6. Reading an ECG
• Description of the QRS complexes
• Description of the ST segements & T waves
0° - I
-30° - aVL
+60° - II
• THEN offer inter
+p
12
r0
e
° t
-a
IIItion
-150° - aVR
• Rhythm
• Rate
• Card
1i8
a
0c
° Axis
• P:QRS complex ration
• PR interval
-90°
+90° - aVF
8. Scoring Systems
• TIMI Risk Score
• GRACE scoring
• CHA2DS2-VASc
• Framingham Risk Score
• Wells Clinical Prediction for DVT & PE
9. Hypertension
A 62-year old ma re. His father suffered from
king 30-
ease and
alks ever
ive as possible ta
nd smoking 5 cigarettes a day
heart dis
minute w
for the past 30 ye l English every d
ing reg e feels he needs
ay for breakfast
the energy
he wo
le attends your GP surgery with concerns about his blood pressu
died at 70-years old from a heart attack. He tries to keep as act
y day, but does admit to drinking 3 pints of strong beer a day a
ars. He accepts his diet probably isn’t the healthiest eating a ful
ularly throughout the day on chocolate biscuits and crisps, but h
n’t be able to manage his farm. On examination his blood pressure is 152/95.
Clinic BP
and snack AGE >80
otherwise
Diabetes
10. o when s t felt like a tig est and she
A 4
ag
be
as
he was out on a jog. I
rt of breath. An amb
spray underneath he
ht band around her ch
arrived and gave her
ain quickly subsided
well as a r tongue. The p and she now
feels well at rest.
Angina
10-29%
CT
calcium
Assessing Functional
Risk Imaging
Angiography
1.All patients should receive aspirin, a
scs
o
tr
ait
n
in
g and a short-acting
nitrate in the absence of a contraindication
2.Use eith7
e
-y
r
eaa
r ol
b
d e
fem
ta
ale
-b
prleo
sec
nt
k
s e
tor
A&
o
Ercoc
m
a
plla
c
in
iin
u
gm
of ch
ce
h
sta
pa
n
in
n
. Ie
t sltab
rte
ld
otc
wo
kh
e
or
urs
first
line
3.If poor r
ce
am
se
p
sh
o
ons3
e0
t-o
60
in
%
itiau
lla
tn
r
ce
e q
a
ut
icm
kly ent increase30
t0
o
mg
m
asa
pir
x
in
imum
tolerated dose
4.After monotherapy use beta-clocker AND calcium channel
blocker
5.If neither is tole
6r1
a-t9
e0
d%
use a long-actC
in
og
ro
n
n
it
arr
a
y
te, ivabradine,
nicorandil or ranolazine
11. Angina
A 60-year old man with stable angina presents for a routine review. He reports he is
still symptomatic despite treatment with verapamil. The pain is starting to come on
with minimal activity and his functioning is severely impeded. He has a spray which
does still help with the symptoms.
13. Secondary Prevention
• ACE inhibitor
• Beta-blocker
• Aspirin
• Statin
• Clopidogrel (after appropriate risk assessment if NSTEMI or 4 weeks if
STEMI)
14. Anticoagulation in AF
Condition Points
C Congestive heart failure 1
H
Hypertension (or treated
hypertension)
1
A2 Age >= 75 years 2
D Diabetes 1
S2 Prior Stroke or TIA 2
V
Vascular disease (including
ischaemic heart disease
and peripheral arterial
disease)
1
A Age 65-74 years 1
S Sex (female) 1
15.
16. Atrial Flutter
• Atrial rate is around 300/min
• Heart rate dependent on conduction
• 2:1 block heart rate will be 150
• Management same as AF
• Medication may be less effective
• More sensitive to cardioversion
• Radiofrequency ablation of tricuspid valve isthmus is curative for
most patients
17. A 45-year old male with a BMI of 56 attended his GP surgery today for a nurses
appointment. He regularly drinks 12 units a day and smokes 15 cigarettes per day.
His diet is high in red meat and his father died of a myocardial infarction at the age
of 53. The nurse is alarmed by the appearance of his ECG as shown below.
Heart Block
First degree Heart block
k
Second degree Heart bloc Mobitz type 1
Mobitz type 2
2:1/3:1 conduction
Complete Heart block
NEEDS PACEMAKER!!!!!
19. Heart Failure
A 72-year old male with established Atrial Fibrillation presents to the Emergency
Department with increasing shortness of breath. He finds he is unable to perform
strenuous activities anymore and can struggle with housework on occasion. He does
not have any chest pain but has noticed ankle swelling and needs to be propped up
on 4 pillows at night when he sleeps. His GP has seen him previously and started him
on Simvastatin, Bisoprolol and Ramipril.
20. Heart Failure
LEFT
• Di
y
ss
p
p
ln
ac
oed
a apex beat
• O
Ga
rt
ll
h
o
o
p
pr
n
h
o
ye
ta
hm
• P
Ha
er
a
o
rx
tym
sm
ur
am
l n
uo
rs
cturnal
dyspnoea
• Wheezing
• Dizziness
• Confusion
RIGHT
• Oedema
• H
Ne
op
ct
au
to
rim
a egaly
• A
Ra
sc
is
it
e
e
d
sJVP
• Parasternal Heave
21. Heart Failure
NYHA Class Symptoms
I
Cardiac disease, but no symptoms and no
limitation in ordinary physical activity,
e.g. shortness of breath when walking,
climbing stairs etc.
II
Mild symptoms (mild shortness of breath
and/or angina) and slight limitation
during ordinary activity.
III
Marked limitation in activity due to
symptoms, even during less-than-
ordinary activity, e.g. walking short
distances (20–100 m).
Comfortable only at rest.
IV
Severe limitations. Experiences
symptoms even while at rest. Mostly
bedbound patients.
22. Heart Failure: Diagnosis
Previous MI?
Echocardiography
Serum
Natriuretic
peptides
ECG and other tests
(if not already done)
Treat for
heart failure
Other
Diagnosis
Investigate
other diagnosis
23. Treatment of Heart Failure
Lifestyle Advice & Vaccination
Manage co-morbid conditions ACEi + Beta-blocker
ARB if ACEi not
tolerated
Aldosterone
antagonist/ARB/
hydralazine +
nitrate
Ivabradine/ Cardiac
Resynchronisation
Therapy alternatives!!
Drug treatment for
all heart failure
Other Interventions
Monitoring
26. Pulmonary Embolism
Two months later the same 26-year old collapses suddenly in the supermarket. An
ambulance is called and she bought into A&E. She is extremely short of breath and
has right sided chest pain on inspiration. The ambulance crew report she had been
coughing up some blood. Her temperature is 37.4°, pulse rate is 102, respiratory rate
is 34 and O2 saturations are 86%.
28. Acute
• Infective
• NSAIDs
• Antibiotics if
indicated
Chronic
• Radio/chemotherap
y
• Autoimmune
disorders
• Treatment depends
on underlying cause
Recurring
• Addition of
colchicine can help
prevent symptoms
returning
