Cardiovasc

Question 1

Chest pain - probability diagnosis?

Answer 1

• Psychogenic
• Musculoskeletal
• Angina

Question 2

AMI - management

Answer 2

Management
o Oxygen – now only indicated if Sa02 <95%
o Aspirin
o GTN 300mcg SL or spray (every 5/60 as necessary up to 3 doses) – be aware of Viagra
o IV access
o IV morphine 2-5mg bolum; 1mg/min until pain relief up to 15mg
o ECG – key is to classify ACS into STEMI or non-STEMI

Key management of STEMI will be to get a patient to a Cath lab for PTCA ideally within an 1 hour of chest pain (if not possible e.g. rural locations thrombolysis is indicated if no CI’s exist)

Post AMI complications to be weary of are: CCF; pericarditis; LV aneurysm; Ventricular septal and mitral valve papillary rupture

Question 3

Pericarditis - Presenting symptoms

Answer 3

• Can cause 3 types of pain – pleuritic (commonest) – often worse with lying flat, pain mimicking AMI, pain synchronous with heart beat and radiating to left shoulder
• O/E – fever, Signs of tamponade

Question 4

Pericarditis - Investigations and Mx

Answer 4

• ECG – PR depression, diffuse saddle shaped STE
• Echo – can detect effusions, tamponate
• Cardiac CT – can show pericardial thickness
• Bloods including inflammatory markers are useful

Management – treat underlying cause, NSAIDS, rest

Question 5

Aortic Dissection - Presenting picture

Answer 5

• Sudden severe midline chest pain – tearing in nature; may be interscapula
• Associated PMhx: Aortic valve disease, Hypertension, Pregnancy, Genetics – Marfans, Ehlers-Danlos

Examination Findings:

• BP (may be high, low or normal)
• Asymmetric pulses
• Signs of tamponade – hypotension, quiet HS, raised JVP, pulsus paradoxus; pericardial friction rub
• Systolic murmur – AR (incompetence)
• Ischaemic neurological deficits – hemiplegia, hemiparesis

Question 6

Aortic Dissection - Ix and Management

Answer 6

Investigations

• CXR – screening test
• TTE or helical CT for diagnosis
• ECG findings – may mimic AMI findings

Management - Surgery

Question 7

Respiratory causes of Chest Pain

Answer 7

• PE
• Lung Cancer
• Pneumonia
• Pleuritis – can be due to infection, pulmonary infarction, tumour, connective tissue disorders

Question 8

Spontaneous Pneumothorax - when to suspect? Hx/Ex/Ix/Mx?

Answer 8

• Suspect in those with history of – Asthma or COPD and young slender males
• O/E – tachycardia, Decreased breath sounds
• Diagnosis is made on CXR – expiratory films
• Management - <25%, no symptoms – can observe, if symptoms drain, >25%. drain

Question 9

CP caused by cox-sackie virus (faecal oral route)

Answer 9

Epidemic Pleuordynia

• Occurs in epidemics and mainly affects children and young adults
• Causes chest/upper abdominal pain – often pleuritic in nature, as well as myalgia elsewhere
• Diagnosis of exclusion
• Management is analgesia

Question 10

What are features of Chostocondritis?

Answer 10

• Often precedes an URTI

Often one sided, sharp and made worse with breathing, physical activity and palpation

Question 11

Unilateral sharp pleuritic chest pain with a tender, fusiform swelling at the chndrosternal junction?

Answer 11

Tietze Syndrome

Cause is not well understood – may relate to physical strain or minor injury

Question 12

Seven masquerades for Chest pain?

Answer 12

• Depression 
• Drugs 
• Diabetes x
• Anaemia  - indirectly
• Thyroid dysfunction x
• Spinal dysfunction  - referred pain from facet joints rather than nerve root pain
• UTI x

Question 13

Chest pain in Children? Most common causes?

Answer 13

Most common cause – idiopathic followed by musculoskeletal, cough related, costochondritis and psychogenic

Question 14

– low chest pain lasting 30s-3mins after exercise – relieved by standing up right and taking slow deep breaths

Answer 14

Precordial Catch aka Texidor twinge or stitch

Question 15

AF - epidemiology?

Answer 15

AF affects 1% of the Australian Population >50% are over 75

RR of stroke is increased by 5x and 3x increased risk of CCF

Question 16

AF - Risk factors?

Answer 16

• Structural e.g. valvular abnormalities, cardiomyopathy
• Conduction e.g sick sinus syndrome, WPW
• Functional e.g AMI, pericarditis
• Stress on the heart e.g. IHD, hypertension, PE
• Physiologic/Hyperadrenergic states – medications and drugs, stress, fever, hyperthyroidism

Question 17

AF - Categories?

Answer 17

• Paroxysmal (usually <48 hours) - 90% have recurrent episodes
• Persistent >7 days
• Permanent >1 year
• Lone (without evidence of structural disease)

Question 18

AF - History?

Answer 18

• Palpitations
• SOB
• Lightheadedness/syncopal episodes
• Focal neurological deficit
• PMhx
• Meds and drugs – e.g. alcohol, caffeine, illicit drugs

Question 19

AF - Examination findings

Answer 19

• Vitals- Pulse irregularly irregular, BP to check for decompensation, fever as potential cause
• HS – listen for murmurs – valvular abnormalitites
• Chest – if CCF bibasal crackles, peripheral oedema, JVP raised

Question 20

AF - Investigations

Answer 20

• ECG

• Absence of p-waves
• Irregular RR intervals

• Echo

• TOE or TTE
• TOE used to exclude left atrial appendage thrombus

Bloods
•	FBE
•	UEC
•	LFT
•	TSH
•	Ca/Mg
•	Fasting glucose
•	Fasting lipid profile

• CXR – check for CCF

Question 21

Acute management AF

Answer 21

In patients without CCF and without pre-excitation:

• Metoprolol 2.5-5mg IV over 2/60, up to 3 doses OR
• Verapamil 0.075-0.15 mg/kg IV over 2/60

In patients with CCF and without pre-excitation – IV digoxin or IV amiodarone

In patients with pre-excitation – IV amiodarone

Question 22

AF - Rate control

Answer 22

• Beta blocker – e.g. metoprolol 50-200mg/day OR
• Non-dihydropyridine calcium channel blocker – e.g. diltiazem or verapamil
• Digoxin – indicated for rate control in patients with CCF, LV dysfunction or sedentary individuals
• Oral amiodarone – may be indicated when other medical therapies fail
• Ablation of AV node or accessory pathways – may be indicated if medical therapies fail

Question 23

AF - Rhythm control?

Answer 23

Rate control preferred – only do if the above measures fail

DC Cardioversion
Recommended if rapid ventricular rate unresponsive to medications and myocardial ischaemia or hypotension or heart failure
If <48 hours of known duration of AF can do without delay for anticoagulation
If >48 hours or of unknown duration – either 3/52 anti-coagulation INR 2-3 OR initial anticoagulation, TOE to confirm no atrial thrombus, then cardioversion within 24 hours

Pharmacologic Cardioversion options include flecainide, amiodarone

Question 24

How do you decide anti-coagualtion for AF?

Answer 24

Determined by the CHA2DS2-VA
Condition and	Points
 C 	 Congestive heart failure (or Left ventricular systolic dysfunction)	
1
 H	 Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)	
1
 A2	 Age ≥75 years	
2
 D	 Diabetes Mellitus	
1
 S2	 Prior Stroke or TIA or thromboembolism	
2
 V	 Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)	
1
 A	 Age 65–74 years	
1

0 - low risk - no therapy or low dose aspirin
1 - moderate risk – benefit from warfarin/anticoagulation
>/= 2 points - high risk and long term oral anticoagulant therapy is strongly recommended

CHADS 2 score	Annual stroke rate
0 			1.9 %
2			4%
4			8.5%
6			18%

Other relevant factors
Echo findings - systolic dysfunction and left atrial enlargement
Vascular factors - previous MI, PVD, complex aortic plaque

Question 25

Risk Mitigation for AF Anticoagulation

Answer 25

Looks at risk of major bleeding whilst on oral anticoagulant treatment Risk of major bleeding is at least 1-1.5% annually HAS-BLED • Helps identify correctable RF’s for bleeding and identify patients at high risk • It should not be used to exclude patients from anticoagulant treatment but rather serve to indicate increased monitoring • Correctable RF’s should be managed ``` Hypertension (Sytolic BP >160mmHg) Abnormal renal or liver function Stroke (history of) Bleeding (Hx of or diathesis) Labile INRS (<6/10 in therapeutic range) Elderly (>65) Drugs (antiplatelet agents, NSAIDS, alcohol >/= 8 SD per week) ```

Question 26

Anticoagulation in AF

Answer 26

Warfarin or novel anticoagulants (target thrombin directly)

Question 27

Warfarin in AF

Answer 27

Its used in valvular AF - mod/sev mitral STENOSIS or mechanical heart valve. Otherwise use a NOAC Reduces the incidence of AF related stroke by about 2/3rds

Question 28

Which novel anticogulants are available? When are they used? What dosage?

Answer 28

Rivaroxaban Dose is 20mg daily – reduce to 15mg OD if CrCl 30-49 PBS approved for: • Preventions of stroke and systemic embolism in non-valvular AF and at least one additional risk factor as defined by the CHADS2 score • Prevention of venous thromboembolism after THR or TKR surgery • Treatment of acute PE; DVT or prevention of venous thromboembolism recurrence in people with a history of VTE * Bleeding risk less than or equal to that of warfarin * No antidote - unlike warfarin * Not to be used in patients with hepatic disease, increased INR, severe renal impairment Pradaxa (Dabigatran) 150mg BD; Dose reduction to 110mg BD for age >/=75, CrCl 30-50, higher risk of bleeding PBS approved for: • Preventions of stroke and systemic embolism in non-valvular AF and at least one additional risk factor as defined by the CHADS2 score • Prevention of venous thromboembolism after THR or TKR surgery • Treatment of acute PE; DVT or prevention of venous thromboembolism recurrence in people with a history of VTE Eliquis (Apixaban) • Requires BD dosing – either 2.5mg BD or 5mg BD • Dose reduction for Age >/= 80; bodyweight = 60kg; Serum Cr >/= 133 • CI – Severe hepatic disease (Child-Pugh C); severe renal impairment CrCl <25; strong clinical risk of bleeding PBS approved for: • Preventions of stroke and systemic embolism in non-valvular AF and at least one additional risk factor as defined by the CHADS2 score • Prevention of venous thromboembolism after THR or TKR surgery *In comparative trials only apixaban was found to have a lower incidence of major bleeds c.f. warfarin

Question 29

Switching anticoagulants in AF?

Answer 29

Stop Warfarin | Commence new anticoagulant once INR <2

Question 30

Hypertension assessment/grading

Answer 30

Blood pressure Category Action BP <120/<80 Normal Recheck in 2 years BP 120-139/80-89 High Normal Recheck in 1 year or as per CV risk 140-159/90-99 Grade 1 Confirm within 2 months 160-179/100-109 Grade 2 Reassess or refer within 1 month ≥180/110 Grade 3 Reassess or refer within 1-7 days Isolated systolic - >140/<90 as per systolic above Isolated systolic with widened pulse pressure >160/<70 - as for grade 3 hypertension

Question 31

Who needs Immediate Anti hypertensive treatment?

Answer 31

Those at high absolute CV risk >15% probability of a CV event in the next 5 years. Can be assumed as high for the following groups: 1. Group A - patients 75 years and over 2. Group B - patients with existing CV disease including IHD/CCF/Previous Stroke/PVD/LVH/Aortic disease 3. Group C - Patients with associated clinical conditions and/or end-organ disease: ``` Associated • Diabetes AND age >60 or microalbuminuria >2.5 mg/mmol males >3.5 females • Dyslipidemia - Total cholesterol >7.5 • Familial hypercholesterolaemia • FHx of premature CV disease ``` ``` AND as per group B (also associated) • IHD • CVA • PVD • Aortic disease ``` End-organ disease • Chronic Kidney disease - eGFR<60 - Proteinuria defined as urine protein >300mg/day or Protein/Cr ratio >/=30 mg/mmol - Microalbuminuria - Alb:Cr ≥ 2mg/mmol males or 2.5 mg/mmol female; 24 hour urinary albumin excretion rate >20 mcg/min • Vascular disease - atherosclerotic plaque - aorta; carotid; coronary; peripheral vasculature • Hypertensive retinopathy AND Grade 3 hypertension or systolic hypertension with widened pulse pressure For everyone else consider use of risk charts

Question 32

Hypertension lifestyle risk reduction?

Answer 32

* 30/60 moderate intensity physical cativity on most if not all days of the week - daily total can be accumulated during the day * Smoking cessation * Dietary salt restriction - ?2 or 4g/day - recommend low-salt and salt-reduced foods * Limited alcohol intake = 2 SD per day for men and = 1 SD per day for women Patient's who need immediate antihypertensive drug treatment include: • Those at high absolute CV risk >15% probability of a CV event in the next 5 years Also consider drug therapy for • Patients with moderate risk of CV disease as estimated using risk calculator • Aboriginal and Torres Strait Islanders

Question 33

Treatment targets for HTN?

Answer 33

• People with no other co-morbidity <140/90 • People with associated conditions or end organ damage <130/80 People with proteinuria >1g/day <125/75

Question 34

First line drugs for HTN therapy?

Answer 34

First line drugs: • ACE-I or ARB • Dihydropyridine Calcium Channel Blockers • Low-dose thiazide diurects (suitable for patients aged 65 years and older - have been associated with increased risk of new-onset diabetesa and should be used with caution in patients with glucose intolerance and/or metabolic syndrome Start dose low, if target BP not reached consider introduction of another first line medication (in addition) before increasing doses. If target is not achieved and both drugs are well tolerated increase doses. Use up to four antihypertensive drugs in combination to achieve target Avoid these combinations: • Beta-blocker plus verapamil (non dihydropyridine calcium channel blocker) • ACE-I plus ARB • ACE-I or ARB plus potassium sparing diuretics e.g. amiloride, spirinolactone Based on estimates 50-75% of patients will not achieve satisfactory BP control on monotherapy Based on the best available evidence the most effective combination is ACE-I or ARB plus calcium channel blocker

Question 35

Beta blockers in HTN?

Answer 35

Beta blockers are no longer recommended as first-line therapy in uncomplicated hypertension because of the increased risk of developing diabetes and the recently described trend towards worse outcomes in patient's treated with these compared with other classes of drugs. Stable patients already on a beta-blocker do not need to have their medication changed

Question 36

Follow up and things to consider if inadequate response to first line HTN therapy?

Answer 36

Follow up Medium-low risk check every 6/12 High risk check every 3/12 Things to consider if inadequate response to treatment • Poor compliance • Lifestyle issues - treatment resistance due to alcohol/recreational drugs; other medications e.g. NSAIDS, high salt intake, volume overload • Undiagnosed secondary hypertension e.g CKD, hyperaldosteronism, renal artery stenosis, phaeochromocytoma, co-arctation of the aorta • Treatment resistance due to sleep apnoea • White coat hypertension

Question 37

Secondary Causes of Hypertension?

Answer 37

Chronic kidney disease • Underlying cause not able to be treated • May be both a cause and consequence of hypertension • Defined as 3 months or more of an eGFR<60 or other markers e.g. albuminuria >30 mcg/mg creatinine in a first morning voided urine sample • ACE-I should be part of regimen Good screening tests: UEC/First morning voided urine for alb:cr ratio Primary hyperaldosteronism • Causes: 60% bilateral adrenal hyperplasia; 35% aldosterone-productng adenomas; remainder due to adrenal cardinoma, unilateral adrenal hyperplasia etc • Often associated with raised BMI; sleep apnoea and hypokalemia (not always present) • These patients are at risk of LVH; AMI; AF; stroke and the metabolic syndrome Good screening test: • Aldosterone/renin ratio - if high >20-40 confirmatory tests may be done which include 2 L n/saline or captopril and remeasurement of ratio if there is supression then treatment is best done with an agent such as spirinolactone. • If there is no suppression HRCT of the adrenals/adrenal venous sampling +/- surgery may occur Renal artery stenosis • Up to a 1/3 of cardiac patients requiring stenting also have renal artery stenosis • Medical management of this has been shown in studies to be just as effective as stenting there the only times where you would consider stenting would be in a patient who cannot tolerate and CAI or ARB or in patients with ongoing poor control despite maximum medical therapy Good screening test: Renal doppler U/S - other options HR CTA or MRA Cushing syndrome Good screening test - Urinary free cortisol >100mcg/day; midnight serum cortisol; high dose dexamethasone suppression tests Pheochromocytoma Good screening test - plasma metanephrines/cathecholamines; 24 hour urine for VMA and metanephrines/catecholamines If the above are positive search for an adrenal lesion should be done via CT or MRI abdomen Coarctation of the aorta Key is blood pressure differences across the limbs; systolic murmur may also be heard Good scrrening test Echo Sleep apnoea

Question 38

Acute Pulmonary Oedema precipitating causes?

Answer 38

``` Cardiac • AMI • Arrhythmias • Uncontrolled hypertension • Significant valvular disease (stenosis and regurgitation) ``` Pulmonary • PE • Infection ``` Others • Anaemia • Hyperthyroidism • Medications • Excessive alcohol and salt intake ```

Question 39

APO investigations?

Answer 39

ECG - check for AF, AMI, LVH CXR • Enlargement of Cardiothoracic ratio >50 • Pulmonary congestion (Bat wing oedema) • Fluid in the fissures • Kerley B lines (interstitial oedema - usually seen at the lung bases) • Prominent upper lobe vessels • Blunting of costophrenic angles ``` Bloods • FBE • UEC • LFT • TSH • CK and Tn • BNP - may be done in larger centres ```

Question 40

APO acute management?

Answer 40

``` • Sit patient upright • Oxygen • ECG • Pulse oximetry • IV access - can do bloods at the same times Medications CPAP ```

Question 41

APO medications?

Answer 41

Medications GTN • Sublingual or topical • To be given if BP systolic >90 mmHg • Given IV in some major hospitals (ensuring that BP is >100mmHg) Lasix • Usual daily dose or 1-1.5mg/kg • Beneficial effect is accelerated by pre-treatment with a vasodilator Morphine • No longer recommended • Emerging data links it use with increased intubation and mortality rates • No studies have ever shown benefit

Question 42

CPAP in APO?

Answer 42

CPAP • Effective in pre-load and afterload reduction • Associated with decreased intubation and mortality Patient with the following conditions may benefit from early CPAP listed in order of evidence: • Acute exacerbations of COPD • Acute cardiogenic pulmonary oedema • Pneumonia - patients with COPD and immunocompromised seem to benefit • COPD or APO where a decision has been made not to intubate - prevent deterioration • COPD or APO where extubation has failed after a brief course of intubation - CPAP might ease the transision *CPAP is not recommended in asthma, ARDS, other causes of respiratory failure

Question 43

Complications of CPAP?

Answer 43

* Pain or ulcer over nasal bridge * Mucosal dryness * Eye irritation - if the mask seal is not complete * Gastric insufflation (air blowing) or aspiration

Question 44

ICU therapies for APO (aside from CPAP?)

Answer 44

* Adrenaline infusion * Vasodilators (sodium nitroprusside) * Inotropes (for cardiogenic shock or hypoperfused state with systolic BP <90mmg Hg) (aramine eg) * Mechanical support e.g. intra-aortic balloon pump)

Question 45

In regards to treatment for peripheral arterial disease, which of the following treatments can improve walking distance? Choose one (1) option. Rampiril 10mg orally daily Smoking cessation Simvastatin 40mg orally daily A graduated walking program All of the above

Answer 45

All of the above https://www.racgp.org.au/afp/2013/june/peripheral-arterial-disease-diagnosis/

Question 46

Patricia is a 65 year old female patient who you have been seeing for several years for management of her diet-controlled type 2 diabetes. She reports a healthy diet which is low in salt and she has recently lost 10% of her body weight. Over the past six months she has started walking for 60 minutes each day with a friend. Patricia is a non-smoker and non-drinker. Six months ago you diagnosed her with hypertension and prescribed perindopril arginine 5mg daily which she has been taking regularly with no side effects. During Patricia’s last consultation three months ago you noted that her blood pressure was still168/95. She had some blood pressure readings performed at the local pharmacy since then which show similar readings. You recheck her blood again today and it is 170/90. How do you manage Patricia’s blood pressure now? Advise Patricia that no change to her anti-hypertensive medication is required at this stage and encourage continued lifestyle change Add amlodipine 5mg daily Add metoprolol 50mg daily Increase Perindopril arginine to 10mg daily Add Irbesartan 150mg daily

Answer 46

The correct response is: Add amlodipine 5mg daily. Current guidelines recommend the use of either an angiotensin-converting enzyme inhibitor (ACE i) or angiotensin receptor blocker (ARB) first line for treatment of hypertension in patients with type 2 diabetes. This is a superior choice to other anti-hypertensives in this group of patients because these drugs have been found to reduce progression to microalbuminuria and reduce the risk of renal impairmen. If monotherapy with an ACEi or ARB does not sufficiently reduce blood pressure the next step is to add one of either a calcium channel blocker or a low dose thiazide or thiazide like diuretic. Combination therapy, defined by the use of at least two antihypertensive drugs, is required in up to 50–70% of patients to reach blood pressure targets. It is widely accepted that combining two classes of antihypertensive drug lowers blood pressure more than doubling the dose of one drug. The Royal Australian College of General Practitioners. General practice management of type 2 diabetes: 2016 – 2018. East Melbourne, Victoria. https://www.racgp.org.au/download/Documents/Guidelines/Diabetes/2015diabetesmanagement.pdf

Question 47

You are seeing a 62 year old female patient who consistently has high blood pressure readings in the clinic. Today her blood pressure is 162/97mmHg. She reassures you she just has “white coat hypertension” and that she is not concerned about her blood pressure. You convince her that you need to obtain some normal blood pressure readings outside of the clinic in order to agree with her diagnosis of “white coat hypertension”. Although she will not agree to a 24 hour ambulatory blood pressure recording, she will agree to home blood pressure monitoring. She borrows the automated blood pressure device the clinic loans out to patients. Which of the following statements about home blood pressure readings is correct? Choose one (1) option. Blood pressure should be monitored at different times in the morning and evening Blood pressure should be checked after eating and vigorous exercise Blood pressure should be checked before taking regular daily medications Blood pressure should be taken three times daily for four consecutive days Caffeine and cigarettes should be avoided for at least 15 minutes before measuring blood pressure

Answer 47

The correct response is: Blood pressure should be checked before taking regular daily medications Patients should be given advice on how to correctly take home blood pressure readings. They should be advised to take the readings before medication, food and vigorous exercise for seven consecutive days. The readings should be taken at the same time each morning and night. Cigarettes and caffeine need to be avoided for at least 30 minutes before taking a reading. Reference: Sharman, J. et al. How to measure home blood pressure: recommendations for healthcare professionals and patients. Australian Family Physician, 2016; 45(1-2):31-34. https://www.racgp.org.au/afp/2016/januaryfebruary/how-to-measure-home-blood-pressure-recommendations-for-healthcare-professionals-and-patients/

Question 48

A 45 year old male presents with episodes of a racing heart, sweating and headaches. He states that these symptoms have increased in the last 6 months and are now a daily occurrence. On examination he appears well, is afebrile and has a blood pressure of 170/110. He has lost 5kg since his last clinic appointment 2 months ago. Which of the following investigations would be a suitable screening test for his most likely diagnosis? Choose one (1) option. Plasma aldosterone to plasma renin activity ratio Early morning cortisol level 24 hour urinary catecholamines and metanephrines Short synacthen test 1mg overnight dexamethasone suppression test

Answer 48

The correct response is: 24 hour urinary catecholamines and metanephrines This case is describing a patient with symptoms and signs consistent with a pheochromocytoma. 24 hour urinary catecholamines and metanephrines have a sensitivity of 90% and specificity of 98% for this condition. Reference: Gendy R, Rashid P. Incidental adrenal masses - A primary care approach. Australian Family Physician 2017; 46(6): 385-390. https://www.racgp.org.au/afp/2017/june/incidental-adrenal-masses-a-primary-care-approach/

Question 49

A 76 year old male presents with fatigue, intermittent palpitations and shortness of breath at rest. He is currently on Perindopril for his hypertension but has no other regular medications. He has a past history of peripheral arterial disease and a transient ischaemic attack (TIA) 2 years ago. On examination you note that he has an irregularly irregular heart rate. You suspect the patient has atrial fibrillation and order an ECG which confirms this diagnosis. You base your decision for anticoagulation for stroke prevention on this patient’s CHA2DS2-VA score. What is this patient’s score? Choose one (1) option. 8 7 6 5 4

Answer 49

The 2018 Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation recommends the use of the CHA2 DS2-VA score to assess stroke risk. This patient’s score is 6: ``` History of hypertension: 1 point Age ≥75 years: 2 points History of prior TIA: 2 points Vascular disease (peripheral arterial disease: 1 point ``` Reference National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Australian Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. https://www.heartlungcirc.org/article/S1443-9506(18)31778-5/fulltext (Accessed November 2019)

Question 50

Your patient, 73 year old Rohan Balci, is concerned about a new small pigmented skin lesion on his forearm. Your examination confirms a 4mm pigmented lesion with some border irregularity. You plan to perform an excisional biopsy but are concerned about bleeding risks as Rohan is on aspirin and prasugrel which was commenced nine months ago following his ST elevation myocardial infarction. This was treated with percutaneous coronary intervention and a single coronary artery stent. What is the most appropriate way in which to manage Rohan’s skin lesion? Choose one (1) option. Excise under local anaesthetic; cease aspirin and prasugrel the day prior to the procedure and resume the next day following the excision. Excise under local anaesthetic; cease aspirin and prasugrel for 10 days prior to the procedure and resume the next day following the excision. Wait for three months until the planned cessation of prasugrel while continuing aspirin; then excise under local anaesthetic. Continue his current medications and excise under local anaesthetic. Continue his current medications and treat the skin lesion with cryotherapy.

Answer 50

The correct response is: Continue his current medications and excise under local anaesthetic. A new pigmented skin lesion with border irregularity requires a histological diagnosis to exclude melanoma. It is not appropriate to wait three months or to treat with cryotherapy. Any cessation of dual anticoagulant therapy in this patient would carry a significant risk of stent thrombosis and recurrent myocardial infarction. There is likely to be increased bleeding at excision when on dual anticoagulation therapy but an excision on the forearm might be managed with additional local measures such as extra local pressure and additional sutures. References: Jayasinghe R, Markham R, Adsett G. Dual antiplatelet therapy: Management in general practice. Australian Family Physician 2013; 42 (10): 702-705. https://www.racgp.org.au/afp/2013/october/dual-antiplatelet-therapy/ (Accessed January 2020).

Question 51

You are seeing a 62 year old female patient who consistently has high blood pressure readings in the clinic. Today her blood pressure is 162/97 mmHg. She reassures you she just has “white coat hypertension” and is not concerned about her blood pressure. You convince her that you need to obtain some normal blood pressure readings outside of the clinic in order to agree with her diagnosis of “white coat hypertension”. Although she will not agree to a 24 hour ambulatory blood pressure recording, she will agree to home blood pressure monitoring. She borrows the automated blood pressure device the clinic loans out to patients. Which of the following statements about home blood pressure readings is correct? Choose one (1) option. Patients should be advised to sit quietly for 1 minute before taking their blood pressure at home Home blood pressure readings are less reliable than clinic readings in terms of determining the true underlying blood pressure Patients should be advised to take one blood pressure measurement morning and evening for seven consecutive days Average home blood pressure readings of 135/85 mmHg or more is the threshold for diagnosing hypertension Patients should be advised to take three blood pressure readings daily over a four week period

Answer 51

The correct response is: Average home blood pressure readings of 135/85 mmHg or more is the threshold for diagnosing hypertension Two measurements of home blood pressure should be taken, one minute apart, after 5 minutes of sitting quietly, morning and evening, for 7 consecutive days. Reference: Sharman, J. et al. How to measure home blood pressure: recommendations for healthcare professionals and patients. Australian Family Physician 2016; 45(1-2): 31-34. https://www.racgp.org.au/afp/2016/januaryfebruary/how-to-measure-home-blood-pressure-recommendations-for-healthcare-professionals-and-patients/

Question 52

Fred is a seven year old boy is brought to you by his parents who say that he has has been complaining of trouble with his vision at school. On examination his blood pressure is 145/90mmHg. You take further history and perform further examination to determine is Fred is likely to be suffering with secondary or essential hypertension. Which feature in this list is MOST likely to fit with essential hypertension? Abdominal bruit Ambiguous genitalia Delayed femoral pulses Diastolic hypertension History of umbilical artery catheterisation History of urinary tract infections Malignant hypertension Nocturnal hypertension Family history of hypertension Oedema Prepubertal child Resistant hypertension despite the concurrent use of 3 anti-hypertensives at adequate doses from different classes Tachycardia, sweating, headache and flushing

Answer 52

Obesity and a family history of hypertension make essential rather than secondary hypertension more likely. Gupta-Malhotra M et al. Essential Hypertension vs. Secondary Hypertension Among Children. Am J Hypertens. 2015 Jan; 28(1): 73–80. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4318949/ (Accessed Dec 2018)

Question 53

Pathophysiology of Heart Failure?

Answer 53

Myocardial injury ↓ LV dysfunction (EF<40%) ↓ Activiation of renin-angiotensin-aldosterone system and the sympathetic nervous system ↓ In turn detrimental to ventricular structure and function

Question 54

Clinical features of Heart Failure?

Answer 54

``` Clinical features • Exertional dyspnoea and fatigue • PND • Orthopnoea • Ankle oedema ```

Question 55

What are the NYHA classification stages of heart failure?

Answer 55

Class 1 - asymptomatic LV dysfunction Class 2 - symptoms with normal activities Class 3 - symptoms with less than normal activities Class 4 - symptoms at rest

Question 56

What are the causes of heart failure?

Answer 56

* IHD – accounts for 50% of patients with CCF in Australia * Hypertension * Valvular heart disease Less common: • Congenital * Diabetes * Thyroid related * Connective tissue diseases * Myocarditis * Peripartum * Drug induced e.g. alcohol or chemotherapy

Question 57

Heart failure examination findings?

Answer 57

``` Raised JVP Ventricular strain - gallop rhythm; tachycardia Bibasal creps Pulsatile hepatomegaly Ascites Peripheral oedema ```

Question 58

Investigations in heart failure?

Answer 58

Bloods • FBE/UEC/LFT/TFT/Fe studies/auto-immune screen • CK and Tn may be relevant • BNP - if <100 pg/ml - make CCF very unlikely; can be elevated in renal failure; CCF, PE, other severe illnesses – useful if an echo cannot be organised in a timely fashion * CXR - bibasal opacity; enlarged cardiothoracic ratio; pleural effusions * ECG – look for ischaemic changes – Q waves, ST changes, LBBB, AF Transthoracic Echo • All patients with suspected CCF should undergo a transthoracic echo to assess LV systolic function • Up to a 1/3 of CHF patients have normal LV systolic function (often termed diastolic failure – failure of ventricular relaxation) – in these patients no specific pharmacologic therapy has been shown to improve mortality • In patients with abnormal diastolic function - diastolic CCF may be considered - often occurs in elderly females with hypertension, can also occur in those with diabetes, obesity, IHD Uses • Can help find causes - e.g. valvular heart disease; LV hypertrophy; pulmonary hypertension; regional wall motion abnormalities • Can be used to assess response of LV function to therapy - serial measurement of EF Normal LVEF 40-70%; reduced is <40% As a routine – annual is recommended

Question 59

What vital signs should you aim for in heart failure?

Answer 59

Should aim for a systolic BP 105-11 and HR 55-60

Question 60

Non pharmacological management in heart failure?

Answer 60

* Fluid restriction - <1.5L; less than 1L in severe (<2L when exacerbations are not present) * Na restriction <2g per day * Daily weighing at home with an action plan * Alcohol cessation in alcohol related cardiomyopathy, o/wise limiting alcoholic and caffeinated beverages to = 2sd/day * Smoking cessation * Regular physical activity but bed rest during acute exacerbations * Vaccination - influenza and pneumococcal

Question 61

ACE and ARBs in heart failure?

Answer 61

* Improve morbidity and mortality * Should be started immediately at low doses and titrated up over 3-4 weeks (do not double dose at less than 2 weekly) – aim to have patient on maximal doses * UEC should be checked within 2 weeks of starting and discontinued with K+ >5.5 or Cr>20% increase from baseline ARBs - shown to have similar improvements in mortality and morbidity • Considered in those who cannot tolerate ACE-I's • Can be combined with ACE-I in those who remain symptomatic – some evidence on decreased hospitalisations but no clear mortality benefit – combination should be left to use by specialists

Question 62

Beta blockers in heart failure?

Answer 62

* Are indicated in all patients with CHF * Improve mortality and morbidity * Beta blockers with proven mortality benefit include - carvedilol, bisoprolol and extended release metoprolol (recently a fourth has been approved nevibolol) * Should be commenced at small doses when a patient is euvolemic and titrated up over 1-2 months – start low and go slow May initially worsen heart failure symptoms and therefore patients should be stable prior to commencement • Euvolemic • No pulmonary crackles • Minimal peripheral oedema • Systolic BP >85 w/out symptomatic postural drop Start at low dose and aim for HR 55-60 - should be reduced if HR<55

Question 63

Side Effects of beta blockers (in heart failure)?

Answer 63

* Hypotension * Fatigue * Bronchoconstriction in patients with reversible obstructive airways disease – should not be withheld for patients with COPD; should be used with caution in patients with mild to moderate asthma * Mild worsening of CCF symptoms initially - important to warn patients of this initially

Question 64

Aldosterone antagonists in heart failure?

Answer 64

Australian guidelines recommend use in those on both an ace-I and beta-blocker and are still symptomatic with severe symptoms * Shown to have a mortality benefit in Class III/IV CCF * Eplenerone (selective aldosterone antagonist)– shown to improve mortality in patients with LV dysfunction post MI * Careful monitoring of electrolytes and renal function is important - can cause hyperkalemia – 1/52 after commencing or changing dose; 1/12 for 6/12 then 6/12 once stable dosing * CI in significant renal impairment Cr cl <30mL/min OR if K .5.5 * Should not be used in those on an ace-I and ARB (or only under guidance of a specialist)

Question 65

Diuretics in heart failure?

Answer 65

* Not appropriate as monotherapy * Used to treat symptoms * Do not have a long term mortality benefit * Once patients are euvolemic diuretics should be reduced or weaned – with other medications uptitrated

Question 66

Digoxin in heart failure?

Answer 66

* In patients with persistent symptoms despite the above - digoxin has been shown to improve symptoms and reduce hospitalisations but have no effect on mortality * Of use when a patient also has AF

Question 67

When is ivabradine indicated? contraindicated in heart failure?

Answer 67

Specific sinus node inhibitor – leading to decreased HR Elevated resting HR is a predictor of death and hospitalisation in CCF Improves outcomes and available on the PBS (authority) where: - Baseline HR >/= 77 - LVEF =35% - NYHA class II or III - In combination with optimal standard CCF treatment CI if: - BP <90/50 - HR < 60 (in the untreated state) - Severe hepatic impairment - SA node is not in the cardiac pacemaker

Question 68

Other pharmacotherapies in heart failure?

Answer 68

Nitrates - useful in reducing nocturnal dyspnoea, pulmonary hypertension, myocardial ischaemia Isosorbid mononitrate may be commenced at 30mg nocte Patients with ischaemic cardiomyopathy should receive aspirin Those with AF or cardiac thrombus should receive warfarin There is no strong evidence of the use of aspirin/warfarin in patients with non-ischaemic cardiomyopathy

Question 69

When should we refer in heart failure?

Answer 69

Specialist referral should be done for all heart failure patient as referral has been shown to improve symptoms, outcomes and decrease hospital admissions ``` As a minimum should be done for: • Diagnostic uncertainty • Age <65 • Questions re: management • Patient has consideration for revascularisation, cardiac device or transplant ```

Question 70

Device therapies in heart failure?

Answer 70

ICD – Decreases mortality in symptomatic CCF patients with LV EF= 35% and in patients with a prior AMI and LVEF = 30% Biventricular pacing Cardiac dyssonchrony seen in 1/3 of CCF patients - cardiac resynchronisation therapy/pacing - shown to improve symptoms, mortality and decrease hospitalisations - current criteria for this is: - Class III/IV – severe symptoms - EF<35% and a broad QRS (greatest benefit in LBBB with QRS >150ms) - Dysynchrony

Question 71

Medications that worsen heart failure?

Answer 71

* NSAIDS * GCS * Thiazolidenidiones – rosiglitazone; pioglitazone * Non-dihydropyridine calcium channel blockers – verapamil or diltiazem * Anti-arrhythmic medicines except for heart failure specific beta blockers and amiodarone * TCA’s

Question 72

Assessing fitness to drive in CCF?

Answer 72

Non commercial • Conditional if satisfactory response to treatment AND • There are minimal symptoms relevant to driving • Not fit if symptoms arise on moderate exertion Commercial A conditional may be considered with advice from a treating specialist if: • There is satisfactory response to treatment AND • Exercise tolerance of >/= 90% of the age/sex predicted capacity according to Bruce protocol AND • EF >40% AND • The underlying cause has been considered • There are minimal symptoms related to driving

Question 73

GP management of heart failure?

Answer 73

Potential KFP question * Call for help/call an ambulance * Commence oxygen • History – focussed PC/PMhx/medications Examination • Vitals – Temp; BP; HR; Sa02; RR • Chest/JVP/HS/Oedema * Monitoring * BP * ECG * Oxygen saturation * Defibrillator on standby Investigations • ECG • CXR - Interstitial oedema (often ‘bats wing’) - Fluid in the fissures - Kerley B lines (oedematous septal lines) - Pleural effusions (usually bilateral, frequently R>L, if unilateral more often on the right) - Peribronchial cuffing – visualisation of small-doughnut shaped rings representing fluid in thickened bronchial walls - The heart may or may not be enlarged • FBE/UEC/LFT/CK and Tn/BNP/ABG ``` Management • Position – upright – if tolerated • Oxygen – high flow 8-10 L • Vitals including pulse oximetry if available • ECG • IV access ``` Medications • Lasix IV – Usual daily dose or up to 1-1.5 mg/Kg – consider repeating after 30-60 minutes • Nitrate 10-20 mcg/min IV – adjusting rate to response and ensuring BP is >100 mmHg (not feasible in GP setting – better to use SL GTN) – augments effect of lasix * Morphine is no longer recommended due to data revealing links with increased intubation and mortality rates CPAP • Reduces preload and afterload • Associated with decreased intubation and mortality rates Conditions which may benefit from early CPAP in order of evidence are: • Acute exacerbations of COPD • Acute cardiogenic pulmonary oedema • Pneumonia – in patients with COPD and immunocompromised patients NOT currently recommended for: • Asthma • ARDS – little benefit has been reported