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44 Cards in this Set

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How important is acute cardiac disease in Australia?
It's the leading cause of death.
What's the most effective method for decreasing further acute events?
Secondary prevention.
What percentage of patients presenting to general practice have a history of IHD?
Slightly more than 1%.
What are the main non-modifiable risk factors for IHD?
- Age.
- Sex.
- Family History.
What are the modifiable risk factors for IHD?
- Smoking.
- Obesity (especially abdominal).
- Sedentary lifestyle.
- Diabetes.
- Hypercholesterolaemia (especially high LDL and low HDL).
- Ratio apolipoprotein A to B.
- Hypertension.
- Stress and psychosocial factors.
- Lack of fruit and veg in diet.
- Lack of regular alcohol.
What should be covered in a consultation with a patient who is post-MI?
History:
- Defining the patient's reason for attendance.
- Check for any risk factors (including co-morbidities and medications).
- Check for any complications.

Examination:
- Examine for signs of associated illnesses and complications.

Investigations

Treatment plan:
- Non-pharmacological.
- Pharmacological.

Education and plan for review:
- Patient's idea of problems, social support, etc.
A 66 y/o male who smokes about 20 cigs a day was admitted to hospital 10 days ago for an MI.

What details of the history needs to be elicited?
History of presenting complaint:
- Site and size of infarction (STEMI, NSTEMI, CK and Troponin levels).
- Treatment - thromboplasty, angioplasty.
- New medications.
- Investigations in hospital.
- Complications.

Prior medical history:
- Diabetes, hypertension, PVD, renal artery stenosis.

Prior medications
A 66 y/o male who smokes about 20 cigs a day was admitted to hospital 10 days ago for an MI.

What complications may present acutely?
- Cardiogenic shock.
- Papillary muscle rupture or VSD.
- Cardiac rupture and tamponade.
- Dressler syndrome.
- Further MI.
A 66 y/o male who smokes about 20 cigs a day was admitted to hospital 10 days ago for an MI.

What complications may present in GP?
- Heart failure.
- Arrhythmias.
- Aneurysm.
- DVT or PE.
- Depression
A 66 year old male who smokes 20 cigs a day was admitted 10 days ago for MI.

What sort of disorders are to be looked out for on examination?
- Heart failure.
- Hypertension.
- Arrhythmias.
- Murmurs.
- PVD.
- DVT.
A 66 year old male who smokes 20 cigs a day was admitted 10 days ago for MI.

During the hospital admission and after the hospital admission, what investigations would have been ordered?
During hospital admission:
- ECG.
- CK-MB, Troponin.
- Exercise tolerance test (looking for uncompensated cogestive heart failure, cardiac arrhythmias, or noncardiac conditions that severely limit their ability to exercise).
- Echo.
- Also check for diabetes.

After the hospital admission:
- Cholesterol.
- ECG.
- +/- blood glucose, thyroid.
A 66 year old male who smokes 20 cigs a day was admitted 10 days ago for MI.

What non-pharmacological treatment modalities would be considered?
- Cardiac rehabilitation program (of proven benefit, but unfortunately only about 17% get this).
- Cease smoking (consider nicotine replacement therapy).
- Weight and diet changes.
- ?Stress management.
- Omega-3 fatty acids are probably beneficial.

NOT BENEFICIAL: low fat diet, beta carotene, vitamin C or E.
A 66 year old male who smokes 20 cigs a day was admitted 10 days ago for MI.

What pharmacological treatment modalities would be considered?
Antiplatelet therapy:
- Aspirin (75-100mg/day) continued indefinitely.
- Clopidogrel/ticlodipine - Use for 12 months after stenting if recurrent STEMI or NSTEMI.

Beta blockers:
- Reduce all cause and coronary mortality for up to 2 years.
- NNT about 50.
- Continue indefinitely.

ACE inhibition:
- HOPE and EUROPA trials suggest benefit in patients with IHD (but not that HOPE did not investigate patients for HF on entry into the trial).
- Use if BP target is not met (< 130/80mmHg).
- AT2-R antagonists on PBL if intolerant to ACE-Is.

Statin treatment:
- Target Total Cholesterol < 4.0 (PBS restriction) and LDL < 1.6.
- NNT 25-50.
- Should start on dose equivalent to atorvastatin 40mg/day.
- Ezetimibe may be used if not controlled or statin is contra-indicated.
What is the prognosis of a patient post-MI?
- 7-15% die within the next year.
- 10% if NSTEMI, 15% of STEMI.
What are the predictors to the prognosis of a post-MI patient?
- LVEF.
- Residual ischaemia.
- Arrhythmia.
When can a post-MI patient go back to work?
Usually in 6-8 weeks.
When can a post-MI patient go back to driving?
2 weeks, 3 months if commercial.
When can a post-MI patient go back to flying?
2 weeks.
A 66 year old male who smokes 20 cigs a day was admitted 10 days ago for MI.
1 week later, his wife calls up saying that he is short of breath and sweating and feeling unwell (note that it is January in Brisbane).

What is the differential diagnosis?
- Heat and dehydration.
- Further MI.
- Pulmonary embolism.
- Arrhythmia.
- Effect of beta blocker.
- Pneumonia.
- UTI.
A 66 year old male who smokes 20 cigs a day was admitted 10 days ago for MI.
1 week later, his wife calls up saying that he is short of breath and sweating and feeling unwell (note that it is January in Brisbane).

What needs to be examined?
- Temperature.
- Pulse.
- BP and postural BP.
- Heart sounds, especially murmur.
- Chest.
- SOA.
Heart failure accounts for what percentage of GP presentations?
0.5%
A 72 year-old woman has been treated for BP and hypothyroidism. She presents with 2 months of fatigue and shortness of breath.

What are the general history taking tasks for consultation of a patient with HF?
History
- Define the reason for attendance and HPC.
- Check risk factors (including meds and medical history).
- Check for triggering factors.
- Check for any complications.
- Patient's idea of problems, social support, etc.
What is the most common reason for a medical admission to hospital?
Heart failure.
What are the risk factors for heart failure?
- Age.
- Sex.
- IHD and MI.
- Diabetes.
- Hypertension.
- Obesity and sedentary lifestyle.
- Rarer -- valve disease, cardiomyopathy, haemochromatosis.
What are the possible trigger factors for heart failure?
- Atrial fibrillation.
- MI.
- Respiratory infection and UTI.
- Anaemia.
- Hyperthyroidism.
- Renal failure.
- Medications (CCBs, NSAIDs, Glitazones).
A 72 year-old woman has been treated for BP and hypothyroidism. She presents with 2 months of fatigue and shortness of breath.

What should be examined in possible heart failure?
- BP.
- HR, especially tachycardia, AF.
- JVP.
- Cardiomegaly.
- S3.
- Peripheral oedema.
- Weight and BMI.
A 72 year-old woman has been treated for BP and hypothyroidism. She presents with 2 months of fatigue and shortness of breath.

What investigations could be ordered for possible heart failure?
- FBE.
- ELFT, lipids, BSL.
- TSH.
- ECG: Q waves, LBBB, T wave inversion, LVH. Rarely normal, but mostly non-specific.
- CXR: CTR, Kerley B lines, pleural effusion, perihilar oedema.
Echocardiogram is useful in defining...
Cardiac function and structure. However, in 10% of patients, a satisfactory echo cannot be obtained.
A high proportion of HF patients (maybe up to 50%) with heart failure have preserved systolic function. What evidence is there for treating these patients?
No evidence base for treating these patients.
Where and when is BNP released?
BNP is released from the ventricles in response to pressure and volume overload. It is a first line 'rule-out' test.
What can BNP predict?
BNP predicts death and cardiovascular events, including in persons with no history of HF.
How do you decide if a patient with SOB and SOA has HF?
- Many have both lung and heart problems, especially smokers.
- Examination - JVP, cardiomegaly, S3.
- Echo, CXR, BNP.
List non-pharmacological treatments for heart failure.
- Exercise (+/- cardiac rehab).
- Cease smoking.
- Weight and diet.
- Fluid restriction.
- Salt restriction.
- Flu and pneumococcal vaccination.
- Management plan -- what to do if symptoms get worse.
List pharmacological treatments for heart failure.
- ACE-I.
- Beta-blocker (not CI in asthma).
- Diuretic.
- Digoxin (signs of toxicity).
- Spironolactone - (CI), Eplerenone.
Prognosis of a patient with LVSD.
- 5 year survival rate of about 50%.
- About equal chance of sudden death and pulmonary oedema.
- Predictors include LVEF, NYHA, BNP.
What are strategies to improve medication compliance for reducing cardiovascular risk?
- Explaining the purpose, benefits and importance of the
medications.
- Explaining the importance of cardiovascular risk reduction and achieving
tighter blood pressure and lipid control.
- Regular follow-up and review.
- Monitor treatment effects.
- Simplify medication regime.
- Psychosocial interventions.
A combination of what medication is recommended for up to 12 months after a stent implantation?
Aspirin + clopidegrel for 12 months, depending on the type of stent and the circumstances of implantation. After that, low-dose aspirin is recommended.
Statin therapy should be started in all patients with ischaemic heart disease irrespective of pretreatment
cholesterol levels. True or false?
True.
What is the aim for LDL levels in cases of cardiovascular disease?
2.5mmol/L.
What should be started in all patients after an MI?
Beta blocker, unless contraindicated.
What 3 beta blockers are approved for use in MI?
- Atenolol.
- Metaprolol.
- Propanolol.
In patients with LV dysfunction, what drug class would be highly recommended?
ACE inhibitor.
What patient would it be recommended that clopidogrel + aspirin conjunction therapy be used long term?
In patients who suffer recurrent acute coronary syndromes with ST-segment deviation or elevated troponin level.

In the absence of ongoing ischaemia, it is not recommended.
Why would IV nitrates be useful in MI?
- Alleviates pain.
- Limits infarct size.
- Reduces short-term mortality.