Cardiology

Question 1

Issue: Cardiovascular risk factor control

Answer 1

1. Confirm the current state of RFs
   
   • Fasting lipids/cholesterol, glucose, HBA1C, ambulatory BP monitoring
2. Rule out secondary causes
   
   • ​​endocrinopathies (Conn’s, Cushing’s, hypothyroidism - lipids, OSA)
3. Screen Complications
   
   • ​​ECG (LVH), TTE (LV wall, diastolic), UPCR/UACR, ABPI
4. Goals
   
   • ​​BP target of (<125/75 [proteinuric], <130/80 [high-risk], 140/90 [general population])
   • Chol (<4), LDL (<2)
   • HBA1C of (…)
   • prevent complications
5. NP:
   
   • Confirm Adherence + address the cause
   • “NP Mx is crucial as it can reduce BP, lipids, glucose significantly - I will educate the patient on this & reiterate the importance of NP and aim to bolster self-efficacy”
   • Diet: salt restriction <2g/d, high-fibre, limit sat fats, dietician
   • Exercise + weight loss: 30 min, moderate, 5/week
   • Smoking & Alcohol cessation
6. Pharm:
   
   • BP: ACEi, BB, CCB, Thiazides…etc.
   • Lipids: Statins, Fibrates, Ezetimibe, PCSK9i (Evolocumab - S/C 2-4 weekly)
   • Monitor for side effects, especially postural hypotension, bradycardia, URTI + rash + arthralgia (PCSK)
   • Recheck targets in 3-6 months

Question 2

Pre-cardiac transplant workup?

Answer 2

Categorise!

Cardiac: TTE (LVEF, valve, exclude LV thrombus), gated-pool scan (EF), 24h-Holter, Angiogram, RHC to exclude p-HTN. Don’t forget Carotid USS

Resp: CXR, LFT, sleep study if OSA

Metabolic: HBA1C (OGTT/fasting glucose), lipids, DEXA (baseline)

Infection: HIV, IGRA, Hep B/C, CMV, EBV, VZV, HSV, Toxoplasma, MRSA carriage

Immunology: Igs, protein electrophoresis, Auto-antibodies

Malignancy: CT CAP (if age >60 or >50 if a smoker), otherwise recent FOBT, PSA, mammogram, PAP-smear

Psychosocial: psychiatry consult, SW, dietician, transplant nurse & coordinator

Question 3

What are DDx for cardiac transplant patients presenting with SOB? (5)

Answer 3

Acute cellular / humoral Rejection (symptoms resemble pericarditis - usually from ischaemia or reperfusion injury)

Arrhythmia - especially SVT is a marker of acute rejection

Coronary Allograft Vasculopathy (=chronic rejection)

Infection (e.g. PJP, pneumonia)

Malignancy (PTLD, Solid organ tumours, Mets)

Renal failure (CNI toxicity)

Psychological (in context of steroids)

Question 4

So how would you investigate this patient? (SOB in transplant patient)

Answer 4

T: Key investigation = ECG (reduced voltage, arrythmia = suggestive of rejection), TTE (LV function), angiogram (CAV), endomyocardial biopsy (lymphocytic infiltrate - rejection).

Confirmatory for CAV = IVUS (intravascular USS) - angiographic technique

E: inflammatory markers, PJP / septic work-up (induced sputum/BAL culture, blood culture, screen for nocardia, toxoplasma, fungal infections), CXR (pneumonia), CTPA, FBC (anemia), EUC (renal failure), CNI levels

Question 5

What is your approach in managing this patient with HF?

Answer 5

First of all, I would like to review his previous echocardiogram for an ejection fraction less than 40% to confirm the diagnosis of HFrEF.

I would also look for segmental hypokinesia which may suggest IHD as a cause for heart failure, as well as assess for ventricular dimensions and for any valvular abnormalities.

• Blood tests - ensure normal K, check for hypoNa and renal dysfunction (impact treatment)
• ECG - tachyarrhythmias precipitating/exacerbating HF,

Goal of treatment: reduce symptoms and improve survival

Non-pharmacological:

• Salt and fluid restriction
• Educate pt to regularly _monitor weigh_t, take extra frusemide if >2kg above baseline weight
• Refer for cardiac rehab - goal: improve symptoms and reduce hospitalisations

In terms of pharmacological management of this patient who has NYHA class II symptoms…

• ACEI (eg ramipril 1.25mg daily), beta-blocker (eg carvedilol 12.5mg daily) and spironolactone

uptitrate to max tolerated dose

• Down the track, if ongoing NYHA class II symptoms or more, change ACEI to entresto ensuring

an adequate washout period of 36hrs post-cessation of ACEI

• Also consider ivabradine if pt in SR and HR >77bpm

With ongoing symptoms despite maximal tolerated medical therapy, I would consider device therapy such as cardiac resynchronization therapy if pt is in sinus rhythm and QRS duration is >130ms.

If the etiology of cardiomyopathy is ischaemic in nature and EF <35% with class III symptoms, I will also consider implantation of AICD for primary prevention for ventricular tachyarrhythmias.

Transplant - NYHA class IV symptoms with e_xpected life expectancy without transplant <1 year_ - Contraindications:

Comorbidities that result in high mortality/morbidity risk

§ Active malignancy

§ Uncontrolled infection (although HIV/HCV/HBV may not be absolute CI)

§ Complicated diabetes

§ Morbid obesity (BMI>30)

§ Lifestyle factors that result in poorer outcomes

§ Substance abuse (alcohol, smoking, illicit drugs) - 6mths abstinence

§ Irreversible damage of other organ systems that preclude rehabilitation