Cardiology

Question 1

Heart Failure Management

Answer 1

1. The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
2. The standard second-line treatment is an aldosterone antagonist
3. Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

ivabradine
criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%

sacubitril-valsartan
criteria: left ventricular fraction < 35%
is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
should be initiated following ACEi or ARB wash-out period

digoxin
digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties
it is strongly indicated if there is coexistent atrial fibrillation

hydralazine in combination with nitrate
this may be particularly indicated in Afro-Caribbean patients

cardiac resynchronisation therapy
indications include a widened QRS (e.g. left bundle branch block) complex on ECG

Other treatments
offer annual influenza vaccine
offer one-off pneumococcal vaccine
adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years

Question 2

Infective endocarditis

Answer 2

Indications for surgery
1. Severe valvular incompetence
2. Aortic abscess(indicated by lengthening of pr interval)
3. Infections resistant to antibiotics/fungal infections
4. Cardiac failure refractory to medical treatment
5. Recurrent emboli after antibiotic treatment

Question 3

Infective endocarditis - causes

Answer 3

1. Staph aureus - most common cause
2. Strep viridans - strep mitis and strep sanguinis - poor dental hygiene
3. Staph epidermidis - following prosthetic valve surgery for first 2 months
4. Strep bovis - strep gallolyticus - colorectal cancer
5. Non-infective - sle , malignancy