Cardio Consultations

Question 1

myocardial ischaemia hx

Answer 1

dull chest tightness
radiated to arm/jaw
exertional / releif on rest
autonomic sx
ddx: cough, pleuritic pain, viral prodrome, indigestion, MSK

RF: smoking, dm, alcohol, cholesterolm bp, fhx

Contraindications to antiplt

Question 2

myocardial ischaemia exam

Answer 2

Hands:
- tar staining
- pulse rate/rhythm
- BP

Eyes:
- xanthelasma
- corneal arcus

Ausc:
- heart murmur
- bibasal creps

Swollen ankles

Question 3

Ix myocardial ischaemia

Answer 3

12 lead ecg
cxr
trop, fbc, RFx, lipid, hba1c
echo

then:
- trop +ve - invasive coronary angiography +/- stent/CABG
- trop -ve - CTCA / functional tests

Question 4

Acute Mx ACS

Answer 4

Antithrombotic/antiplt: GpIIb/IIIa inhibitor if high risk (TIMI>4)

Anti-anginal: BB + GTN

Risk modify: statin, ACEI

+ GRACE/TIMI to risk stratify? invasive Mx

Question 5

Long-term Mx stable angina

Answer 5

Life style
Statins
Aspirin
Antianginals - B, nitrate, nicorandil, ranolazine, ivabradine

CTCA
Revascularisation if stable angina with symptoms despite 2x anti-anginal + signifies left main stem disease

Question 6

Pericarditisn with effusion Hx

Answer 6

Pleuritic CP
Relief on sitting forward
Viral prodrome

Cause: viral, HIV/TB, uraemia, cancer, AI (RA, SLE,), recent MI/cardiac surgery

DDx: cough, SOB, PE RFx

Question 7

Pericarditisn with effusion Exam

Answer 7

Hands:
- RA
- tar staining
- uraemic flap
- pulse
- BP - expiration + inspiration (pulsus paradoxicus - SBP drops >10mmHg)

Face/neck:
- JVP - elevated on inspiration
- LN for virus
- lupus

Ausc
- Pericardial rub

Question 8

Pericarditis with effusion Ix

Answer 8

ECG: global STE, electrical alternans
Bloods: fbc, ue, creat, esr, crp, trop, autoantibodies
CXR: globular heart,
Echo: bright pericardium, effusion,
+/- Diagnostic pericardiocentesis
+/- CT/MRI

Question 9

Pericarditis Mx

Answer 9

Acute = self limiting +/- NSAID/Colchicine
Recurrent pericarditis - ? steroids

Question 10

Tamponade Dx

Answer 10

clinical = Beck’s Triad: hypotension, JVP raised/distended, muffled heart sounds
+ tachycardia

Echo: RV collapse
= medical emergency: brisk volume expansion: IVF/leg raise + image guided pericardiocentesis

Question 11

pericardiocentesis complications

Answer 11

RV puncture
coronary/internal mammary puncture
PTX
liver laceration

Question 12

AF Mx

Answer 12

• Treat cause /lifestyle + education (avoid alcohol/nsaid/stroke/bleeding)
• Rate control: BB, CCB, digoxin
• Rhythm: chemical/electric cardioversion with DOAC at least 3 wks if >48hr
• If pt better in sinus - ?ablation
• Anticoag:
  –> non-valvular = DOAC
  –> valvular = warfarin
  CHADSVACS/ORBIT

Question 13

HTN Hx

Answer 13

End-organ Sx
Oestrogen (COCP/pregnancy)
Renal/Cardiovascular disease
RF: smoking, DM, thyroid, obesity, Salt consumption, Alcohol , Illicit drugs

Endo Sx
- Paroxysmal symptoms (phaeo)
- Cushings symptoms
- Conns syndrome (cramps)
- Acromegaly (hands size)

Question 14

HTN exam

Answer 14

Appearance - endo
Pulse
BP both arms (coarctation)
Heart
Renal
Neuro + fundoscopy

Question 15

Grades of HTN retinopathy

Answer 15

Grade 1: silver wiring (increased reflection from thickened arterioles)
Grade 2: + AV nipping (narrowing of veins as arteries cross them)
Grade 3: + cotton-wool spot + flame haemorrhage
Grade 4: + papilloedema (blurred optic disc)

Question 16

HTN Ix

Answer 16

End organ damage (fundoscopy, ECG LVH, RFx, HF

• pregnancy test
• urine acr
• RFx (Conns: low K+, high bicarb)

+/-
- aldosterone/renin ratio (ARR)
—> high in Conns >30
—> low in secondary

• plasma/urine metanephrins (phaeo)

Question 17

Mx of accelerated phase HTN

Answer 17

= medical emergency
Grade III/IV retinopathy + HTN
- bed rest
- long acting ccb - gradual reduction

+ encephalopathy/stroke/MI/LV failure/dessection/aneurysm:
- venodilators (nitroglycerin) + BB (labetelol) +/- a-blocker (aortic syndrome/phaeo)
- invasive bp monitoring

need to fall gradually to aboid watershed cerebral and retinal infarct

Question 18

DDx of optic disc swelling

Answer 18

papilloedema
optic neuritis
accelerated HTN
CRVO
AION

Question 19

Eisenmengers syndrome hx

Answer 19

PMH: congenital heart disease (ASD, VSD, AVSD, PDA)

SOB, HF, oedema, syncope, palpitatuons, haemoptysis, cyanosis

EXPLORE family planning - CI in severe PAH
IE?

Complications:
- viscosity sx (polycthaemia): headache, visual porblems, MI, stroke, skin ulcer
- gall stones/gout/renal stones - high urate/bili due to RBC turnover
- paradoxical emboli

Question 20

Ix

Answer 20

CXR - HF
ECG - Right heart strain
BNP
FBC - polycythaemia + iron

Pulm function
CTPA
Echo

Question 21

Mx of Eisenmengers (PAH)

Answer 21

• pulmonary vasodilator
• anticoag (stroke)
• symptom mx: allourinol, iron, diuretic, oxygen
• supportive/education: contraception, avoid anaemia/infection
• cannot reserve shunt
• HEART_LUNG transplant