Long case

Question 1

Ischemic heart disease

Answer 1

History
1. Subtype
2. Current symptoms
3. Management history: acute (thrombolysis, PCI, CABG), anti platelet, anti-anginal, statin, ACEi
4. Risk factors and control: lipids, diabetes, BP, family hx, smoking, obesity, PVD
5. Investigations: stress test, echo, mibi, angio
6. Complications: valve, HF, arrhythmia

Exam: per cards short

Management
1. Acute = PCI (optimal within 90mins) > thrombolysis, CABG for multi vessel or left main
2. Investigate 1. EF 2. Complications 3. Ischeamia 4. Viability
3. Chronic: anti platelet, b-blocker, ACEi if large, statin LDL<1.8, BP <130/80, diet, exercise 3x weekly for total >150mins, smoking cessation

Question 2

Possible questions for IHD
1. How would you quantify and manage this patient’s future cardiac risk?

2. What would you advise a surgeon or anaesthetist about the risks of surgery for this patient?
3. How would you manage his or her anti-platelet treatment in the perioperative period?

Answer 2

1. If event then will be by definition high risk&raquo_space; manage via risk factor modification and medication
2. Dependent on urgency of surgery - optimisation is preferred, review meds and hold appropriate
3. Depends on recency of event - minimum 3 months DAPT, surgery on SAPT but this is operator dependent (7 days interruption for neurosurg)

Question 3

Possible questions for Revascularization
1. How would you anage this patient’s anticoagulation during a future presentation with an acute coronary syndrome?

2. In what circumstances would a drug-eluting stent be preferable to a bare metal one?

Answer 3

1. Continue anticoagulation and add DAPT for 1 week then go down to SAPT for 12 months
2. DES always preferred nowadays (obviously you need DAPT)

Question 4

Infective endocarditis

Answer 4

History
1. Symptoms
2. Embolic phenomena
3. Recent procedures
4. Hx of rheumatic fever and other heart surgery
5. IVDU
6. TOE and microbiology results
7. Management - abx +/- surgery

Exam
1. Hands: clubbing, splinter haemorrhages, Osler’s nodes (tender subcut nodules), janeway lesions (palmar maculopapular lesion)
2. Eyes: roth spots, conjunctival petechiae
3. Splenomegaly
4. Joints
5. Heart murmurs
6. Signs of heart failure
7. Source of infection

Investigations
1. 3 blood cultures
2. ECG
3. Urine - hematuria and proteinuria
4. Echo

Management
1. 4-6 weeks for native and 6-8 weeks for prosthetic
2. Valve replacement: resistant organism, valvular dysfunction with mod-severe HF, persistently positive blood cultures, conduction disturbance/ paravalvular abscess, recurrent embolic phenomena
3. Future prophylaxis

Question 5

Causes of culture negative endocarditis (6)

Answer 5

1. Previous abx
2. Hemophilous parainfluenza
3. Histoplasmosis
4. Brucella
5. Candida
6. Q fever

Question 6

Possible questions for IE
1. What would persuade you that this patient now needs surgery for his or her infec- tive endocarditis?

2. What would make you decide to treat this culture-negative patient for endocarditis?

Answer 6

1. Resistant organism, valvular dysfunction with mod-severe HF, persistently positive blood cultures, conduction disturbance/ paravalvular abscess, recurrent embolic phenomena
2. Echo evidence + 3 minor: predisposing cardiac condition or IVUD, fever, peripheral stigmata