01.02 Cardio

Written By Joan

01.02 Cardiology [PDF link]: Ischaemic heart disease (IHD) – stable angina, Atrial fibrillation (AF), Adult life support (ALS) – 4Hs 4Ts, cardiac arrest, shockable vs non-shockable rhythms (VF / VT, PEA, asystole)

External links

More on ischaemic heart disease / stable angina / coronary artery disease

  • NICE guidelines – CG95 Recent onset chest pain (last updated 2016), CG126 Stable angina: management (2016)

  • Further investigations for stable angina are outlined in CG95 (not included here because they’re quite specialist)

  • Revascularisation therapy [as stated in the CG126]

    • CABG has results in less mortality in pts with DM, >65yo, or have anatomically 3-vessel disease

    • CABG also carries lower risk of need for re-intervention

    • However, where both procedures are possible options, PCI seems to be the more cost-effective procedure

  • Cardiac syndrome X, aka microvascular angina (MVA)

    • D: Cardiac-sounding chest pain (ie angina) in the absence of significant coronary vascular abnormalities

    • R: More common in females, especially peri/post-menopausal. Population tends to be slightly younger (mean 49yo). Anxiety. Traditional risk factors for IHD apply as well.

    • Aetiology: many proposed mechanisms contributing, including viral illness precipitating angina, hormonal mechanisms, essential hypertension, etc

    • S/smx: present with typical/atypical angina

    • Ix: CTCA (by definition) will not show significant coronary artery disease. Lots of nuance in interpreting stress testing, which I will leave to the experts.

    • Mx: as per stable angina (eg GTN, preventative therapy with aspirin and statin, etc)

More on atrial fibrillation (AF)

  • NICE guidelines NG196

  • CHA2DS2VASc score specifically calculates risk of stroke in AF

  • TTE / TOE indicated for specific reasons

    • If deemed that baseline echo is important for further Mx (literally what NICE says)

    • If rhythm control might be deployed

    • If there is suspicion that underlying structural heart problem may affect management of AF

    • “In whom refinement of clinical risk stratification for antithrombotic therapy is needed” (no idea what this means)

  • Left atrial appendage occlusion is a treatment option to consider if anticoagulants are not tolerated

  • Pill-in-the-pocket strategy

    • Suitable if infrequent paroxysmal episodes ± known trigger

    • Inclusion criteria

      • Know how to take the pill

      • No Hx of left ventricular dysfunction, valvular or ischaemic heart disease

      • SBP >100 mmHg, HR >70

    • NG196 doesn’t elaborate on what exactly this pill-in-the-pocket strategy is. The ESC guidelines recommend one-off flecainide or propafenone (weight-based dosing).

    • This is presumably initiated by cardiologists who are confident with the use of these medications.

    • References

      • Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37:2893–962. https://doi.org/10.1093/eurheartj/ehw210.

      • Alboni P, Botto GL, Baldi N, Luzi M, Russo V, Gianfranchi L, et al. Outpatient Treatment of Recent-Onset Atrial Fibrillation with the “Pill-in-the-Pocket” Approach. New England Journal of Medicine 2004;351:2384–91. https://doi.org/10.1056/NEJMoa041233. → Quite a good article with practical instructions given on how/what to do.

      • Reiffel JA, Blomström-Lundqvist C, Boriani G, Goette A, Kowey PR, Merino JL, et al. Real-world utilization of the pill-in-the-pocket method for terminating episodes of atrial fibrillation: data from the multinational Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey. Europace 2023;25:euad162. https://doi.org/10.1093/europace/euad162. → Interesting to see what drugs clinicians in different countries prefer.

  • Elective electrocardioversion

    • NG196 1.7.17 – consider amiodarone 4 weeks before and up to 12 months after to maintain sinus rhythm

  • Catheter ablation

    • NG196 doesn’t discuss much about this; I find the 2016 ESC guidelines more detailed and useful (see link above)

    • “Complete pulmonary vein isolation (PVI) on an atrial level is the best documented target for catheter ablation.”

    • NG196 also doesn’t explicitly state that anticoagulation is required before/after procedure, but the ESC guidelines state that anticoagulation should be continued at least 8 weeks after procedure (see section 11.3.4)

      • Nothing is explicitly stated about minimum duration of anticoagulation before procedure :(

    • ESC guidelines also state that antiarrhythmics are commonly given 8-12 weeks after ablation to reduce early recurrence of AF

    • References

      • 2016 ESC guidelines as above

      • Calkins H, Hindricks G, Cappato R, Kim Y-H, Saad EB, Aguinaga L, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017;14:e275–444. https://doi.org/10.1016/j.hrthm.2017.05.012.

More on ALS

  • No specific guidance is given in Resus UK about the energy to be delivered when shocking patients in VF/pVT – depends on manufacturer of the defibrillator. Only states that first shock delivered can be within 120-360 J range, with subsequent shocks at fixed or increasing levels up to maximum output of defibrillator.

  • Out-of-hospital cardiac arrests (OOHCA)

    • NICE CKS recommends 30:2 compressions:breaths as per in-hospital arrests

    • Hands-only CPR is recommended by the American Heart Association for bystanders

      • Similar outcomes for those who had compression-only vs compression and rescue breaths CPR

      • I think if there is a trained medical professional (who is able to consider the reason for cardiac arrest), the decision would be slightly different though.

      • Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD. Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest. Circulation 2008. https://doi.org/10.1161/CIRCULATIONAHA.107.189380.

Vasospastic / Prinzmetal / variant angina

  • Rest (night) angina which respond to short-acting nitrates, attributable to coronary artery vasospasm

    • ECG: can be a/w ST elevation or ST depression

  • Features that distinguish it from stable / unstable angina

    • Typically occurs at night – midnight to early morning

    • Angina not typically triggered by effort or exercise

    • Hyperventilation can trigger vasospastic angina

    • Episodes may occur in clusters

    • Responds very quickly to GTN

  • Mx: GTN and otherwise as per stable angina (CCB preferred to beta-blockers). If there are known triggers, deal with them.

Joan
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