Cardiac long case Flashcards
Acute coronary syndrome history
o Presence of chest pain, at rest or with exercise, emotion; intensity of pain, prolonged length of pain
o Diagnosis on ECG and troponin
o Requirement of thrombolysis
o Presence of heart failure and ICU
o Stent insertion
Coronary stent history
o Diagnosis on stress testing, and/or stable angina symptoms
o Angiogram – single or multiple arteries
o Antiplatelet therapy o Follow up echocardiogram
o Chest pain post nstemi, repeat angiogram
o Stent thrombosis, coronary artery dissection
Coronary bypass history
o Diagnosis stress testing following stable angina, angiogram results o Sternotomy vs. minimally invasive o Bypass grafts, how many, saphenous veins, radial arteries, mammary arteries ?venous insufficiency o Subsequent chest pain and follow up angiogram o Use of aspirin
Long term management - CAD (non pharm)
o Cardiovascular rehabilitation program
o Regular exercise
o Medication adherence
o Regular cardiologist and GP review
o Alcohol avoidance, smoking cessation
o Green leafy vegetables
o Coronary risk factor management
Coronary artery disease risk factor managment
o Dyslipidaemia – prior cholesterol, HDL and LDL levels
Statins or fibrates
Statin intolerance – myositis
o Hypertension – initial diagnosis, ongoing monitoring
Medications
Complications monitoring TTEs, renal function, regular ophthalmology testing by GP
Low salt diet, alcohol, green leafy vegetables
o Smoking
Amount, what exactly
Awareness of association
Attempts to quit
o T2DM
o Other factors, CKD, chronic inflammatory disease, obesity, stress
Precipitants for acute heart failure
o Poor adherence to fluid restriction
o NSTEMI/STEMI
o Intercurrent infection
o PE
o Pregnancy
o Thyroitoxicosis
o Post-operative setting
o Anaemia and acute haemorrhage
o Arrythmias
o Drugs – NSAIDs, amitriptyline, pioglitazones
o Sleep apnoea/ILD/COPD for RHF
Systolic heart failure causes
IHD
Alcohol
Valvular disease
Congenital/idiopathic dilated cardiomyopathy
Hypertrophic cardiomyopathy
Tachyarrhythmic cardiomyopathy
Viral cardiomyopathy
Noradrenaline induced cardiomyopathy – amphetamines, tachosubo cardiomyopathy
Familial myopathies – fredericks ataxia, myotrophica dystonica
Causes of diastolic failure
o Diastolic failure in the setting of hypertension, T2DM, age
o Restrictive cardiomyopathy
Amyloidosis
Haemochromatosis
Metastatic disease
Lipid/glycogen storage diseases
Loeffler’s syndrome
o Constrictive pericarditis
Management of heart failure
o Medications – beta blockers, ACEI, spironolactone, frusemide
o Management of precipitants – avoid drugs, manage and treat anaemia, thyrotoxicosis, management of arrythymias, PEs, antibiotics etc.
o General measures – fluid restrict, low sodium diet, daily weights, heart failure action plan o Heart failure rehabilitation program
o Influenza and pneumococcal vaccinations
o Device therapy AICDs, biventricular pacing
o Regular follow up and monitoring – TTEs, GP reviews, regular UECs, LFTs, regular INRs if on warfarin for mechanical valves, mitral stenosis o Heart transplantation
Contraindications to transplant
o Age >65
o Active infection with HBV, HCV, HIV
o Active malignancy within 5 years
o Pulmonary hypertension with > 5 wood units
o Poor social supports
o Ongoing drinking or smoking
o Intractable renal or liver failure
o Diagnosis of degenerative brain disease
Pre-transplant work up
o Cardiopulmonary exercise testing
o Pulmonary function tests FEV1, FVC, DLCO
o CXR and ECG
o TTE and coronary angiogram
o FBE, UEC, urinary protein/creat, HBA1c TFT, iron studies, serum immunoglobulins and electrophoresis, ANA, ANCA, ENA, C3/4, coags, lupus anticoagulant o
LFTs renal and liver USS
o Sleep study
o DEXA scan
o Cancer screening – PSA, PR exam, pap smears, mammography/breast USS, endometrial USS
o HIV, HBV and HCV screening, quantiferon gold test, CMV, EBV serology, other tests directed by travel history
Post transplant work up
o Immunosuppression regime
o Regular angiogram and Bx for coronary vascular arteriopathy
o Graft rejection
Acute, chronic o Infections – post operatively, 3 months, 1 year o Regular appointments o Metabolic Osteoporosis HTN T2DM secondary to immunosuppressants Dyslipidaemia
Atrial fibrillation
- Diagnosis – incidental, symptoms post stroke
- Anticoagulation CHADS2Vasc, HASBLED scores
- History WPW
- Prior electrophysiological studies and ablation
- Prior maze therapy or left atrial appendage removal – watchman device (on aspirin) - Prior stroke, large atria - TTE
HASBLED score
hypertension, age >65, anti-coagulant meds, alcohol use, stroke, liver and renal disease
CHADSVASC score
CCF, HTN, age >65, stroke, vascular disease, sex
Indications for pacemaker
o Complete heart block with
Symptomatic bradycardia
Cardiac failure
Arrhythmias that require treatment with drugs to slow conduction
- Asystole of more than 3 seconds with escape <40bpm
- Confusion improvement with temporary pacing
o second degree heart block with symptomatic bradycardia
Automated implantable cardioverter-defibrillator device indications
o Primary prophylaxis
MI and persisted LVEF<30% after 40 days
LVEF <35% and dilated cardiomyopathy
o Secondary prevention
Those candidates for CRT device HF w/ intraventricular conduction delay >120ms
Sustained VT or VT to VF w/ structural heart disease that are not amenable to ablation/refractory
Congential long QT with recurrent symptoms and torsades de pointes
Hypertrophic cardiomyopathy, Brugada, catecholaminergic polymorphic VT and arrhythmogenic right ventricular cardiomyopathy
Softer indications for pacemaker
- Softer indications for pacemaker
o Asymptomatic CHB rate >40
o Symptomatic second degree heart block without demonstrated symptomatic bradycardia
o Bifascicular or trifascicular block with syncope of unclear indication
