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44 Cards in this Set
- Front
- Back
How important is acute cardiac disease in Australia?
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It's the leading cause of death.
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What's the most effective method for decreasing further acute events?
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Secondary prevention.
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What percentage of patients presenting to general practice have a history of IHD?
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Slightly more than 1%.
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What are the main non-modifiable risk factors for IHD?
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- Age.
- Sex. - Family History. |
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What are the modifiable risk factors for IHD?
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- 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. |
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What should be covered in a consultation with a patient who is post-MI?
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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. |
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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 |
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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. |
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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 |
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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. |
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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. |
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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. |
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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. |
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What is the prognosis of a patient post-MI?
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- 7-15% die within the next year.
- 10% if NSTEMI, 15% of STEMI. |
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What are the predictors to the prognosis of a post-MI patient?
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- LVEF.
- Residual ischaemia. - Arrhythmia. |
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When can a post-MI patient go back to work?
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Usually in 6-8 weeks.
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When can a post-MI patient go back to driving?
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2 weeks, 3 months if commercial.
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When can a post-MI patient go back to flying?
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2 weeks.
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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. |
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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. |
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Heart failure accounts for what percentage of GP presentations?
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0.5%
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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. |
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What is the most common reason for a medical admission to hospital?
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Heart failure.
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What are the risk factors for heart failure?
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- Age.
- Sex. - IHD and MI. - Diabetes. - Hypertension. - Obesity and sedentary lifestyle. - Rarer -- valve disease, cardiomyopathy, haemochromatosis. |
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What are the possible trigger factors for heart failure?
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- Atrial fibrillation.
- MI. - Respiratory infection and UTI. - Anaemia. - Hyperthyroidism. - Renal failure. - Medications (CCBs, NSAIDs, Glitazones). |
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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. |
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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. |
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Echocardiogram is useful in defining...
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Cardiac function and structure. However, in 10% of patients, a satisfactory echo cannot be obtained.
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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?
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No evidence base for treating these patients.
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Where and when is BNP released?
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BNP is released from the ventricles in response to pressure and volume overload. It is a first line 'rule-out' test.
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What can BNP predict?
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BNP predicts death and cardiovascular events, including in persons with no history of HF.
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How do you decide if a patient with SOB and SOA has HF?
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- Many have both lung and heart problems, especially smokers.
- Examination - JVP, cardiomegaly, S3. - Echo, CXR, BNP. |
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List non-pharmacological treatments for heart failure.
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- 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. |
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List pharmacological treatments for heart failure.
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- ACE-I.
- Beta-blocker (not CI in asthma). - Diuretic. - Digoxin (signs of toxicity). - Spironolactone - (CI), Eplerenone. |
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Prognosis of a patient with LVSD.
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- 5 year survival rate of about 50%.
- About equal chance of sudden death and pulmonary oedema. - Predictors include LVEF, NYHA, BNP. |
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What are strategies to improve medication compliance for reducing cardiovascular risk?
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- 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. |
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A combination of what medication is recommended for up to 12 months after a stent implantation?
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Aspirin + clopidegrel for 12 months, depending on the type of stent and the circumstances of implantation. After that, low-dose aspirin is recommended.
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Statin therapy should be started in all patients with ischaemic heart disease irrespective of pretreatment
cholesterol levels. True or false? |
True.
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What is the aim for LDL levels in cases of cardiovascular disease?
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2.5mmol/L.
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What should be started in all patients after an MI?
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Beta blocker, unless contraindicated.
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What 3 beta blockers are approved for use in MI?
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- Atenolol.
- Metaprolol. - Propanolol. |
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In patients with LV dysfunction, what drug class would be highly recommended?
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ACE inhibitor.
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What patient would it be recommended that clopidogrel + aspirin conjunction therapy be used long term?
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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. |
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Why would IV nitrates be useful in MI?
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- Alleviates pain.
- Limits infarct size. - Reduces short-term mortality. |