Cardiac long case Flashcards
Acute coronary syndrome history
o Presence of chest pain, at rest or with exercise, emotion; intensity of pain, prolonged length of pain o Diagnosis on ECG and troponin o Requirement of thrombolysis o Presence of heart failure and ICU o Stent insertion
Coronary stent history
o Diagnosis on stress testing, and/or stable angina symptoms
o Angiogram – single or multiple arteries
o Antiplatelet therapy
o Follow up echocardiogram
o Chest pain post nstemi, repeat angiogram
o Stent thrombosis, coronary artery dissection
Coronary bypass history
o Diagnosis stress testing following stable angina, angiogram results
o Sternotomy vs. minimally invasive
o Bypass grafts, how many, saphenous veins, radial arteries, mammary arteries ?venous insufficiency
o Subsequent chest pain and follow up angiogram
o Use of aspirin
Long term management
o Cardiovascular rehabilitation program o Regular exercise o Medication adherence o Regular cardiologist and GP review o Alcohol avoidance, smoking cessation o Green leafy vegetables o Coronary risk factor management
Coronary artery disease risk factor managment
o Dyslipidaemia – prior cholesterol, HDL and LDL levels
Statins or fibrates
Statin intolerance – myositis
o Hypertension – initial diagnosis, ongoing monitoring
Medications
Complications monitoring TTEs, renal function, regular ophthalmology testing by GP
Low salt diet, alcohol, green leafy vegetables
o Smoking
Amount, what exactly
Awareness of association
Attempts to quit
o T2DM
o Other factors, CKD, chronic inflammatory disease, obesity, stress
Precipitants for acute heart failure
o Poor adherence to fluid restriction o NSTEMI/STEMI o Intercurrent infection o PE o Pregnancy o Thyroitoxicosis o Post-operative setting o Anaemia and acute haemorrhage o Arrythmias o Drugs – NSAIDs, amitriptyline, pioglitazones o Sleep apnoea/ILD/COPD for RHF
Systolic heart failure causes
IHD
Alcohol
Valvular disease
Congenital/idiopathic dilated cardiomyopathy
Hypertrophic cardiomyopathy
Tachyarrhythmic cardiomyopathy
Viral cardiomyopathy
Noradrenaline induced cardiomyopathy – amphetamines, tachosubo cardiomyopathy
Familial myopathies – fredericks ataxia, myotrophica dystonica
Causes of diastolic failure
o Diastolic failure in the setting of hypertension, T2DM, age o Restrictive cardiomyopathy Amyloidosis Haemochromatosis Metastatic disease Lipid/glycogen storage diseases Loeffler’s syndrome o Constrictive pericarditis
Management of heart failure
o Medications – beta blockers, ACEI, spironolactone, frusemide
o Management of precipitants – avoid drugs, manage and treat anaemia, thyrotoxicosis, management of arrythymias, PEs, antibiotics etc.
o General measures – fluid restrict, low sodium diet, daily weights, heart failure action plan
o Heart failure rehabilitation program
o Influenza and pneumococcal vaccinations
o Device therapy AICDs, biventricular pacing
o Regular follow up and monitoring – TTEs, GP reviews, regular UECs, LFTs, regular INRs if on warfarin for mechanical valves, mitral stenosis
o Heart transplantation
Contraindications to transplant
o Age >65 o Active infection with HBV, HCV, HIV o Active malignancy within 5 years o Pulmonary hypertension with > 5 wood units o Poor social supports o Ongoing drinking or smoking o Intractable renal or liver failure o Diagnosis of degenerative brain disease
Pre-transplant work up
o Cardiopulmonary exercise testing
o Pulmonary function tests FEV1, FVC, DLCO
o CXR and ECG
o TTE and coronary angiogram
o FBE, UEC, urinary protein/creat, HBA1c TFT, iron studies, serum immunoglobulins and electrophoresis, ANA, ANCA, ENA, C3/4, coags, lupus anticoagulant
o LFTs renal and liver USS
o Sleep study
o DEXA scan
o Cancer screening – PSA, PR exam, pap smears, mammography/breast USS, endometrial USS
o HIV, HBV and HCV screening, quantiferon gold test, CMV, EBV serology, other tests directed by travel history
Post transplant work up
o Immunosuppression regime o Regular angiogram and Bx for coronary vascular arteriopathy o Graft rejection Acute, chronic o Infections – post operatively, 3 months, 1 year o Regular appointments o Metabolic Osteoporosis HTN T2DM secondary to immunosuppressants Dyslipidaemia
Atrial fibrillation
- Diagnosis – incidental, symptoms post stroke
- Anticoagulation CHADS2Vasc, HASBLED scores
- History WPW
- Prior electrophysiological studies and ablation
- Prior maze therapy or left atrial appendage removal – watchman device (on aspirin)
- Prior stroke, large atria
- TTE
HASBLED score
hypertension, age >65, anti-coagulant meds, alcohol use, stroke, liver and renal disease
CHADSVASC score
CCF, HTN, age >65, stroke, vascular disease, sex
Indications for pacemaker
o Complete heart block with
Symptomatic bradycardia
Cardiac failure
Arrhythmias that require treatment with drugs to slow conduction
-Asystole of more than 3 seconds with escape <40bpm
-Confusion improvement with temporary pacing
o second degree heart block with symptomatic bradycardia
Automated implantable cardioverter-defibrillator device indications
o Primary prophylaxis
MI and persisted LVEF<30% after 40 days
LVEF <35% and dilated cardiomyopathy
o Secondary prevention
Those candidates for CRT device HF w/ intraventricular conduction delay >120ms
Sustained VT or VT to VF w/ structural heart disease that are not amenable to ablation/refractory
Congential long QT with recurrent symptoms and torsades de pointes
Hypertrophic cardiomyopathy, Brugada, catecholaminergic polymorphic VT and arrhythmogenic right ventricular cardiomyopathy
Softer indications for pacemaker
- Softer indications for pacemaker
o Asymptomatic CHB rate >40
o Symptomatic second degree heart block without demonstrated symptomatic bradycardia
o Bifascicular or trifascicular block with syncope of unclear indication
Risk factors for AF
o Thyrotoxicosis o OSA o etOH o Mitral valve disease o Post operative setting o COPD o PE o Hypertension o Atrial septal defect o Age
Infective endocarditis history
- History, investigations, complications management
- Differentials, severity indices, adherence/insight, tolerance
- Risk factors for infective endocarditis
o Intravenous drug use
o Prior infective endocarditis
o Endoscopic, dental procedure or operation
Antibiotic prophylaxis
o Heart operation
o Antibiotic allergies
o Organ transplantation on immunosuppression
o Steroid use and other immunosuppression
o Joint and vascular prostheses
o Weight loss/night sweats/loss of weight loss of appetite
o TTE results
Risk factors for infective endocarditis
o Prosthetic valve – mechanical or tissue o Mitral disease Mitral repair Mitral regurgitation Mitral stenosis o Aortic disease Aortic regurgitation Aortic stenosis o Congenital Bicuspid aortic valve Persistent ductus arteriosus Ventricular septal defect Coarctation of aorta Pacemaker leads
Microbial infections causing IE
o Prostate/UTI and S. faecalis
o Colonic polyps and S. bovis
o Oral procedures and S. viridians (subacute)
o IV lines, IVDU – S aureas
o Prosthetic valves -S. epidermidis, S. aureas
Indications for valve replacement
o Valvular dysfunction causing heart failure, AR most severe
o Resistant organisms
o Positive blood cultures despite treatment
o Paravalvular infections causing bradycardia
Factors in IE indicating poor prognosis
o Shock o CCF o Age o Aortic valve involvement o Multiple valves o Culture negative IE o Delay in treatment o Prosthetic valves o S. aureus, fungal, and gram negative (rare)
Differentials for IE
o Cardiac thrombus o Atrial myxoma o Occult malignancy o Polyarteritis nodosa o Post strep glomerulonephritis o PUO
Indications for prophylaxis
o Complex congenital HD
o Partially repaired congenital heart disease w/ synthetic material
o Prior infective endocarditis
o Prosthetic heart valves
o Cardiac transplant with valve dysfunction
Prophylaxis regime
o Ampicillin 2g or clindamycin 600mg oral 1 hour prior
o IV gentamicin with high risk cases
Hyperlipidaemia - Familial hypercholesterolaemia
o Autosomal dominant
o Heterozygous AMI 30-40, homozygous in 20s (AMI, even aortic stenosis)
o Tendon xanthomas, arcus corneus
Hyperlipidaemia- dysbetaproteinaemia
o Palmar xanthomata
o Coronary artery disease increase particularly in T2DM, obesity and hypothyroidism
o Often strong peripheral vascular disease history
Hyperlipidaemia - Familial hypertriglyceridaemia
o Eruptive painful xanthomata on elbows buttocks
o Often associated with pancreatitis, obesity, hyperuricaemia
Hyperlipidaemia -secondary causes
nephrotic syndrome, hypothyroidism, HRT, etOH
Measures of heart function - history
- Dyspnoea and exercise tolerance (ET)
- Severity of orthopnoea and pillow requirement
- Paroxysmal nocturnal dyspnoea and sleep disturbance
- Frequency of hospital admissions
- Number of heart failure medications
- Chest pain with walking and ET
Measures of heart function - examination
- End organ damage o Cyanosis and oxygen requirements o Oligouria/anuria o Delirium o Hepatitis - Raised jugular venous pressure - Loud and prolonged murmurs - Displaced apex beats, thrusting or heaving apex beats (dilated and hypertrophic cardiomyopathies) - Parasternal heaves (RVF) - Absent S1 or loud S2
Measures of heart function - investigations
- TTE – ejection fraction, regurgitant fraction (MR, AR), valve area and gradient(AS,MS), E/E’ (HFpEF), left atrial index (HFpEF), right ventricular systolic pressure (pulmonary hypertension)
- LVH, LBBB/RBBB, AF etc.
