Troponin +ve

68. STEMI
ST elevation
Troponin +ve

69. Back to the case
What next?

70. History and Examination

71. Investigation.
ECG & Troponin

72. Anatomy

73. ST: Elevation: Localisation
Right Left

74. ST: Elevation: Localisation

75. ST: Elevation
Mechanism behind ECG changes:
 Complete occlusion of coronary vessel leads to ischaemia/infarction which
is seen as ST elevation.
 The mechanism is, however, poorly understood.
 Injury wave hypothesis= abnormal currents are generated between normal
and infarcted tissue and detected as an ‘injury wave’.
 Localisation:
 Right Coronary Artery (Post. Descending/ Marginal): Inferior STEMI: Leads II, III, avF
 Left Anterior Descending: Anterior STEMI: V1-V4
 Left circumflex: Lateral STEMI: I, aVL, V5, V6

76. Gavin’s ECG

77. Initial Treatment
 Morphine – 5-10mg IV (+ metoclopramide)
 Oxygen – aim for SaO2 > 95%
 Nitrate – 2 puffs or 1 tablet
 Aspirin – 300mg PO
 Restore coronary perfusion

78. Restore Coronary Perfusion
 Primary PCI
 Rx of choice if within 12h
 Thrombolysis
 Contraindicated beyond 24hr
 Streptokinase, Alteplase

79. Gavin has Primary PCI at the London Heart
Hospital. He survives and is very grateful.
What is the next stage of his management?

80. Subsequent Management
 Modifiable risk factors
 Antiplatelet – Aspirin, Clopidogrel
 B-blockers
 Statin
 ACE

81. Summary
 Pathophysiology
 Definitions
 Presentation
 Investigations
 Management of STEMI

82. A 45 year old man suffers sudden central
chest pain while at rest. It spreads across
his chest and up to his neck. After 20 mins,
the pain has not eased and he is
increasingly sweaty and short of breath.
This is the third such episode in the last 3
months
12hr Troponin I <0.05 ug/L

83. What is the single most accurate classification of
this event?
A. Acute Coronary Syndrome
B. Non-ST elevation myocardial infarction
C. ST elevation myocardial infarction
D. Stable angina
E. Unstable angina

84. What is the single most accurate classification of
this event?
A. Acute Coronary Syndrome
B. Non-ST elevation myocardial infarction
C. ST elevation myocardial infarction
D. Stable angina
E. Unstable angina

85. A 55 year-old woman has noticed her heart
beating fast. It happens infrequently and is not
assosciated with any other symptoms. She is
anxious about the cause of these attacks as she
has no other medical problems.
HR 80bpm, BP 115/75mmHg
After a normal ECG, a 24hr tape is performed

87. Which is the single most appropriate
treatment?
A. Amiodarone 100mg PO once daily
B. Digoxin 62.5mcg PO once daily
C. Flecainide 150mg PO as required
D. Metoprolol 25mg PO twice daily
E. Sotalol 40mg PO twice daily

88. Which is the single most appropriate
treatment?
A. Amiodarone 100mg PO once daily
B. Digoxin 62.5mcg PO once daily
C. Flecainide 150mg PO as required
D. Metoprolol 25mg PO twice daily
E. Sotalol 40mg PO twice daily

89. SBAs:
Which of the following is not a reversible
cause of cardiac arrest?
 Hypoxia
 Hypo/Hyperkalaemia
 Tension Pneumothorax
 Hyperthyroidism
 Tamponade

90. SBAs:
Which of the following is not a reversible
cause of cardiac arrest?
 Hypoxia
 Hypo/Hyperkalaemia
 Tension Pneumothorax
 Hyperthyroidism
 Tamponade

91. SBAs:
A 67 year old lady has just been diagnosed with persistent AF.
Cardioversion has previously failed. She is symptomatic, has
coronary artery disease but no heart failure. What1st line treatment
would you prescribe?
 Paracetamol
 Beta Blocker
 Flecainide
 Sotalol
 Amiodarone

92. SBAs:
A 67 year old lady has just been diagnosed with persistent AF.
Cardioversion has previously failed. She is symptomatic, has
coronary artery disease but no heart failure. What1st line treatment
would you prescribe?
 Paracetamol
 Beta Blocker
 Flecainide
 Sotalol
 Amiodarone

93. A 48-year old patient gives a 5 day history of dyspnoea.
He is found to be in atrial fibrillation. Which is the most
appropriate management plan?
A. Chemical cardioversion with IV amiodarone
B. Chemical cardioversion with IV flecainide
C. Anticoagulation with warfarin and rate control
D. Transthoracic echocardiogram to exclude thrombus
followed by DC cardioversion
E. Anticoagulation with warfarin then initiation of oral
amiodarone

94. A 48-year old patient gives a 5 day history of dyspnoea.
He is found to be in atrial fibrillation. Which is the most
appropriate management plan?
A. Chemical cardioversion with IV amiodarone
B. Chemical cardioversion with IV flecainide
C. Anticoagulation with warfarin and rate control
D. Transthoracic echocardiogram to exclude thrombus
followed by DC cardioversion
E. Anticoagulation with warfarin then initiation of oral
amiodarone