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 - CAD (non pharm)
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 areus
o Prosthetic valves
-S. epidermidis, S. areus
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.
Antihypertensive agents - beta-blockers
- Contraindications and cautions to beta-blockers
- Beta blockers interfere with glucose control and may worsen blood lipids; may also cause bradycardia, hypotension,depression and cold peripheries
They are contraindicated in peripheral vascular disease, Caution in COPD/asthma
Good in patients with CCF, IHD, history of gout and suitable in pregnancy
Anti-hypertensive agents - ACEI and ARBs
Cautions and contraindications
Uses
May cause angio-oedema, cough, postural hypotension, hyperkalaemia, worsening of renal failure and first dose hypotension (with low sodium diets and diuretics)
ARBs do not cause cough
Wait until diuresis is complete before starting
Good for T2DM, IHD, CCF, PHx gout, dyslipidaemia, and diabetic nephropathy
Antihypertensive agents - thiazide diuretics
Cautions and contraindications to thiazide diuretics
Uses
Can cause hyperlipidaemia, hyperglycaemia, thrombocytopaenia and gout
Do not use in patients with gout, dyslipidaemia or poorly controlled T2DM
Antihypertensive agents - Calcium channel blockers
cautions and contraindications
May cause bradycardia and precipitate heart block; may also cause headaches, sweating, palpitations and ankle oedema
Use in stable angina, peripheral vascular disease, IHD, dyslipidaemia, gout, T2DM
Caution in CCF
Antihypertensive agents - Alpha blockers and other peripheral and central vasodilators
- Cautions, contraindications and uses of alpha blockers
- Cautions contraindications and uses of perpherial vasodilators
- Cautions, contraindications and uses of central vasodilators
- May cause severe postural hypotension; for use in peripheral vascular disease, gout pts , pregnancy, and BPH
- minoxidil - causes sodium and water retention, peripheral oedema/pericardial effusion and hypertrichosis
- Hydralazine used in pregnancy and African-American populations; can cause SLE and ANCA vasculitis;
Differentials for hypertension
Essential (95%)
Obesity
OSA
Alcoholism
Medications (OCP, corticosteroids, cyclosporin)
Anxiety and pain
Renal artery stenosis
Parenchymal renal disease
Hyper and hypothyroidism
Acromegaly
Cushing’s syndrome
Conn’s syndrome (primary hyperaldosteronism)
Phaeochromocytoma
Coarctation of aorta
Polycythemia vera
Raised intracranial pressure
Acute intermittent porphyria
Examination for hypertension
HR, RR
Radiofemoral delay (coarctation)
BP, including postural drop and opposite arm (coarctation)
Tremor
Palmar erythema and conjunctival pallor
Fundoscopy (hypertension), EM exam (diabetes), lid lag, chemosis/conjunctival oedema (thyroid eye disease)
Hand, jaw, ear and nose size (acromegaly)
Large tongue (acromegaly, hypothyroidism)
Buffalo hump, moon facies, striae, bruising (Cushing’s)
Hirsuitism (adrenal carcinoma, CAH)
Cervical lymphadenopathy, swallowing, goitre and thyroid bruit (hyperthyroidism)
Neck circumference (OSA)
carotid bruit, AAA, femoral bruit, dorsalis pedis pulses, tibial pulses, cap. refill and sensation (PVD, T2DM)
Cardiovascular exam - lateral apex beat (IHD), MR
Abdominal exam - HSM (acromegaly), masses (adrenal carcinoma, PKD), renal bruit (renal artery stenosis)
Proximal limb weakness (Cushing’s, hypothyroidism)
Reflexes (hyper/hypothyroidism)
Management of Hypertension
- Indications for treatment
- Lifestyle modifications
- Drug combinations
- Investigation
- Treat with antihypertensives immediately if signs of end organ damage and SBP >160 or DBP >100 and systolic >200 mmHg; otherwise 24hr BP monitor and/or observe for 3-6 months w/ lifestyle modifications
- Reduce alcohol intake and quit smoking, Exercise 3-4x per week for 20-30mins at a time, salt restriction <4g/day, High green leafy vegetable intake
- Commence w/ thiazide (if >65 w/o CI) or ACEI/ARB (if metabolic syndrome); consider ACEI/ARB as a second line and calcium channel blocker as a 3rd line
Management of cardiac failure
- Acute
- Chronic
- Treat respiratory distress IV frusemide, O2, CPAP
1a. Consider GTN if hypertensive and no previous RHF
1b. Consider the use of nesiritide (recombinant BNP agonist)
1c. If hypotensive will require inotropes (levosimendan or dobutamine) w/ frusemide (for reducing cardiac preload) +/- aortic balloon pump may be required
1d. Investigate cause -ECG, CXR, ABG, FBE, UEC +/- Swan Ganz catheter - Beta blocker, ACEI if EF <40%, frusemide, spirinolactone, cardiac resynchronisation if QRS >120ms, ACID, warfarin if mural thrombus, digoxin for AF, LVAD
**Differentials for diastolic HF
Chronic HTN
IHD
Persistent/recurrent tachyarrthymias
T2DM
Restrictive cardiomyopathy - amyloidosis, haemochromatosis, sarcoidosis
Hypertrophic obstructive cardiomyopathy
Constrictive pericarditis
Territories for Myocardial Infarct
Anterior MI - V1-V6 LAD, distal, inferior reciprocal changes
Septal MI - V1-4, Loss of Q in V5-6 LAD - septal branches
Lateral MI I, aVL, V5-6 II, III, aVF Left Circumflex artery
Inferior MI II, III, aVF I, aVL Right coronary artery (80%) or Right circumflex
Posterior MI V7-9 High R in V1-3 with ST depression V1-3 >2mm Right Circumflex artery
Right Ventricle MI V1, V4R I, aVL Right Coronary Artery
