CHF + Coarctation of aortic + constrictive pericarditis

Question 1

Diagnosis of chronic heart failure?

Answer 1

N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test first-line

if levels are ‘high’ arrange specialist assessment (including transthoracic echocardiography) within 2 weeks

if levels are ‘raised’ arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks

Question 2

How does clopidogrel work?

Answer 2

antagonist of the P2Y12 adenosine diphosphate (ADP) receptor

:. inhibiting the activation of platelets

Question 3

What does clopidogrel interact with?

Answer 3

• Concurrent use of proton pump inhibitors (PPIs) may make clopidogrel less effective
• Omeprazole and esomeprazole
• Other PPIs such as lansoprazole should be OK

Question 4

What is clopidogrel used for?

Answer 4

First-line in patients following an ischaemic stroke and in patients with peripheral arterial disease

Question 5

What is coarctation of the aorta?

Answer 5

• Congenital narrowing of the descending aorta
• More common in males (despite association with Turner’s syndrome)

Question 6

What are the features of coarctation of the aorta?

Answer 6

1. Infancy: heart failure
2. Adult: hypertension
3. Radio-femoral delay
4. Mid systolic murmur, maximal over back
5. Apical click from the aortic valve
6. Notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children

Question 7

What is coarctation of the aorta associated with?

Answer 7

Associations:

• Turner’s syndrome
• Bicuspid aortic valve
• Berry aneurysms
• Neurofibromatosis

Question 8

How do you manage stable CVD?

Answer 8

• Normally all patients are recommended to be prescribed an antiplatelet
• If indication for anticoagulant exists (for example atrial fibrillation) it is indicated that anticoagulant monotherapy is given without the addition of antiplatelets

Question 9

How do you manage post-ACS/PCI patients?

Answer 9

• Much stronger indication for antiplatelet therapy
  
  • Patients are given triple therapy (2 antiplatelets + 1 anticoagulant) for 4 weeks-6 months after the event
  • Dual therapy (1 antiplatelet + 1 anticoagulant) to complete 12 months
• Variation from patient to patient however given that the stroke risk in atrial fibrillation varies according to risk factors

Question 10

How do you manage VTE?

Answer 10

• if a patient on antiplatelets develops a VTE they are likely to be prescribed anticoagulants for 3-6 months
• HAS-BLED score should be calculated.
  
  • low risk of bleeding may continue antiplatelets
  • intermediate or high risk of bleeding consideration should be given to stopping the antiplatelets

Question 11

What are the features of complete heart block?

Answer 11

Features:

• syncope
• heart failure
• regular bradycardia (30-50 bpm)
• wide pulse pressure
• JVP: cannon waves in neck
• variable intensity of S1

Question 12

What is constrictive pericarditis?

Answer 12

The heart is encased in a rigid pericardium

Question 13

What are the causes of constrictive pericarditis?

Answer 13

• Often unknown (UK)
• Elsewhere TB
• After any pericarditis.

Question 14

What are the clinical features of constrictive pericarditis?

Answer 14

• RVF + Oedema:
• ↑jvp (with prominent x and y descents)
• Kussmaul’s sign (jvp rising paradoxically with inspiration)
• Dyspnoea
• Soft, diffuse apex beat, quiet heart sounds, Loud s3 = diastolic pericardial knock (sudden cessation of rapid ventricular filling due to pericardial constraint)
• Hepatosplenomegaly, ascites

Question 15

What investigations do you perform in constrictive pericarditis?

Answer 15

CXR: small heart ± pericardial calcification (if none, ct/mri helps distinguish from other cardiomyopathies)

Echo: cardiac catheterization

Question 16

What is the managment of contrictive pericarditis?

Answer 16

Surgical excision