Cardiology Flashcards

Question

EXAM = Describe findings in tricuspid regurgitation and signs of severity

Answer 1

Findings = - pansystolic murmur, loudest at lower left sternal edge on inspiration Signs of severity = - pulsatile liver - prominent v wave - signs of RV failure

Answer 2

Findings: - Mid diastolic rumbling murmur - tapping apex beat Signs of severity = - small pulse pressure - early opening snap - length of murmur - diastolic thrill at apex - pulmonary HTN

Answer 3

Findings = - high pitched early diastolic crescendo murmur heard at mid sternal region or LLSE sitting forward in full expiration Signs of severity - Collapsing pulse - Wide pulse pressure - Soft S2 - S3 - Length of murmur - Austin Flint murmur - Signs of LV failure

Answer 4

Findings = - ejection systolic murmur loudest over right second intercostal space and radiates to the carotids, louder with expiration - Apex beat -> non-displaced, pressure loaded Signs of severity = - Narrow pulse pressure - Low volume carotid pulse - Soft S2 - Paradoxical split S2 - S4 - Thrill - Signs of LV failure

Answer 5

Findings = - pan-systolic murmur loudest at apex, radiating to axilla and loudest on expiration - Apex beat -> displaced and volume loaded Signs of severity = - Small pulse volume (very severe) - Soft S1, Split S2 - S3 - Pulmonary hypertension - Evidence of LV failure - Early diastolic rumble (flow murmur)

Answer 6

- Goal in this patient is the prevention of total mortality, so risk of death from other underlying medical conditions needs to be carefully considered - If this person has a life expectancy of less than 1 year, it may not be appropriate - It does not improve QoL as it does not prevent malignant arrhythmias from occurring, it simply shocks after it has occurred, which is a very unpleasant experience - I would need to have a detailed discussion with the patient about the goals of therapy and whether it is in line with his wishes for his care

Answer 7

Bridging is very rarely required, as these agents return to therapeutic level quickly The timing of cessation will depend on - the patient's Creat Clearance AND - the procedure's bleeding risk Thus I would determine this in consultation with the surgeon, but be looking at ceasing apixaban/rivaroxaban anywhere between 1-3 days prior, and dabigatran 1-4 days prior

Answer 8

Long term management = 1. Secondary prevention of recurrent rheumatic fever - Antibiotic prophylaxis (benzathine penicillin) ○ 10 years if mild ○ Until 35 years if moderate ○ Until 40 / lifelong if severe or have had cardiac surgery 2. Preventing IE - Dental hygiene and regular review is paramount - Amoxicillin prophylaxis for high risk procedures ○ Deep dental ○ Infected skin/ soft tissue ○ ENT ○ GI if infection present Address valve lesions if meeting usual criteria for intervention

Answer 9

Assess severity = - clinical signs - TTE findings - presence of heart failure / CAD Indications for surgery = - severe symptomatic AS - severe AS with HFrEF - If Moderate or Severe AS in patients who require CAGS - Markedly impaired exercise tolerance - Peak velocity of > 0.3m/s/yr Type of surgery = - TAVI for most - SAVR for low risk patients with anatomy that precludes TAVI

Answer 10

Monitoring - q1 year TTE - Vasodilators (Nifedipine or ACEI) - Aggressive Rx of HTN (↓ afterload) ``` SURGICAL INDICATIONS Symptomatic - Severe AR and symptoms of heart failure - Severe AR with angina Asymptomatic - LV dysfunction EF< 50% - Significant LV dilatation - Significant aortic root dilatation ```

Answer 11

The focus will be on palliative management of symptoms and improving QoL - optimising haemodynamics -> cautious treatment of HTN and avoidance of diuretics/vasodilators if possible - treating co-morbidities such as AF - Preventative care to avoid decompensating events such as infection / anaemia. Vaccination will be key in this - involvement of Pall Care team to begin discussions around EOLC and wishes for care

Answer 12

Clinical symptoms/signs of HF Ix: - BNP >35 (may be normal if done when at rest. Would go up on exertion) - Echo ○ High LA pressures -> E/e’ >13, indication of left atrial pressure ○ Structural change -> Large left atrium

Answer 13

- Diagnosis + presentation - RFs ○ IHD ○ Arrhythmias ○ Valves ○ HTN ○ Medication ○ FHx - Ix ○ TTE findings - Course ○ Exacerbations / flares ○ Triggers - Current symptoms / NYHA status and IMPACT - Management ○ Non-pharm § Fluid monitoring ○ Pharm § Guideline-directed therapy ○ Advanced § Devices - Complications ○ ?CKD - Monitoring - Future ○ ?Tx - Don't forget CVRFs

Answer 14

Heart Failure Management Spiel - Assess current status ○ Anaemia / CKD, check for iron deficiency or thyroid dysfunction ○ TTE and trend ○ BNP, ECG - Address underlying RFs / aetiology ○ CVRFs / valves if relevant ○ Address triggers -> arrhythmias, avoid troublesome meds e.g. TCAs, steroids - Patient education on HF Self Management and linking with a comprehensive care team to support care and reduce hospitalisation Specific management ○ Non-Pharmacological § Fluid restriction/monitoring § Regular physical activity (tailored to NYHA) and referral for cardiac rehab § Diet -> sodium restriction and maintenance of a healthy weight § Smoking cessation / ETOH restriction § Regular screening for depression ○ Pharmacological § Symptomatic -> Diuretics for fluid mx § Improving survival with cardioprotective agents □ ACEi or ARB □ BB (Carvedilol, Bisoprolol, Metoprolol XR, Nebivolol) □ MRA (spiro, eplerenone) -> if K level and BP tolerates § Uptitrating to maximal tolerated therapy □ If ongoing LVEF <40% despite OMT (BB + ACE/ARB)--> ARNI □ If SR > 77 bpm despite maximal BB --> Ivabradine □ Consider SGLT2 (particularly if DM) § Last line agents: can consider digoxin or other vasodilator therapy with nitrates/hydralazine if not tolerating ACEI ○ Advanced Therapies § CRT = sinus, LVEF <35% and QRS > 130 msec, particularly LBBB. Weaker indications in AF § ICD -> Primary prevention if LVEF <35% § LV Assist Device as bridge to transplant § Heart Transplant -> End-stage HF with severe symptoms, poor prognosis and no alternative options I would ensure regular follow up and monitoring of UEC. renal fx and BP. I would also liaise closely with GP to ensure coordinated approach to care

Answer 15

- CKD can limit dosing and choices of medication, with more risk of significant hyperkalaemia with ACEI/ARB / MRA - Requires close monitoring Management -> General measures are same - Assess current status ○ Anaemia / CKD, check for iron deficiency or thyroid dysfunction ○ TTE and trend ○ BNP, ECG - Address underlying RFs / aetiology ○ CVRFs / valves / IHD if relevant ○ Address triggers -> arrhythmias, avoid troublesome meds e.g. TCAs, steroids - Patient education on HF Self Management and linking with a comprehensive care team to support care and reduce hospitalisation -> Non-pharm remains same as always (education on fluid management, salt restriction, weight) -> Address fluid overload with diuretics and dialysis -> Optimise medical therapy with use of BBs (carvedilol) and ACEI/ARB if tolerated Close monitoring every month for electrolytes, BP, fluid status

Answer 16

- Most important issue in patients with reduced LVEF and persistent AF is restoration and maintenance of sinus rhythm when possible - Sinus rhythm is preferred to AF for most patients with HF, due to loss of atrial kick which worsens cardiac output - Reversible contributors should be addressed -> TFT, electrolytes, ETOH use - Assess likely duration of AF -> TTE for atrial enlargement, which can give an indication of likelihood of restoring sinus rhythm - Can consider catheter ablation for persistent AF, which can avoid burdensome AEs of anti-arrhythmics - Otherwise rate control is reasonable, with cardioselective BB - Ongoing monitoring to assess response and evaluate for AEs is important