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2020 Long Case Nosh > Cardiology > Flashcards

Cardiology Flashcards

1
Q

DRILL = List CV RFs to ask for in history

A

Demographic =

- Age 
- Gender (male)
- FHx
- ATSI

Co-morbidities =

- Chronic inflammatory state (CTD / HIV etc)
- CKD (particularly proteinuria)
- Post transplant 
- Chronic steroid exposure 
- HTN
- Dyslipidaemia
- DM

Lifestyle =

- Weight / diet
- Exercise 
- Smoking 
   - ETOH
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2
Q

What is the criteria for MetS?

A

MetS Criteria =

	- Elevated WC 
		○ Men >94
		○ Women >80
	- PLUS 2 of 
		○ High triglycerides
		○ Low HDL
		○ Impaired glucose tolerance
		○ HTN

*International Diabetes Federation

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3
Q

Is this patient a candidate for bariatric surgery? Discuss

e.g. Josephine G

A

Indications =

- BMI >40
- BMI >35 with obesity-related co-morbidities
- Patient must be willing and understand risks

Benefits =

- Improves CV risk factors and T2DM 
- Can lead to significant weight loss to then markedly improve function and QoL

Important Considerations to address pre-operatively =

- Patient's expectations of surgery 
- Addressing psychological factors including disturbed eating habits
- Ensuring adequate social supports 
Contraindications = 
	- Untreated psychiatric illness 
	- Current substance use
	- Prohibitive operative risk
		○ Anaesthetic assessment 
		○ Review respiratory and cardiac function / OSA
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4
Q

What are some medications which promote weight gain and can worsen obesity?

A

Insulin / Sulfonylureas

Steroids

Atypical antipsychotics and clozapine

OCP

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5
Q

DRILL =

List your dietary history

A

Dietary History =

- Number of meals per day and frequency of 
      snacks
- Content of meals 
- Prevalence of takeaway / soft drinks / refined 
      sugars
    - Barriers to healthy diet (finances / rural / 
      depression)
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6
Q

DRILL =

List your obesity Hx

A
  • Definition
    • Duration / onset
    • RFs
      ○ FHx
      ○ Co-morbidities (mood / decreased mobility)
      ○ Exacerbating medications (Insulin, antipsychotics, steroids)
    • Dietary Hx as above (summarised)
    • Interventions / Mx
      ○ Diets
      ○ Exercise programs (and barriers to this)
      ○ Psychology
      ○ Bariatric surgery
    • Complications
      ○ MSK
      § OA / gout
      ○ CV
      § IHD
      § HF / AF
      ○ Resp
      § OSA
      § OHS
      ○ GIT
      § NASH
      ○ Psych
      § Depression
    • IMPACT
      • Insight
    • Don’t forget to include other CV RFs
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7
Q

What are some HIV medications which contribute to CV risk?

A

Protease Inhibitors =

  • Ritonavir
  • Darunavir
  • Lopinavir

Abacavir
- Nucleoside Analog Reverse Transcriptase Inhibitor (NRTI)

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8
Q

How much weight can one expect to lose with lifestyle measures alone?

A

`5-7%

This still has been shown to have health benefits

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9
Q

How would you manage this person’s obesity?

A

Obesity Management Spiel

- Assess current status 
	○ Weight, WC
	○ Other CV RFs -> HTN, lipids, DM
- Exclude secondary causes
	○ Thyroid
	○ Cushings 
	○ PCOS
- Goals 
	○ To reduce weight to reduce CV risk and other Cx, in order to improve Fx and QoL
	○ Start out by SMART goal setting with patient 
- Cornerstone of management is going to be regular follow up to assess progress and address barriers

Management options =
- Lifestyle measures will be the foundation of management in order to achieve sustainable weight loss
○ Dietary advice
§ Low fat, hypocaloric -> Dietician input to create meal plan
§ Focus on problem areas e.g. Soft drinks
○ Exercise
§ 150 minutes of exercise per week (walking is good)
§ Aerobic + resistance training for CV health and strengthening
○ Behavioural modification
§ Focusing on stimulus control and self-monitoring, to modify eating behaviours
§ Psychology input may be useful here, particularly if concurrent depression
- Pharmacological therapy is a useful adjunct for severe obesity, but cannot be used in isolation
a. Liraglutide (GLP-1 agonist) -> daily injection. EXPENSIVE. Can cause GI upset
b. Orlistat -> GI upset can make it difficult to tolerate
c. Combination Phentermine/Topiramate -> off label so is expensive, can cause insomnia/sympathomimetic effects
- Surgical is a reasonable consideration to achieve significant weight loss, but must be carefully considered with multidisciplinary team assessment prior
○ Roux-en-Y (more efficacious) -> restrictive and malabsorptive
○ Gastric Sleeve (safer) -> primarily restrictive but causes hormonal changes that decrease hunger
- Address other CV RFs

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10
Q

What is your management of dyslipidaemia?

A

Assess the lipid profile to determine the best options and tailor management

Address RFs (obesity / T2DM / CKD / ETOH)

Specific management options:
	- Lifestyle 
		○ Dietary modification for weight loss (reducing intake of saturated and trans fats, increasing soluble fibre)
		○ ETOH avoidance
		○ Exercise 
		○ For increasing HDL = Increasing physical activity + losing weight 
	- Pharmacotherapy
		○ LDL
			1. Statin therapy
			2. Ezetimibe 
		○ Triglycerides
			§ Statins + Fenofibrate combination 
			§ Fish oil for severe triglyceridaemia
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11
Q

How would you treat HTN in CKD?

A
  • Target -> 140/90 generally
    ○ If DM or proteinuria -> 130/80
    • Lifestyle risk factors (diet, exercise 30 mins each day, salt <6g per day, smoking)
    • Start ACE/ARB, uptitrate to maximum dose
    • Can add CCB / diuretic / BB
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12
Q

Who needs treatment for HTN?

A

Decision for treatment -> based on CV risk / absolute BP level

  1. BP persistent >160/100 regardless of CV risk
  2. BP persistent >140/90 with moderate CV risk (10-15% 5 year risk)
  3. > 15% CV risk
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13
Q

Targets for HTN?

A

Generally <140/90

Target <130/80 if =

  • DM
  • CKD
  • older than 65
  • atherosclerotic disease of any kind
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14
Q

Guidelines for Pharm Rx of HTN?

A

1st line General
o ACEI/ARB
o CCBs (dihydropyridine)
o Thiazide
*CKD -> ACEI / ARB
*ACS or heart failure -> ACEIs / Beta blockers
*Symptomatic angina -> Beta blockers / CCBs

Resistant:

  • Spironolactone
  • Alpha blocker / moxonidine (do not use in HF)
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15
Q

Lifestyle modification for HTN?

A
  • Regular aerobic exercise
  • Reduction of alcohol intake
  • Sodium restriction to >6g / day
  • Weight reduction in overweight patients
  • Smoking cessation
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16
Q

DRILL = Hx for AF

A
  • Diagnosis / onset
    • Presentation
    • RFs
      ○ RHD
      ○ Obesity / OSA
      ○ ETOH
      ○ Thyroid
      ○ MR / dilated CM
    • Course
      ○ Admissions
      ○ Symptoms / effect on lifestyle
    • Management
      ○ Rate vs rhythm
      ○ TE prophylaxis + CHADsVA
      ○ Invasion
    • Complications
      ○ HF
      ○ Strokes / infarcts
      ○ Anticoagulation Cx
      • Current status and monitoring
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17
Q

How would you manage this person’s chronic symptomatic AF?

A 
Principles 
	- Reducing symptom burden 
	- Avoiding complications
		○ TE events
		○ Heart failure 
Assess
	- TTE
		○ LV function 
		○ LA morphology to see if likely to be persistent AF
		○ Mitral valve
	- Rule out other contributors
		○ TFT
		○ UEC, CMP 
Management 
	- Specific therapy for AF
		○ Rate vs rhythm control strategy
			§ Considerations are 
				□ Symptoms
				□ Age of patient
				□ Likelihood of permanence
				□ LV dysfunction 
			§ Rhythm options
				□ Flecainide if NO structural heart disease
				□ Amiodarone in HF
				□ Sotalol in CAD if LVEF >30%
			§ Rate
				□ Beta blockers
				□ CCBs (not in HF)
				□ Digoxin (if BP not tolerating other agents, or acute HF)
			§ Refractory
				□ Catheter ablation (risk of complications)
				□ LAA surgery 
	- TE prophylaxis depending on CHADSVA
		○ NOACs vs warfarin 
	- Addressing underlying RFs
		○ Obesity
		○ ETOH etc
18
Q

DRILL = IHD History

A
  • Diagnosis / presentation
    • RFs:
      ○ All CVRFs
      ○ Triggers = anaemia, arrhythmias
    • Ix + Management
      ○ Acute events / revascularisation
      ○ Secondary prevention / RF modification
    • Current symptoms / impact on function
      ○ Admissions
    • Complications
      ○ HF
      ○ LV aneurysm
      ○ Arrhythmias
    • Monitoring
19
Q

How are you going to manage the antiplatelet therapy in peri-operative period?

A

If procedure occurring within first 30 days -> try to delay due to high risk of stent thrombosis

Aspirin does not increase the severity of bleeding complications, so can likely be continued for most procedures. I would discuss this with the surgeon involved. If requiring cessation -> 3 days before the procedure

Clopidogrel / ticagrelor -> 5 days before the procedure

Prasugrel -> 7 days before the procedure

I would aim to restart antiplatelet therapy as soon as possible postprocedurally, ideally within 48 hours, in discussion with the surgeon.

20
Q

How are you going to manage this person’s persistent angina?

A
  • Patient education about resting when angina begins, and if persistent after 2 doses of GTN spray then call an ambulance
  • Prevention of angina:
    ○ Addressing underlying risk factors
    ○ Pharmacotherapy
    1. Beta blockers
    1) ndCCBs (avoid in LVF) as ALTERNATIVE to BB
    2. dCCBs in addition to BBs for refractory symptoms
    3. Long acing nitrate
    4. Nicorandil
    5. Ivabradine
  • If refractory
    ○ Consideration of surgical mx
21
Q

Do you think this patient with MR needs surgery?

A

Indications for surgery =

  • Symptomatic patients (NYHA III/IV symptoms) with chronic severe primary MR with LV dysfunction but LVEF >30%
  • Asymptomatic patients with chronic severe primary MR and LVEF 30-60% and/or LVESD >40mm
22
Q

This person has known IHD with recent CAGs. How are you going to manage surgical risk?

A

Assess risk
○ Patient factors
§ Clarify current functional capacity (>4 METs or not)
§ Current concerning symptoms e.g. SOB, unstable angina
○ Surgical factors
§ Type and duration of surgery and anaesthetic required

If poor or unknown functional status, warrants further evaluation
○ Baseline ECG for abnormalities
○ Stress testing depending on local availability. Reasonable options that I would consider are Nuc Med MPS, or dobutamine stress echo
○ Stress ECG lower sensitivity and specificity, also limited utility if resting ECG is abnormal

Non cardiac issues

- AKI
- Delirium
- BSL mx
23
Q

How will you manage this person’s peri-operative anticoagulation on warfarin?

A

Reasons for bridging =

  1. Very high CHADSVA
  2. Acute VTE
  3. Mechanical valve

Process for bridging =

  • Withhold warfarin ~5 days pre-op and when INR <2 start therapeutic clexane
  • Withhold therapeutic clexane 24h prior to surgery
  • Restart warfarin post-operatively in conjunction with surgeons, generally on the day of surgery
  • Clexane bridge until 2 consecutive days of therapeutic INR
  • Safe to operate generally if INR <1.5

If no bridging required =
- assuming INR sitting in therapeutic range, cease 5 days pre-op

24
Q

EXAM = Describe findings in aortic regurgitation and signs of severity

A

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
25
Q

EXAM = Describe findings in tricuspid regurgitation and signs of severity

A

Findings =
- pansystolic murmur, loudest at lower left sternal edge on inspiration

Signs of severity =

  • pulsatile liver
  • prominent v wave
  • signs of RV failure
26
Q

EXAM = Describe findings in mitral stenosis and signs of severity

A

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
27
Q

EXAM = Describe findings in aortic regurgitation and signs of severity

A

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
28
Q

EXAM = Describe findings in aortic stenosis and signs of severity

A

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
29
Q

EXAM = Describe findings in mitral regurgitation and signs of severity

A

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)
30
Q

Do you think this person should have an ICD inserted for secondary prevention?
(Bruce)

A
  • 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
31
Q

How would you manage this person’s anticoagulation with a NOAC peri-operatively?

A

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

32
Q

How are you going to manage this person’s rheumatic heart disease long term?

A

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

  1. 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

33
Q

How would you address their aortic stenosis as one possible contributor to multifactorial SOB?

A

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
34
Q

Management of Aortic Regurg?

A

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
35
Q

This person does not want a valve replacement for their severe AS. How will you manage them?

A

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
36
Q

How will you confirm / diagnose HFpEF?

A

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

37
Q

DRILL = List your history for HF

A
  • 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
38
Q

How are you going to optimise this person’s HF Mx?

A

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

39
Q

How would you manage this person’s HF in setting of their ESRF?

A
  • 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

40
Q

How would you manage this person’s AF in light of their co-existent HF?

A
  • 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

2020 Long Case Nosh (13 decks)

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