Cardiology Flashcards
Antenatal history for cardiac long cases
- Morphology scans, foetal echocardiograms, amniocentesis for genetic diagnoses
- Maternal infections
- CHD: Rubella
- Congenital cardiomyopathy: CMV, HSV, coxsackie, parvovirus B19, HHV6, toxoplasmosis and possibly HIV
- Maternal medications
- Anticonvulsants, ACE inhibitors, Lithium, Retinoic acid, Valproic acid, warfarin
- Maternal drugs/alcohol/smoking
- Maternal conditions
- CHD: DM, HTN, obesity, phenylketonuria, thyroid disorders, systemic connective tissue disorders, and epilepsy
- CCHB: SLE/Sjogren’s
- Fertility treatment
- Has been linked to increased risk of septal defects and cyanotic CHD
Screening questions for cardiac cases
- Weight gain
- Cyanosis
- Tachypnoea
- Periorbital oedema
- Frequency of respiratory infections
- Exercise intolerance
- Chest pain
- Syncope
- Dizziness
- Palpitations
- Joint symptoms
- Neurological symptoms
Complications to screen for in cardiac cases
Complications:
- Stroke
- Global hypoxic insult
- Infective endocarditis
- Arrhythmias + blocks
Often affected:
- Neurodevelopment: increased risk if on bypass or cyanotic
- Increased risk of ADHD
- Growth / nutrition
- Immunisations: ensure up to date including fluvax +/- RSV prophylaxis
Risk of recurrence in siblings for congenital heart disease
Baseline risk = 1%
In close relatives of patient with CHD risk increases to 3-7%
Infectious endocarditis prophylaxis
- Endocarditis after dental/other procedures is infrequent, so prophylaxis prevents very few cases
- More likely to result from bacteraemia associated with daily activities, so the maintenance of good oral health and hygiene is more important than periprocedural antibiotics
- NICE guidelines don’t recommend prophylaxis for anyone
- eTG recommends for a restricted group:
- Prosthetic valve or material used for valve repair
- Previous infective endocarditi
- Congenital heart disease if:
Unrepaired cyanotic defects including palliative shunts/conduits
Repaired defects with residual defects
RHD in high risk patients
Consider post heart transplant
- In the exam say you would check with the patient’s cardiologist
When do patients need IE prophylaxis?
Dental procedures—only those involving manipulation of the gingival or periapical tissue or perforation of the oral mucosa (e.g. extraction, implant placement, biopsy, removal of soft tissue or bone, subgingival scaling and root planing, replanting avulsed teeth).
Dermatological or musculoskeletal procedures—only those involving infected skin, skin structures or musculoskeletal tissues.
Respiratory tract or ear, nose and throat procedures—only for tonsillectomy or adenoidectomy, or invasive respiratory tract or ear, nose and throat procedures to treat an established infection (e.g. drainage of abscess).
Genitourinary and gastrointestinal tract procedures—only if surgical antibiotic prophylaxis is required or for patients with an established infection.
Intercurrent illness management in cardiac disease
- Taking documentation of child’s condition when travelling
- Risk from increased PVR during respiratory infections
- Dehydration may predispose to thrombosis in polycythaemic patients or lead to hypokalaemia in patients of diuretics or cause toxicity in patients taking digoxin
- Febrile illness = increased metabolic demand
- Fever = increases risk of arrhythmia in Brugada syndrome
Exercise restriction in cardiac disease
ALL sports
- Insignificant left to right shunts (ASD / VSD / PDA ) can engage in all sports
- Wait 3-6 months until post repair
- Mild PS / AS
- Coarct without aortic arch dilatation or BP difference
- Normal or near normal funtion (EF >50%)
Low intensity only
- Significant left to right shunts (ASD / VSD / PDA) with pulmonary HTN (>25mmHg) have decreased capacity for exercise and may develop chest pain, arrhythmias + syncope or SCD
- > moderate PS / AS
- Severe PR
- Coarctation with aortic arch dilatation or BP difference
- Ventricular dysfunction (EF <40-50%)
Restrict if;
- Ventricular dysfunction
- Outflow obstruction
- Recurrent or uncontrolled arrhythmias
- Exercise intolerance
- Exercise induced ischaemia
- Fontan circulation
- ALCAPA pending repair
- LQTS
- CPVT
- Anticoagulated: avoid spots with body impacts*
- Pacemaker: avoid sports with direct blows to chest*
Cardiac disease
- Pregnancy + contraception considerations
Pregnancy
- Contraindicated in Eisenmenger’s or severe PHTN of any cause
- Relative CI: severe CCF, severe cyanosis (spO2 < 80%)
Contraception
- Theoretical risk of thrombosis potentiated by oestrogens
- IUD potential source of bacteraemia
Cardiac transplantation
- General facts
- Immunosuppressants
- MMF, tacrolimus, steroids
- Risk of rejection highest in first 6 months (most common cause of mortality for first 3 years)
- Infections (bacterial / fungal / viral)
- Coronary artery disease (cardiac allograft vasculopathy)
- Neoplasia (PTLD)
- Hypertension
- Abnormal renal function
- Osteoporosis
Causes of aortic root disease
Connective tissue disorders
- Marfans
- Loeys-Dietz
- Ehlers-Danlos syndrome
- Osteogenesis imperfecta
- Familial thoracic aortic aneurysmal disease
Non-connective tissue disorders
- Bicuspic aortic valve
- Conotruncal abnormalities
- Turner syndrome
Bicuspid aortic valve monitoring
- Lifelong surveillance required
- Screen family members
- Exercise restrict if > moderate AS
- Control hypertension
- Valve replacement
Cyanotic heart lesions
6 T’s 2D’s 1 H + 1P
1: TA truncus arteriosus (1 trunk)
2: tricuspid atresia
3: tricuspid ectasia (ebsteins)
4: TOF
5: TAPVD
6: TGA
DORV
DILV
Pulmonary atresia
HLHS
Common cardiac conditions that are inheritable
- Cardiomyopathy
- Arrhythmia syndromes: (LQT, Brugada, CPVT, SQT)
What are the 3 general classess of cardiac surgery repairs?
Repaired
Unrepaired
Palliated
Common cardiac long case management issues
- Development
- Growth + nutrition
- Infective endocarditis prophylaxis
- Intercurrent illness management
- Social issues
- Exercise restriction
- Pregnancy / contraception
- Cardiac transplantation
- ADHD screening
- Aortic root disease
- Transition
