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Cardiology for RACP > Cardiac long case > Flashcards

Cardiac long case Flashcards

1
Q

Acute coronary syndrome history

A 
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
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2
Q

Coronary stent history

A

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

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3
Q

Coronary bypass history

A

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

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4
Q

Long term management

A 
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
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5
Q

Coronary artery disease risk factor managment

A

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

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6
Q

Precipitants for acute heart failure

A 
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
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7
Q

Systolic heart failure causes

A

 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

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8
Q

Causes of diastolic failure

A 
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
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9
Q

Management of heart failure

A

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

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10
Q

Contraindications to transplant

A 
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
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11
Q

Pre-transplant work up

A

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

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12
Q

Post transplant work up

A 
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
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13
Q

Atrial fibrillation

A
  • 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
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14
Q

HASBLED score

A 
hypertension,
age >65, 
anti-coagulant meds, 
alcohol use,
 stroke, 
liver and renal disease
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15
Q

CHADSVASC score

A 
CCF,
HTN, 
age >65, 
stroke, 
vascular disease, 
sex
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16
Q

Indications for pacemaker

A

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

17
Q

Automated implantable cardioverter-defibrillator device indications

A

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

18
Q

Softer indications for pacemaker

A
  • 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
19
Q

Risk factors for AF

A 
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
20
Q

Infective endocarditis history

A
  • 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
21
Q

Risk factors for infective endocarditis

A 
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
22
Q

Microbial infections causing IE

A

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

23
Q

Indications for valve replacement

A

o Valvular dysfunction causing heart failure, AR most severe
o Resistant organisms
o Positive blood cultures despite treatment
o Paravalvular infections causing bradycardia

24
Q

Factors in IE indicating poor prognosis

A 
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)
25
Q

Differentials for IE

A 
o	Cardiac thrombus
o	Atrial myxoma
o	Occult malignancy
o	Polyarteritis nodosa
o	Post strep glomerulonephritis
o	PUO
26
Q

Indications for prophylaxis

A

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

27
Q

Prophylaxis regime

A

o Ampicillin 2g or clindamycin 600mg oral 1 hour prior

o IV gentamicin with high risk cases

28
Q

Hyperlipidaemia - Familial hypercholesterolaemia

A

o Autosomal dominant
o Heterozygous AMI 30-40, homozygous in 20s (AMI, even aortic stenosis)
o Tendon xanthomas, arcus corneus

29
Q

Hyperlipidaemia- dysbetaproteinaemia

A

o Palmar xanthomata
o Coronary artery disease increase particularly in T2DM, obesity and hypothyroidism
o Often strong peripheral vascular disease history

30
Q

Hyperlipidaemia - Familial hypertriglyceridaemia

A

o Eruptive painful xanthomata on elbows buttocks

o Often associated with pancreatitis, obesity, hyperuricaemia

31
Q

Hyperlipidaemia -secondary causes

A

nephrotic syndrome, hypothyroidism, HRT, etOH

32
Q

Measures of heart function - history

A
  • 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
33
Q

Measures of heart function - examination

A 
-	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
34
Q

Measures of heart function - investigations

A
  • 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.

Cardiology for RACP (6 decks)

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