Heart Failure and IHD Flashcards
(26 cards)
Indications for cardiac resynchronisation therapy
Maximal medical therapy
LBBB appearance QRS width > 150ms
LVEF <35% NYHA II to IV symptoms
Dilated LV >55mm
Indications for ICD placement
40 days post MI with either:
- LVEF <40% and non-sustained VT
- LVEF <30% NYHA I
- LVEF <35% NYHA II or III
Non ischaemic LVEF <35% NYHA II
Long QT Brugada
Hypertrophic cardiomyopathy
Arrrhythmogenic right ventricular cardiomyopathy
Catecholaminergic polymorphic VT
Causes of dilated cardiomyopathy
Alcoholism
Beri-beri - thiamine, selenium deficiency
Cocaine abuse/catecholaeminaemia
Drugs - Doxirubicin (anthracyclines), Trastuzumab Haemochromatosis
Peripartum cardiomyopathy
Viral infection -parvovirus p19, coxsackie, CMV, HIV
Chagas disease
Idiopathic Takosubo
Causes and diagnosis of hypertrophic cardiomyopathy
LV wall thickening >15mm in the absence of HTN, IHD or LVOTO
ECG presence of pathologic Q waves, LAD, TW inversion (to distinguish from Athlete’s heart)
End diastolic diameter of <54mm (to distinguish from Athlete’s heart)
Other causes of hypertrophy: - Fabry’s disease, glycogen storage disease, Noonan’s syndrome, mitochondrial disease, Frederich’s ataxia
Genetic causes of cardiomyopathy
Sarcomeric gene mutations (most common)
- B myosin, A-myosin (autosomal dominant)
Non-sarcomeric genes - laminin-alpha4 (may also have conduction abnormalities)
Desminopathies - desmin 3 protein (autosomal dominant) SCN5A
Dystrophinopathy - DMD, Becker’s Barth’s syndrome
Causes of restrictive cardiomyopathy
Previous mediastinal radiotherapy
Amyloidosis
Sarcoidosis
Fabry’s disease
Haemochromatosis
Metastasis
Loeffler’s syndrome (secondary to eosinophilic leukemia)
Endomyocardial fibrosis (Africa, mural thrombi)
Endocardial fibroelastosis (children)
Indications for ICD in Hypertrophic cardiomyopathy
Prior non-sustained or sustained VT
Family history of HCM (Autosomal dominant trait)
Syncope Thickness >30mm
Hypotensive with exercise
Definition of systolic and diastolic heart failure
Systolic heart failure
- HF with reduced ejection fraction <40%
- HF with mid-range ejection fraction 40-49%
Diastolic heart failre
- HF with preserved ejection fraction >50%
- ddx Mitral regurgitation w/ supranormal EF
Differentials for cardiac failure
BNP > 100
Ischaemic heart disease (2/3 of HFrEF)
Valvular heart disease (MR, AS, MS, AR)
Hypertrophic cardiomyopathy (HTN)
Tachyarrhythmia associated cardiomyopathy
Alcoholic cardiomyopathy
Viral myocarditis
Takosubo cardiomyopathy
Noradrenaline associated cardiomyopathy (metamphetamine o/d)
High output cardiomyopathy (hyperthyroidism, anaemia, pregnancy, AVM, paget’s disease of the bone)
HOCM
ASD/VSD
Eisemenger syndrome
Management of Myocardial infarction
- STEMI
- NSTEMI
- Unstable angina
- General management
- PCI, thrombolysis if travel is >2hrs, IV heparin, clopidogrel, aspirin, +/- tirofiban, morphine, +/- frusemide if ADHF, IV fluid (if inferior infarct/RHF or cardiogenic shock), inotropes +/- balloon pump if cardiogenic shock, nitrates (contraindicated in inferior infarcts), oxygen if O2 <94, ACEI and statin
2+3. as above w/o urgent PCI, can be delay 24hrs; also consider TIMI risk score; may need PRBC, increase oral nitrates, beta-blocker, calcium channel inhibitor and/or ranolazine
- Cardiac rehab, quit smoking and alcohol, high green leafy vegetables and fruit, 20-30mins exercise 4x/week, Treat depression
Examination for amiodarone toxicity
Pulse rate and rhythm
BP
HTN
Signs of hyperthyroidism
Murmurs of MR, MS
CCF
Side effects of amiodarone toxicity (lungs for fibrosis, tremor, episcleral promience, warm peripheries for hyperthyroidism, nails and cornea, neurological exam for polyneuropathy)
Contraindications to Heart Transplant
Active substance abuse
Age >65-70
Pulmonary vascular resistance > 5 wood units
BMI >30
Active systemic infection or connective tissue disease
T2DM with end organ damage
CRF eGFR <40
Recent PE <6 weeks
Unhealed peptic ulcer
Active malignancy, consideration if disease free 3-5years
Psychosocial instability, inability to comply with follow up care
Indications for Heart Transplant
NYHA IV heart failure not responsive to medical therapy
VO2 max <12mL/kg/min
Intractable severe ischaemia not amenable to revascularisation
Recurrent uncontrolled VT
Types - myopathies w/ cardiac involvement such as Becker’s muscular dystrophy, DCM, ischaemic CM
Work up for cardiac transplant
Cancer/general - BMI, FOBT if over 50yrs, CT BCAP > 60yrs and smokers > 50yrs, for females PAP smear clear past year and mammogram >45yrs, DEXA, PSA in males >50yrs
Cardiac :ECG, gated blood pool thallium scan (within 3 months), TTE, 24hr holter monitor, Carotid duplex w/ IHD and all patients >50yrs, Right heart catheterisation, coronary angiography if indicated, Endomyocardial biopsy > 5 specimens (in some aetiologies)
Haematology - Blood group, FBE/ESR, INR/APTT, SPEP
Biochemistry - UEC, CMP, LFTs, CK, troponin, fasting lipids, urine SPEP, albumin/creatinine ratio, TFT
Microbiology - MRSA/VRE screen, Quantiferon gold, MSU
Serology - HBsAg, core and surface antibody, HCV, HIV1&2, CMV, EBV, HSV, VZV, toxo
Immunoglobulin levels, ANA and dsDNA
Sleep study, pulmonary function testing
Orthopantomogram (OPG)
Needs referral to social worker, PT/OT, cardiac transplant manager and nursing staff and dietician
Post Heart transplantation specific management
1) Regular endomyocardial biopsies weekly for the first month, then monthly, (15 total) to assess for acute allograft rejection
2) Additional biopsy indicated for hypotension, new dyspnoea, arrthymias (particular SVT/AF/flutter), unexplained fever, reduced LVEF, oedema, functional decline
3) 6-12 angiograms w/ intravascular US or dobamine stress TTE for development of coronary allograft vasculopathy
4) Immunosuppression - cyclosporin, mycophenolate mofetil and prednisolone; sirolimus, tacrolimus and azathioprine may be indicated along with Basiliximab (IL-2 receptor antibody) early in course
Complications of Heart Transplantation
Sepsis, particularly early in course; will require PJP prophylaxis, and antifungal prophylaxis; Not for live vaccines
Rejection - may be hyperacute (in theatre), acute cellular (most common) /acute humoral and chronic; monitored by endometrial biopsies; IV methylpred used for rejections +/- anti-thymocyte globulins
Atrial arrhythmias - sign of acute rejection
Persistent bradycardia post transplant, requiring PPM
Late graft failure/chronic rejection - caused by coronary intimal hyperplasia; irreversible, may respond to stenting, statins
Skin, solid organ and lymphoproliferative tumours
Hypertension secondary to cyclosporin and/or prednisolone +/- renal failure
Dyslipidaemia from cyclosporins, prednisolone
Renal failure, mulifactorial, cyclosporins
T2DM secondary to prednisolone, cyclosporin and tacrolimus
Psychiatric disturbance from steroids
Common precipitants for decompensated HF
- Poor adherence to fluid restriction
- NSTEMI/STEMI
- Intercurrent infection
- PE
- Pregnancy
- Thyroitoxicosis
- Post-operative setting
- Anaemia and acute haemorrhage
- Arrythmias
- Drugs – NSAIDs, amitriptyline, pioglitazones
- Sleep apnoea/ILD/COPD for RHF
Principles of HF management
Commence medications that improve mortality - ACEI/ARB, beta blocker, mineralocorticoid antagonist
Device therapies - cardiac resynchronisation therapy, AICD
Treatment of causes - Coronary artery bypass, reduce MI by HTN, dyslipidaemia and T2DM management, valve replacement if indicated, thyroid function, sleep study for OSA etc.
Symptom management - diuretics, fluid restriction
Cardiac rehabilitation with multidisciplinary team
Regular review from GP and cardiologist, TTE, monitor potassium and renal function, remove medications that may contribute
Consideration for cardiac transplant and/or ventricular assist devices
Management of chronic coronary syndrome
Medical management - Beta blocker, followed by calcium channel blocker, nitrate and ranolazine
Coronary artery revascularisation (CABG or PCI)
- Intractable symptoms despite therapy
- Significant risk of MI, prior VT w/ arrest, EF <50%
Risk factor prevention - quit smoking, HTN, lipid and glycaemic control, investigation and treatment of anaemia, thyroid dysfunction etc.
Multidisciplinary team w/ graduated exercise therapy e.g. walking club
Consideration of heart transplant
Indications for cardiac stress testing
- Symptoms suggesting angina
- Acute chest pain in low risk patients
- Post MI without intervention or incomplete revascularisation 3/12 for risk assessment
- Known CHD and recent change or candidates for revascularisation
- Post PCI >2 years and CABG >5 years
- patients with valvular heart disease severe MR/MS/AR or equivocal low flow AS
- Patients with newly diagnosed HF for investigation
- Pre-operative workup for non-cardiac surgery if METs<4 and cardiovascular risk or vascular surgery with significant CV risk
- Investigation of exercise induced arrhythmias
Choosing appropriate stress testing modality
- Unable to exercise - pharmacological stress testing - vasodilator or inotropic testing
- Airway bronchospasm, bradyarrythmias, hypotension CI to vasodilator testing
- recurrent VT or rapid AF or significant LTOT CI to inotropic testing - LBBB or ventricular pacing - echocardiogram or nuclear testing
- Obesity - stress radionucleotide imaging with PET
- Myocardial viability - radionucleotide with PET, CMR or SPECT
- Valve function and concurrent AS- TTE
- No evidence of acute unstable angina or STEACS
Indication for CT angiography
Moderate to low risk ischaemic chest pain
“rule out” CAD
Identify non-obstructive plaque
Reduce radiation dose as compared to coronary angiogram
Complications of myocardial infarct
Ventricular tachycardia and fibrillation (if >24hrs, poor prognosis and ACID required)
Systolic heart failure
Ventricular aneurysm (persistent ST elevation)
Ventricular rupture (60-80% mortality)
Functional mitral regurgitation (cordae tendinae rupture)
Dressler’s pericariditis
Complete heart block (Inferior infarcts)
Important MI ECG syndromes
Wraparound LAD due to anterior-inferior infarct Occlusion of type III LAD variant that involves inferior and precordial leads
Left main coronary occlusion Widespread ST depression with ST elevation in aVR >1mm
Wellen’s Syndrome Deep T waves or Biphasic T waves in V2-3 that indicates tight LAD stenosis
De Winter’s T waves LAD occlusion indicated by upsloping ST depression and symmetrically peaked T waves in praecordial leads
