Cardiology

Question 1

Management of infective endocarditis

Answer 1

1) 3 sets of bloods cultures taken within 90 minutes
2) administration of antibiotics (Pen/Vanc + Gent in native valves)
3) Criteria: Major ( 2+ve cultures of typ organism, echo: valve regard or lesion), Minor (T>38deg, embolic or immunological phenomena)
4) Investigations: Cultures, TTE (sens 60%) vs TOE (80-90%), MSU.
5) Complications: Abscess, valve lesion,/prolapse, embolisation, CHF, surgery.

Question 2

Management of Hypertension

Answer 2

1) definition: systolic >140, diastolic >90.
2) causes: Primary (e.g. essential) Secondary (e.g. renal, vascular, endocrine)
3) End organ damage: FBC, ECG, Uric Acid, Urine Microalbumin
4) Non pharmacological management: weight loss, exercise, smoking cessation, low salt diet, limit EtOH.
5) Thiazide, then depending on other risk factors, ACE-i/CCB/ARB, B-blocker, aldosterone antagonist.

Question 3

Management of AF (flutter)

Answer 3

confirm on ECG - irreg, irreg, no P waves (or A Flutter)

rate control strategy

• most appropriate in elderly (less likely to stay in SR)
• less appropriate if dilated LA, structural abnormalities

rhythm control strategy

• DCCV: must be anti coagulated for 1 month prior unless onset within 24 hours
• pharmacological: Amiodarone, Sotalol

stroke prevention: CHADS2Vasc
valvular AF must be anti-coagulated regardless of CHADSVasc

Urgent DCCV if haemodynamically compromised

Manage/check RFs:
electrolytes, TFTs, caffeine intake, heart failure

Question 4

Management of metabolic syndrome

Answer 4

1. Assessment of risk
   - measure waist circumference, BP, lipids and glucose at least once every 3 years in those with risk factors
   - calculate cardiovascular risk score (Framingham)
2. Abdominal obesity
   - reduce body weight by 7-10% over 1 year
   - aim for a BMI less than 25
   - combination of diet, exercise and consider pharmacological and surgical options
3. Physical inactivity
   - at least 30 mins of moderate intensity excercise at least 5x per week
4. Diet
   - low saturated fats, trans fats and cholesterol
   - Mediterranean diet = benefits in CVD
5. Dyslipidemia
   - reduce LDL to less than 2.6, raise HDL
   - atorvastatin if indicated for primary prevention (CVD risk greater than 15%) or secondary prev
6. Blood pressure
   - reduce to less than 140/90 (130/80 if diabetic)
7. Glucose tolerance
   - aim HBA1c less than 7% (less than 50)
   - consider metformin in those with impaired glucose tolerance
8. Consider aspirin
   - depending on CVD risk
9. Screen for associated disorders/complications
   - PCOS, gout, cognitive impairment, fatty liver, renal impairment, cancer screening

Question 5

Smoking Cessation Advice

Answer 5

1) simple advice (health, cost)
2) Involve whanau
3) Organisations (quitline/referral to CADS)
4) NRT (gum, patches,lozenges, buproprion NB CI in depression/seizure, varenicline)

Question 6

Congestive Heart Failure

Answer 6

1. Confirm diagnosis + clarify severity/grade - NYHA
2. Assess underlying cause and treat
3. Pharmacological management
   Mortality benefit:
   - ACE-I/ARB - stabilise remodelling, improve mortality
   - B-blocker - most benefit on mortality
   - aldosterone antagonist -class 3/4, EF less than 35%
   - nitrates - benefit in african americans
   Symptom control:
   - diuretics, digoxin
   Newer medications: ivabradine, neprilysin
4. Consider devices
   - CRT: Class 3/4, EF less than 35%, QRS more than 120ms, LBBB, class 2-4, max medical mx
   - ICD: EF less than 35%, class 2-4, at least 1y survival
5. Consider surgical management if appropriate
   - revascularization
   - valve replacement/repair
   - heart transplant
6. Non pharmacological managment
   - cardiac rehabilitation class/graded exercise programme
   - dietary advice - salt restriction, fluid restriction
   - education - daily weight, HF nurse
   - vaccinations
   - manage CVD risk - smoking, HTN, cholesterol
   - consider anticoagulation if appropriate
   - review medications - avoid drugs which worsen CHF, treat side effects
   - advanced care planning
   - driving restrictions

Question 7

Ischaemic heart disease

Answer 7

1. Risk stratification (post ACS) - echo, stress test
2. Manage aggravating factors - HTN, arrhythmia, CHF, anaemia
3. Non pharmacological management
   - smoking cessation
   - manage HTN, lipids, glycaemic control, diet
   - cardiac rehabilitation/exercise programme
   - education - GTN protocol, angina mx
   - affect on career/driving
4. Medical management
   - secondary prevention - antiplatelet agents, statin, b-blocker, ACE-I (if EF less than 40%, HF, anterior MI)
   - anti-anginals: nitrates, calcium channel blockers, nicorandil, perhexiline
5. Surgical management
   - revascularisation - favoured in ACS, no mortality benefit in chronic stable angina
   - CABG