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Cardiology for RACP > Heart Failure and IHD > Flashcards

Heart Failure and IHD Flashcards

1
Q

Indications for cardiac resynchronisation therapy

A

Maximal medical therapy

LBBB appearance QRS width > 150ms

LVEF <35% NYHA II to IV symptoms

Dilated LV >55mm

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2
Q

Indications for ICD placement

A

40 days post MI with either:

  • LVEF <40% and non-sustained VT
  • LVEF <30% NYHA I
  • LVEF <35% NYHA II or III

Non ischaemic LVEF <35% NYHA II

Long QT Brugada

Hypertrophic cardiomyopathy

Arrrhythmogenic right ventricular cardiomyopathy

Catecholaminergic polymorphic VT

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3
Q

Causes of dilated cardiomyopathy

A

Alcoholism

Beri-beri - thiamine, selenium deficiency

Cocaine abuse/catecholaeminaemia

Drugs - Doxirubicin (anthracyclines), Trastuzumab Haemochromatosis

Peripartum cardiomyopathy

Viral infection -parvovirus p19, coxsackie, CMV, HIV

Chagas disease

Idiopathic Takosubo

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4
Q

Causes and diagnosis of hypertrophic cardiomyopathy

A

LV wall thickening >15mm in the absence of HTN, IHD or LVOTO

ECG presence of pathologic Q waves, LAD, TW inversion (to distinguish from Athlete’s heart)

End diastolic diameter of <54mm (to distinguish from Athlete’s heart)

Other causes of hypertrophy: - Fabry’s disease, glycogen storage disease, Noonan’s syndrome, mitochondrial disease, Frederich’s ataxia

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5
Q

Genetic causes of cardiomyopathy

A

Sarcomeric gene mutations (most common)

  • B myosin, A-myosin (autosomal dominant)

Non-sarcomeric genes - laminin-alpha4 (may also have conduction abnormalities)

Desminopathies - desmin 3 protein (autosomal dominant) SCN5A

Dystrophinopathy - DMD, Becker’s Barth’s syndrome

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6
Q

Causes of restrictive cardiomyopathy

A

Previous mediastinal radiotherapy

Amyloidosis

Sarcoidosis

Fabry’s disease

Haemochromatosis

Metastasis

Loeffler’s syndrome (secondary to eosinophilic leukemia)

Endomyocardial fibrosis (Africa, mural thrombi)

Endocardial fibroelastosis (children)

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7
Q

Indications for ICD in Hypertrophic cardiomyopathy

A

Prior non-sustained or sustained VT

Family history of HCM (Autosomal dominant trait)

Syncope Thickness >30mm

Hypotensive with exercise

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8
Q

Definition of systolic and diastolic heart failure

A

Systolic heart failure

  • HF with reduced ejection fraction <40%
  • HF with mid-range ejection fraction 40-49%

Diastolic heart failre

  • HF with preserved ejection fraction >50%
  • ddx Mitral regurgitation w/ supranormal EF
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9
Q

Differentials for cardiac failure

BNP > 100

A

Ischaemic heart disease (2/3 of HFrEF)

Valvular heart disease (MR, AS, MS, AR)

Hypertrophic cardiomyopathy (HTN)

Tachyarrhythmia associated cardiomyopathy

Alcoholic cardiomyopathy

Viral myocarditis

Takosubo cardiomyopathy

Noradrenaline associated cardiomyopathy (metamphetamine o/d)

High output cardiomyopathy (hyperthyroidism, anaemia, pregnancy, AVM, paget’s disease of the bone)

HOCM

ASD/VSD

Eisemenger syndrome

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10
Q

Management of Myocardial infarction

  1. STEMI
  2. NSTEMI
  3. Unstable angina
  4. General management
A
  1. PCI, thrombolysis if travel is >2hrs, IV heparin, clopidogrel, aspirin, +/- tirofiban, morphine, +/- frusemide if ADHF, IV fluid (if inferior infarct/RHF or cardiogenic shock), inotropes +/- balloon pump if cardiogenic shock, nitrates (contraindicated in inferior infarcts), oxygen if O2 <94, ACEI and statin

2+3. as above w/o urgent PCI, can be delay 24hrs; also consider TIMI risk score; may need PRBC, increase oral nitrates, beta-blocker, calcium channel inhibitor and/or ranolazine

  1. Cardiac rehab, quit smoking and alcohol, high green leafy vegetables and fruit, 20-30mins exercise 4x/week, Treat depression
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11
Q

Examination for amiodarone toxicity

A

Pulse rate and rhythm

BP

HTN

Signs of hyperthyroidism

Murmurs of MR, MS

CCF

Side effects of amiodarone toxicity (lungs for fibrosis, tremor, episcleral promience, warm peripheries for hyperthyroidism, nails and cornea, neurological exam for polyneuropathy)

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12
Q

Contraindications to Heart Transplant

A

Active substance abuse

Age >65-70

Pulmonary vascular resistance > 5 wood units

BMI >30

Active systemic infection or connective tissue disease

T2DM with end organ damage

CRF eGFR <40

Recent PE <6 weeks

Unhealed peptic ulcer

Active malignancy, consideration if disease free 3-5years

Psychosocial instability, inability to comply with follow up care

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13
Q

Indications for Heart Transplant

A

NYHA IV heart failure not responsive to medical therapy

VO2 max <12mL/kg/min

Intractable severe ischaemia not amenable to revascularisation

Recurrent uncontrolled VT

Types - myopathies w/ cardiac involvement such as Becker’s muscular dystrophy, DCM, ischaemic CM

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14
Q

Work up for cardiac transplant

A

Cancer/general - BMI, FOBT if over 50yrs, CT BCAP > 60yrs and smokers > 50yrs, for females PAP smear clear past year and mammogram >45yrs, DEXA, PSA in males >50yrs

Cardiac :ECG, gated blood pool thallium scan (within 3 months), TTE, 24hr holter monitor, Carotid duplex w/ IHD and all patients >50yrs, Right heart catheterisation, coronary angiography if indicated, Endomyocardial biopsy > 5 specimens (in some aetiologies)

Haematology - Blood group, FBE/ESR, INR/APTT, SPEP

Biochemistry - UEC, CMP, LFTs, CK, troponin, fasting lipids, urine SPEP, albumin/creatinine ratio, TFT

Microbiology - MRSA/VRE screen, Quantiferon gold, MSU

Serology - HBsAg, core and surface antibody, HCV, HIV1&2, CMV, EBV, HSV, VZV, toxo

Immunoglobulin levels, ANA and dsDNA

Sleep study, pulmonary function testing

Orthopantomogram (OPG)

Needs referral to social worker, PT/OT, cardiac transplant manager and nursing staff and dietician

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15
Q

Post Heart transplantation specific management

A

1) Regular endomyocardial biopsies weekly for the first month, then monthly, (15 total) to assess for acute allograft rejection
2) Additional biopsy indicated for hypotension, new dyspnoea, arrthymias (particular SVT/AF/flutter), unexplained fever, reduced LVEF, oedema, functional decline
3) 6-12 angiograms w/ intravascular US or dobamine stress TTE for development of coronary allograft vasculopathy
4) Immunosuppression - cyclosporin, mycophenolate mofetil and prednisolone; sirolimus, tacrolimus and azathioprine may be indicated along with Basiliximab (IL-2 receptor antibody) early in course

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16
Q

Complications of Heart Transplantation

A

Sepsis, particularly early in course; will require PJP prophylaxis, and antifungal prophylaxis; Not for live vaccines

Rejection - may be hyperacute (in theatre), acute cellular (most common) /acute humoral and chronic; monitored by endometrial biopsies; IV methylpred used for rejections +/- anti-thymocyte globulins

Atrial arrhythmias - sign of acute rejection

Persistent bradycardia post transplant, requiring PPM

Late graft failure/chronic rejection - caused by coronary intimal hyperplasia; irreversible, may respond to stenting, statins

Skin, solid organ and lymphoproliferative tumours

Hypertension secondary to cyclosporin and/or prednisolone +/- renal failure

Dyslipidaemia from cyclosporins, prednisolone

Renal failure, mulifactorial, cyclosporins

T2DM secondary to prednisolone, cyclosporin and tacrolimus

Psychiatric disturbance from steroids

17
Q

Common precipitants for decompensated HF

A
  • Poor adherence to fluid restriction
  • NSTEMI/STEMI
  • Intercurrent infection
  • PE
  • Pregnancy
  • Thyroitoxicosis
  • Post-operative setting
  • Anaemia and acute haemorrhage
  • Arrythmias
  • Drugs – NSAIDs, amitriptyline, pioglitazones
  • Sleep apnoea/ILD/COPD for RHF
18
Q

Principles of HF management

A

Commence medications that improve mortality - ACEI/ARB, beta blocker, mineralocorticoid antagonist

Device therapies - cardiac resynchronisation therapy, AICD

Treatment of causes - Coronary artery bypass, reduce MI by HTN, dyslipidaemia and T2DM management, valve replacement if indicated, thyroid function, sleep study for OSA etc.

Symptom management - diuretics, fluid restriction

Cardiac rehabilitation with multidisciplinary team

Regular review from GP and cardiologist, TTE, monitor potassium and renal function, remove medications that may contribute

Consideration for cardiac transplant and/or ventricular assist devices

19
Q

Management of chronic coronary syndrome

A

Medical management - Beta blocker, followed by calcium channel blocker, nitrate and ranolazine

Coronary artery revascularisation (CABG or PCI)

  • Intractable symptoms despite therapy
  • Significant risk of MI, prior VT w/ arrest, EF <50%

Risk factor prevention - quit smoking, HTN, lipid and glycaemic control, investigation and treatment of anaemia, thyroid dysfunction etc.

Multidisciplinary team w/ graduated exercise therapy e.g. walking club

Consideration of heart transplant

20
Q

Indications for cardiac stress testing

A
  1. Symptoms suggesting angina
  2. Acute chest pain in low risk patients
  3. Post MI without intervention or incomplete revascularisation 3/12 for risk assessment
  4. Known CHD and recent change or candidates for revascularisation
  5. Post PCI >2 years and CABG >5 years
  6. patients with valvular heart disease severe MR/MS/AR or equivocal low flow AS
  7. Patients with newly diagnosed HF for investigation
  8. Pre-operative workup for non-cardiac surgery if METs<4 and cardiovascular risk or vascular surgery with significant CV risk
  9. Investigation of exercise induced arrhythmias
21
Q

Choosing appropriate stress testing modality

A
  1. Unable to exercise - pharmacological stress testing - vasodilator or inotropic testing
    - Airway bronchospasm, bradyarrythmias, hypotension CI to vasodilator testing
    - recurrent VT or rapid AF or significant LTOT CI to inotropic testing
  2. LBBB or ventricular pacing - echocardiogram or nuclear testing
  3. Obesity - stress radionucleotide imaging with PET
  4. Myocardial viability - radionucleotide with PET, CMR or SPECT
  5. Valve function and concurrent AS- TTE
  6. No evidence of acute unstable angina or STEACS
22
Q

Indication for CT angiography

A

Moderate to low risk ischaemic chest pain

“rule out” CAD

Identify non-obstructive plaque

Reduce radiation dose as compared to coronary angiogram

23
Q

Complications of myocardial infarct

A

Ventricular tachycardia and fibrillation (if >24hrs, poor prognosis and ACID required)

Systolic heart failure

Ventricular aneurysm (persistent ST elevation)

Ventricular rupture (60-80% mortality)

Functional mitral regurgitation (cordae tendinae rupture)

Dressler’s pericariditis

Complete heart block (Inferior infarcts)

24
Q

Important MI ECG syndromes

A

Wraparound LAD due to anterior-inferior infarct Occlusion of type III LAD variant that involves inferior and precordial leads

Left main coronary occlusion Widespread ST depression with ST elevation in aVR >1mm

Wellen’s Syndrome Deep T waves or Biphasic T waves in V2-3 that indicates tight LAD stenosis

De Winter’s T waves LAD occlusion indicated by upsloping ST depression and symmetrically peaked T waves in praecordial leads

25
Q

Rare causes of cardiac hypertrophy

A

Fabry’s disease,

glycogen storage disease,

Noonan’s syndrome,

mitochondrial disease,

Frederich’s ataxia

26
Q
A

Cardiology for RACP (6 decks)

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