Cardiology Long Case

Question 1

Ischaemic Heart Disease (History)

Answer 1

1. Risk factors
   - modifiable
   - non-modifiable
2. Presentation
   - ACS
   - stable angina
3. Investigations
   - ECG, troponin
   - CXR
   - TTE
   - LHC
   - Stress testing
4. Management
   - risk factor modification
   - cardiac rehabilitation
   - optimal medical therapy
   - early revascularization
5. Complications
   - arrhythmias
   - heart failure

Question 2

Ischaemic Heart Disease (Management)

Answer 2

1. Risk factor modification
   - Mediterranean diet
   - Regular exercise 150 minutes/week
   - Weight loss
   - Smoking cessation
   - Alcohol in moderation (<2 for males, < 1 for females)
   - Cardiac rehabilitation
2. Optimal medical therapy
   - Dual anti platelet therapy
   - Statins +/- ezetimibe
   - ACEI
   - Beta blocker
   - Eplerenone
   - Anti-anginal therapy
3. Revascularization
   - CABG - TVD, LMCA, reduced LVEF. diabetes
   - PCI for prognostic benefit vs symptomatic benefit

Question 3

Infective Endocarditis (History)

Answer 3

1. Risk factors
   - previous IE, rheumatic fever
   - IVDU
   - immunosuppressed
2. Presentation
   - source of bacteraemia
   - fevers
   - embolic phenomena
3. Investigations
   - Blood cultures x 3
   - TTE +/- TOE
   - FBE, CRP, CXR, ECG
4. Management
   - IV antibiotics 6 weeks (directed)
   - source control
   - indications for valve replacement
5. Long-term
   - Prophylaxis

Question 4

Infective Endocarditis (Management)

Answer 4

1. Identify source of bacteraemia
   - skin/lines
   - colonic masses
2. Confirm diagnosis
   - JONES criteria
3. IV antibiotic therapy (directed)
4. Valve replacement
   - cardiac failure
   - heart block
   - recurrent embolic event, vegetation > 1cm
   - resistant organisms
5. Long-term prophylaxis
   - high risk cardiac condition
   - dental procedures/GI or urinary tract with current infection

Question 5

Congestive Cardiac Failure (History)

Answer 5

1. Risk factors
   - IHD
   - alcohol, thyrotoxicosis, post-partum, familial
   - haemochromatosis, amyloidosis, sarcoidosis
   - valvular disease
2. Presentation
   - triggers
   - decompensated/compensated
   - NYHA class, ET
   - orthopnoea/PND/ankle swelling
3. Investigations
   - FBE, UEC, TFT, iron studies
   - CXR, ECG
   - TTE
   - LHC
   - Cardiac MRI
4. Management
   - manage triggers (ischaemia, infection, arrhythmias)
   - diuresis, fluid restriction, target weight
   - HFrEF therapy
   - CRT
   - VADS/transplantation

Question 6

Congestive Cardiac Failure (Management)

Answer 6

1. Determine if HFrEF or HFpEF
2. Identify and address triggers
3. Diuresis, fluid restriction, target weight
4. Guideline directed medical therapy for HFrEF
   - ACEI/ARB
   - Beta blocker
   - Spironolactone
   - ARNI
   - SGLT-2
   - Ivabradine
5. Cardiac resynchronisation therapy
   - persistent NYHA class II symptoms despite OMT
   - LBBB, QRS > 150msecs
   - sinus rhythm
6. VADS/transplantation

Question 7

Hypertension (History and Management)

Answer 7

1. Risk factors
   - obesity
   - OSA
   - endocrine (PA, Cushing’s, Acromegaly, phaeo)
   - coarctation of the aorta
   - renal
   - medication
2. Presentation
   - values
   - symptomatic
3. Investigations
   - UEC
   - urine PCR
   - renal artery Dopplers
   - ARR, midnight salivary cortisol, IGF-1, urinary cathecholamines
   - ECG - LVH
4. Management
   - lifestyle (salt restriction, exercise, weight loss, alcohol in moderation)
   - pharmacological (ACEI, ARB, Beta blocker, CCB, Thiazide or spironolactone)

Question 8

Arrhythmias (History and Management)

Answer 8

1. Risk factors
   - thyrotoxicosis
   - metabolic syndrome/OSA
   - alcohol
   - IHD
   - inherited cardiomyopathies
2. Presentation
   - palpitations
   - syncope
   - heart failure
3. Investigations
   - ECG
   - Holter
   - TTE
   - TFT, FBE, LFT
   - cardiac MRI
4. Management
   - Lifestyle
   - Pharmacological (rate/rhythm/anticoagulation)
   - EPS (ablation)
   - device therapy (AICD, PPM)

Question 9

Heart Transplantation (History)

Answer 9

1. Timing
2. Underlying cardiac disease
3. Transplantation (matched)
4. Post-operative complications
5. Investigations
   - biopsies
   - TTE
   - coronary angiogram
6. Rejection
7. Medications
   - Tacrolimus
   - MMF
   - prednisolone
8. Side effects of medications
9. Infections
10. Prophylaxis
11. Current function
12. Hypertension, dyslipidaemia
13. Malignancy
14. Impact/prognosis

Question 10

Heart Transplantation (Indications and Contraindications)

Answer 10

1. Indications
   - refractory symptomatic cardiac failure
2. Contraindications
   - advanced age
   - comorbidities - CKD, CLD, pulmonary disease, fixed pulmonary hypertension
   - alcohol abuse
   - smoking