Dr Hafeez Cardiology SMO OPD

First Consultation Follow up review Post admission review
Patient Name: GP:

Issues

AF HF Angina
Family Husband Wife Partner Parents Mum Dad Children Alone
Yes No

Clinical Profile

No T1DM T2DM T2DM insulin-dependent
No Yes
ACE Inhibitors ARBs Beta Blockers CCBs Diuretics Other
No Yes
No Yes
Never Current Quit: Days ago Weeks ago yrs ago Pack years:
No Rarely Occasionally standards/day standards/week
Explained implications of smoking and alcohol
NAD Hypothyroidism Hyperthyroidism
No Yes
Reasonable Poor High Salt High Sugar
/day
No Yes
Snores Daytime Somnolence Partner reports periods of apnoea
Never <5yr ago >5yr ago
Currently uses Did not Tolerate Never used
Active Reasonably active Deconditioned Sedentary Has gained weight Has lost weight No Limitations

Other Medical Conditions

Medications

Allergy

NKDA

History

No significant symptoms Chest Pain Shortness of breath Palpitations Pre-syncope Syncope in daily activities
No previous cardiac issue No previous cardiac workup

Examination

HR: , BP: / , RR: , O2: , Temp:
Height: Weight:
Ankle Oedema: No Yes JVP: cm
x2 x3 x4
No Ejection-systolic Pan-systolic Crescendo-decrecendo Blowing
No Yes
Normal air entry Creps Rhonchi Wheeze
L R Lower Middle Upper Zone Sided Bibasal

Investigations

Sinus rhythm No significant abnormalities Abnormal
TWI: I II III aVF aVL aVR V1 V2 V3 V4 V5 V6
STE: I II III aVF aVL aVR V1 V2 V3 V4 V5 V6
STD: I II III aVF aVL aVR V1 V2 V3 V4 V5 V6
AF AFRVR Slow AF Flutter 2:1 3:1 4:1 Variable block RBBB LBBB Junctional Rhythm Wide QRS LAD RAD Isolated Frequent PAC Isolated
Total Cholesterol: LDL: HDL: TG: Explained genetic, lifestyle factors and implications of high lipids
T4: TSH:
HbA1c:
New Improved Worsened HFrEF HFmrEF HFpEF
Infrequent Frequent Atrial Ventricular Ectopy AF

Assessment

Status

Stable compensated cardiac status Fluid Overloaded Deconditioned

Diagnosis/Differential

Explained the whole clinical scenario.
Overall underlying cardiac etiology/rhythm issues can not be ruled out, keeping in view the profile
Unlikely secondary to any significant cardiac etiology
Multifactorial clinical scenario
Reassuring no significant cardiovascular symptoms

Plan

Investigations Ordered: TTE TOE Holter CTCA Myocardial Perfusion Scan Exercise Stress Echo Exercise Stress Test
Then Other work up, functional testing/CTCA, if required
Cardiac risk factors to be monitored
Heart healthy lifestyle including diet and exercise to lose weight
Urgent ECG/ED visit, in case of significant symptoms/concern
Lot of counseling has been done
Cardiology Follow Up: Next available appointment 3 month 6 month 12 month in a few weeks in a few months Face to Face Phone Review Chart Review
Prior to Follow up GP to kindly complete: FBC Chem20 Fasting Lipid Profile HbA1c TFTs Lipoprotein (a) levels CXR OSA screening Monitor renal function/potassium
Referral: HF nursing clinic referred for GDMT Electrophysiologist to consider Ablation DCCV/Cardioversion
To Consider: Beta Blocker Metoprolol Atenolol Bisoprolol RAASi Entresto Ramipril SGLT2i Spironolactone
BB RAASi SGLT2i MRA CCB Digoxin Diuretics Lipid-Lowering Anti-Anginal Ivabradine Anti-Arrhythmic
Metoprolol: 12.5mg 25mg 50mg 75mg 100mg OD BD
Atenolol: 25mg 50mg 100mg OD BD Alternate Days
Bisoprolol: 1.25mg 2.5mg 3.75mg 5mg 7.5mg 10mg OD
PBS (Bisoprolol): Moderate-Severe HF (NYHA ≥ III) + Stable on RAASi
Sotalol: 40mg 80mg 120mg 160mg BD (GP to kindly check QTc in 1wk)
Entresto: 24/26mg 49/51mg 97/103mg BD
PBS (Entresto): symptomatic + NYHA ≥ II + on BB/ACEi or ARB + LVEF ≤ 40%
Perindopril: 2.5mg 5mg 10mg OD
Ramipril: 1.25mg 2.5mg 5mg 10mg OD BD
Dapagliflozin: 10mg OD
PBS: stable + NYHA ≥ II + on BB/RAASi + LVEF ≤ 40%
PBS: stable + NYHA ≥ II + on BB/RAASi + LVEF > 40%
+ Echo findings that would be expected to cause diastolic dysfunction (e.g. LV hypertrophy)
+ one of:
(i) diastolic dysfunction with high filling pressure on echocardiography, stress echocardiography or cardiac catheterisation;
(ii) hospitalisation for heart failure in the 12 months prior to initiating treatment with this drug;
(iii) requirement for intravenous diuretic therapy in the 12 months prior to initiating treatment with this drug;
(iv) elevated N-terminal pro brain natriuretic peptide (NT-proBNP) levels in the absence of another cause
Spironolactone: 12.5mg 25mg 50mg 100mg OD
Amlodipine: 2.5mg 5mg 10mg OD
Diltiazem IR: 30mg 60mg 90mg 120mg 180mg 240mg OD BD TDS QID
Verapamil IR: 40mg 80mg 120mg 160mg BD TDS
Digoxin: 62.5mcg 125mcg 250mcg 500mcg OD
Frusemide: 20mg 40mg 80mg 120mg OD BD
Hydrochlorothiazide: 12.5mg 25mg 50mg 100mg OD BD 3days/wk 4days/wk 5days/wk
Atorvastatin: 10mg 20mg 40mg 80mg OD
Ezetimibe: 10mg OD
Evolocumab: 140mg Q2W 420mg Monthly
PBS (Evolocumab): Combonation with Diet/Exercise + Genetic Test showing Familial homozygous hypercholesterolaemia (or Dutch Lipid Clinic Network Score ≥ 7) + LDL > 1.8 mmol/L + completed 12wk trial of max dose Statin Fish Oil: 1g 2g 3g OD
Fenofibrate: 48mg 96mg 145mg OD
Niacin (Nicotonic Acid): 125mg 250mg 500mg 750mg 1g TDS
Inclisiran: SC 284mg, repeat at 3months, then 6monthly
PBS (Inclisiran) Familial heterozygous hypercholesterolaemia: Combination with Diet/Exercise + Genetic Test (or Dutch Lipid Clinic Network Score ≥ 6) + LDL > 5 mmol/L (or >1.8 + symptomatic atherosclerotic CVD) + completed 12wk trial of max dose Statin + completed 12wk combination Statin/Ezetimibe + not on PCSK9i
PBS (Inclisiran) Non-familial hypercholesterolaemia: Combination with Diet/Exercise + Symptomatic atherosclerotic CVD + LDL > 1.8mmol/L + completed 12wk trial of max dose Statin + completed 12wk combination Statin/Ezetimibe + not on PCSK9i
+ 1 of:
Atherosclerotic disease in ≥ 2 vascular territories (coronary, cerebrovascular, peripheral)
Severe multi-vessel CAD (≥ 50% stenosis in ≥ 2 large vessels)
≥ 2 major cardiovascular events (i.e. myocardial infarction, unstable angina, stroke or unplanned revascularisation) in the last 5 years
DM + microalbuminuria/≥ 60yr old/Aboriginal or Torres Strait Islander
Thrombolysis in MI (TIMI) risk score for secondary prevention of ≥4
ISMN: 30mg 60mg 90mg 120mg OD
Sublingual GTN Spray: 400mcg/spray as needed
Sublingual GTN Tablet: 300mcg as needed
Ivabradine: 2.5mg 5mg 7.5mg BD
PBS (Ivabradine): symptomatic + NYHA II/III + sinus + HR ≥ 77bpm (after 5min rest and documented) + on maximal HF meds (incl. BB) + LVEF ≤ 35%

Brief Clinical Summary

Monitoring, work up and optimal conservative management