Cardio

Question 1

Chronic Heart Failure:
Aetiology
RFs
Signs/Sx
Ix
Mx

Answer 1

Aetiology:

TRIAD of Sx
* SOB, ankle oedema, fatigue

TRIAD of Signs
* Raised JVP, crackles in lungs, peripheral oedema

Ix:
1. NT-proBNP >125, BNP >35 - ECG as well
2. Echo - measure LVEF - ≥50% = “preserved”, 41-49% = “mildly reduced”, ≤40% = “reduced”

Mx:
* 1st line = ACEi + B-blocker
* 2nd line = Spironolactone/eplerenone
* 3rd line = Refer to specialist for cardiac resynchronisation therapy or digoxin

Extra Mx:
Offer annual flu vaccine + 1-time pneumococcal vaccine

Question 2

ACS

Answer 2

Oxygen only when actually desaturating!!

STEMI: Mona
IV Morphine + Metoclopramide
Dual anti-platelets (Aspirin 300mg + Ticagrelor 180mg)

During PCI: IV Unfractionated Heparin

NSTEMI + Unstable Angina:
1. Same initial plan as STEMI
2. If still symptomatic (chest pain) give GTN spray

If GTN relieves Sx completely, no need for PCI. Just give Fondaparinux 2.5mg

If STILL SYMPTOMATIC -> Calculate GRACE Score + ?Immediate PCI

Long-term Mx

STEMI + NSTEMI:
* Aspirin 75mg OD + Clopidogrel 75mg OD / Ticagrelor 90mg OD
* Bisoprolol 1.25/2.5mg OD
* ACEi (same dose as bisoprolol)
* Atorvastatin 80mg OD

Unstable Angina: Dual antiplatelet + Atorvastatin
NO NEED for beta-blocker + ACEi

Question 3

MI Complications

Answer 3

DARTH VADER

Death

Arrhythmia:
* Heart block: Atropine in Inferior MI, Pacemaker in Anterior MI
* VF (most common cause of death post-MI)

Rupture
* Acute Mitral Regurg (15-60%, occurs in 1st wk) - 2ndary to Papillary muscle rupture - New early/mid-systolic murmur, pulmonary oedema, acute hypotension
* Ventricular septal rupture (1-2%, occurs in 1st wk) - Acute HF, chest pain, new Pan-systolic murmur. ECHO to exclude Acute MR.
* LV Free Wall Rupture (3%, occurs 1-2wks later) - Acute HF 2ndary to TAMPONADE

Thrombus

Haemorrhage

Valvular Heart Disease

Aneurysm - LV wall. SOB + Persistent ST elevation + NO chest pain.

Dressler’s Syndrome (2-6wks) OR Pericarditis (<48hrs) Fever, Pleuritic pain, Pericardial effusion. raised ESR = Dressler’s.

Embolism

Re-infarct - Use CK-MB instead of Trop

Question 4

Acute Pulmonary Oedema

Answer 4

Investigations
1. ECG
2. ABG, BNP
3. CXR

Acute Management:
1. Sit up -> High flow O2
2. IV Diamorphine + Metoclopramide
3. IV Furosemide 40-80mg
4. GTN spray x2 (if SBP ≥100 use IV)
5. More Furosemide + Nitrate (Maintain SBP ≥90) + CPAP if needed

Once stable:
1. Measure daily weights, Repeat CXR
2. Switch to PO Furosemide
3. ACEi (LVEF <40%), Beta-blocker (LVEF <35%), Spironolactone.