1 LOBS Flashcards
Define blood pressure. How would you describe what blood pressure is to patients
(avoiding medical jargon).
High blood pressure (hypertension) means that your blood is pumping with more force than normal through your arteries. The added stress on the arteries can speed up the clogging of arteries with fatty plaques (atherosclerosis). Atherosclerosis contributes to many illnesses, such as heart attack and stroke.
What happens when blood pressure is too low? Too high? Review how blood
pressure is regulated.
Blood pressure which is too high or too low can lead to a wide range of pathology (e.g. ruptured blood vessels, reduced perfusion to organs).
Define essential hypertension
persistently elevated arterial blood pressure that has no underlying (secondary) cause
Define Iatrogenic hypertension
high blood pressure caused by a chemical substance or medicine.
Define Secondary Hypertension
It is high blood pressure that’s caused by another medical condition. It can be caused by conditions that affect the kidneys, arteries, heart or endocrine system.
What are the 5 common causes of secondary hypertension?
- Obesity
- Pregnancy
- Kidney disease - Glomerulonephritis, Diabetic nephropathy and Renal cell carcinoma
- Vascular disease - Diabetic nephropathy and Renal cell carcinoma
- Endocrine disease - Hyper/hypothyroidism and Cushing’s syndrome
- Drugs - Alcohol, Illicit drugs (e.g. cocaine), Corticosteroids, Non-steroidal anti-inflammatories (NSAIDs) and Venlafaxine
- AND other causes like Connective tissue disorders (e.g systemic sclerosis, systemic lupus erythematosus and polyarteritis nodosa) and Obstructive sleep apnoea
Define Malignant/Accelerated hypotension
Clinic BP is usually higher than 180/120 mmHg with signs of papilloedema and/or retinal haemorrhage.
Can be fatal due to heart failure, cerebral haemorrhage, or renal failure.
Define masked hypertension
Masked hypertension is defined as a normal blood pressure (BP) in the clinic or office (<140/90 mmHg), but an elevated BP out of the clinic (ambulatory daytime BP or home BP>135/85 mmHg)- within the hypertensive range
Define white-coat hypertension
This condition occurs when blood pressure readings at a health care provider’s office are higher than they are in other settings, such as at home. Home or ambulatory blood pressure monitoring readings are lower, with a discrepancy of > 20/10 mmHg.
They may also exhibit signs in clinic such as tachycardia, sweating, or palpitations.
Review the types of antihypertensive medications in common practice
- Patients aged <55 years who are not of Black African or African-Caribbean descent: offer an ACE inhibitor such as ramipril.
-If an ACE inhibitor is not tolerated offer an angiotensin-II receptor blocker such as losartan.
OR - Patients aged ≥55 years and patients of Black African or African-Caribbean descent: offer a calcium channel blocker such as amlodipine.
- Patients already taking an ACE inhibitor or angiotensin-II receptor blocker: offer a calcium channel blocker such as amlodipine or a thiazide-type diuretic such as indapamide.
- Patients already taking a calcium channel blocker: offer an ACE Inhibitor such as ramipril or a thiazide-type diuretic such as indapamide.
If an ACE Inhibitor is not tolerated offer an angiotensin-II receptor blocker such as losartan.
Angiotensin-II receptor blockers preferred in patients Black African or African-Caribbean descent.
- Offer a combination of an ACE inhibitor or angiotensin-II receptor blocker plus a calcium channel blocker and thiazide-type diuretic.
What are the long-term implications of uncontrolled hypertension?
Please focus on
end-organ disease, specifically the brain, heart, kidneys and eyes (hypertensive
retinopathy).
Heart: left ventricular hypertrophy, angina/previous myocardial infarction, previous coronary revascularization, and heart failure
Brain: stroke or transient ischemic attack, dementia
Chronic kidney disease
Peripheral arterial disease
Retinopathy
List the modifiable and non-modifiable risk factors that predispose a patient to
coronary artery disease.
Smoking. (M)
Lack of exercise. (M)
Diet. (M)
Obesity. (M)
High blood pressure. (M and NM)
High LDL or low HDL cholesterol levels. (M and NM)
Family history of heart disease or other cardiovascular disease. (NM)
Age (NM)
What is metabolic syndrome and why is it important?
Metabolic syndrome is the medical term for a combination of diabetes, high blood pressure (hypertension) and obesity. or
The metabolic syndrome is the name of a cluster of risk factors that, when they appear together, dramatically raise your risk of heart disease, heart failure, stroke and diabetes, as well as other non-cardiovascular conditions.
What is dyslipidaemia and how can we measure and treat it?
Dyslipidemia is the imbalance of lipids such as cholesterol, low-density lipoprotein cholesterol, (LDL-C), triglycerides, and high-density lipoprotein (HDL).
Dyslipidaemia is a broad term describing a number of conditions, including hypercholesterolaemia, hyperlipidaemia and mixed dyslipidaemia, in which disturbances in fat metabolism lead to changes in the concentrations of lipids in the blood.
The most commonly used options for pharmacologic treatment of dyslipidemia include bile acid–binding resins, HMG-CoA reductase inhibitors, nicotinic acid and fibric acid derivatives.
What lifestyle advice is customary to give to individuals with cardiovascular risk
factors?
What are some techniques clinicians can use to successfully encourage
individuals to change their behaviours?
What are some strategies available to medical providers to encourage smoking
cessation?
- Nicotine replacement therapy
- Counselling
- Acupuncture
- Physical activity
- Relaxation techniques like yoga
Develop a differential diagnosis for palpitations.
Arrhythmias:
Atrial fibrillation/flutter
Bradycardia caused by advanced arteriovenous
block or sinus node dysfunction
Bradycardia-tachycardia syndrome (sick sinus syndrome)
Multifocal atrial tachycardia
Premature supraventricular or ventricular contractions
Sinus tachycardia or arrhythmia
Supraventricular tachycardia
Ventricular tachycardia
Wolff-Parkinson-White syndrome
Psychiatric causes:
Anxiety disorder
Panic attacks
Drugs and medications:
Alcohol
Caffeine
Certain prescription and over-the-counter agents (e.g., digitalis, phenothiazine, theophylline, beta agonists)
Street drugs (e.g., cocaine)
Tobacco
Nonarrhythmic cardiac causes:
Atrial or ventricular septal defect
Cardiomyopathy
Congenital heart disease
Congestive heart failure
Mitral valve prolapse
Pacemaker-mediated tachycardia
Pericarditis
Valvular disease (e.g., aortic insufficiency, stenosis)
Extracardiac causes:
Anemia
Electrolyte imbalance
Fever
Hyperthyroidism
Hypoglycemia
Hypovolemia
Pheochromocytoma
Pulmonary disease
Vasovagal syndrome
Describe the pathophysiology of atrial fibrillation and link it to the typical ECG
findings.
Atrial fibrillation (AF) is a cardiac arrhythmia characterised by disorganised electrical activity within the atria resulting in ineffective atrial contraction and irregular ventricular contraction.
AF is a type of supraventricular cardiac arrhythmia meaning the origin of the arrhythmia arises from above the ventricles.
What are the risk factors for essential hypertension?
- Sex - up to 65 M>W, 65-74 W>M
- Ethnicity: people of Black African and Black Caribbean origin are at a higher risk of developing HTN.
- Age: blood pressure rises with increasing age.
- Lifestyle factors: cigarette smoking, excess alcohol consumption, excess dietary salt intake, obesity and lack of physical activity.
- Genetic factors
- Social deprivation
- Stress and anxiety
What are the risk factors for essential hypotension?
Sex: up to 65 years women tend to have lower blood pressures than men, however, between the ages of 65-74 years women tend to have higher blood pressures.
Ethnicity: people of Black African and Black Caribbean origin are at a higher risk of developing HTN.
Age: blood pressure rises with increasing age.
Lifestyle factors: cigarette smoking, excess alcohol consumption, excess dietary salt intake, obesity and lack of physical activity.
What are the risk factors for cardiovascular disease, including social History and family history?
High blood pressure
Smoking
High cholesterol
Diabetes
Lack of physical activity
Being overweight or obese
Family history of CVD
Ethnic background
Age
Gender
Diet
Alcohol
What is meant by the term pack year?
A pack-year is used to describe how many cigarettes you have smoked in your lifetime, with a pack equal to 20 cigarettes.
Is gender considered a CVS risk factor?
YES.
What is the management for essential hypertension? Including blood tests.
Management of essential hypertension:
- Take BP: offer ABMP or HBMP to rule out white coat
- Blood Tests: Glucose, eGFR, Lipid profile, Electrolytes, Plasma renin, Thyroid function, Plasma Aldosterone, ACR
- Urine dipstick
- CXR: Might show Cardiomegaly
- ECG: Might show left ventricular hypertrophy
- Lifestyle modification: Diet, exercise, stress, smoking, alcohol
What is end-organ damage?
Damage occurring in major organs fed by the circulatory system.
What sort of end-organ damage can blood pressure cause?
stroke, chronic heart disease, heart failure, renal failure, peripheral vascular disease, or retinopathy
What are the categories of BMI?
- <18.5 = underweight
- 18.5 – 25 = healthy
- 25 – 30 = overweight
- > 30 = obese
What are the health implications of a raised BMI?
The higher your BMI, the higher your risk for certain diseases such as heart disease, high blood pressure, type 2 diabetes, gallstones, breathing problems, and certain cancers.
What are the reasons that someone could have a raised BP?
- are overweight.
- eat too much salt and do not eat enough fruit and vegetables.
- do not do enough exercise.
- drink too much alcohol or coffee (or other caffeine-based drinks)
- smoke.
- do not get much sleep or have disturbed sleep.
are over 65. - pregnancy
Understand the terms atherosclerosis and arteriosclerosis
Atherosclerosis – build-up of fats, cholesterol, and other constituents in and on artery walls. The build-up forms a plaque that causes arteries to narrow and harden therefore constricting blood flow. It can cause arteriosclerosis.
Arteriosclerosis – the hardening of the arteries. Blood vessels that carry oxygen and nutrients from heart to rest of body become hard and stiff as a result restricting blood flow to organs and tissues.
Can urine dip rule out altered kidney function? What is urine ACR?
No because …
Urine albumin to creatinine ratio helps identify kidney disease that occur as a complication of diabetes. The higher the ACR level, the higher the indication of severe kidney disease
What is an ECG and what is it used for?
ECG is used to look for signs of cardiac arrhythmias and heart failure. (check answer)
What does a normal ECG look like?
What is HBa1c?
indicates average blood glucose concentration over the previous 3 months; high levels may suggest diabetes.
What is meant by metabolic syndrome?
Metabolic syndrome is the medical term for a combination of diabetes, high blood pressure (hypertension), unhealthy cholesterol levels and obesity. It puts you at greater risk of getting coronary heart disease, stroke and other conditions that affect the blood vessels.
What does cholesterol/HDL ratio mean?
the level of good cholesterol in your blood compared to your overall cholesterol level. Higher ratios mean high risk of heart disease.
What are the stages of hypertension?
stage 1: Clinic BP 140/90mmHg up to 159/99mmHg and ABPM and HBPM 135-80mmHg - 149/94mmHg
stage 2: Clinic BP 160/100mmHg - up to 180/120mmHg and ABPM and HBPM BP of 150/95mmHg or higher
stage 3: clinic systolic BP of 180mmHg or higher OR clinic diastolic BP of 120mmHg or higher
What are anti-hypertensive categories?
- ACE Inhibitors
- ARBs
- Alpha Blockers
- Beta-blockers
- Calcium channels blockers (CCBs)
- Diuretics
What are the NICE guidelines for treatments for hypertension?
look at the NICE guidelines
What are the common and important arrythmias?
- Atrial fibrillation – heart beats irregularly
- Bradycardia – heart beats more slowly than normal
- Supraventricular tachycardia – episodes of abnormally fast heart rate at rest
? anymore
What are the causes of palpitations?
- Emotional responses such as stress, anxiety, or panic attacks
- Stimulants including caffeine, cocaine, or amphetamines
- Hormonal changes such as menstruation, pregnancy, or menopause
- Vigorous exercise
pheochromocytoma
hyperthyroidism.
fever
check answer.
What is atrial fibrillation? (and read the CKS guidance)
Atrial fibrillation is an arrhythmia that results from an irregular/disorganised electrical activity in the atria leading to an ineffective atrial contraction and an irregular ventricular rhythm/contraction.
In atrial fibrillation, the heart rate is irregular and can sometimes be very fast. In some cases, it can be considerably higher than 100 beats a minute.
What are some causes of atrial fibrillation?
Cardiac or valve conditions, such as:
- Congestive heart failure.
- Rheumatic valvular disease.
- Atrial or ventricular dilation or hypertrophy.
- Pre-excitation syndromes (such as Wolff–Parkinson–White syndrome).
- Sick sinus syndrome.
- Congenital heart disease.
- Inflammatory or infiltrative disease (such as pericarditis, amyloidosis, or myocarditis).
Non-cardiac conditions, such as:
- Acute infection.
- Autonomic neuronal dysfunction (such as vagally induced AF).
- Electrolyte depletion (such as hypokalemia and hyponatremia).
- Cancer (such as primary lung cancer involving the pleura and pericardium, and cancers such as breast cancer and malignant melanoma metastasising to the pericardium).
- Pulmonary embolism.
- Thyrotoxicosis
- Diabetes mellitus
Dietary and lifestyle factors, such as:
- Excessive caffeine intake.
- Alcohol abuse (especially in susceptible individuals such as those with structural heart disease)
- Obesity
- Smoking.
- Medication exposure (such as thyroxine or bronchodilators).
What is a CHA2DS2-VASc score?
A clinical prediction for estimating risk of stroke in AF patients.
It comprises eight components which when added together guide the decision of whether to offer a patient anticoagulation therapy.
What is an ORBIT score?
Bleeding risk score for AF patients predicting bleeding risk in patients on anticoagulation (medicine that help prevent blood clot)
What is rivaroxaban and propranolol and why is it used?
Rivaroxaban – an anticoagulant - helps prevent blood clot, reduce risk of heart attack and stroke
Propranolol – type of beta blocker - used to treat heart attack problems, help with anxiety, and prevent migraines
Explain, and give the rationale behind the investigations, acute and long-term
management for atrial fibrillation, including anticoagulation to prevent thrombus
formation (immediate with heparin and longer term with DOAC or warfarin). Please
include side effects + contraindications.
What is Isolated systolic HTN and who does it happen to?
It should be suspected in a person (especially > 60 years) with systolic pressure of at least 160 mmHg and a diastolic pressure below 90 mm Hg. NO DIFFERENCE IN MANAGEMENT.
Investigation for essential hypertension:
- Under 40 with stage 1 HTN and no evidence of end-organ damage —> refer for secondary HTN investigations
- Consider Rx if under 60 with stage 1 HTN & QRISK3 < 10%
- Consider Rx in people >80 with Stage 1 HTN if clinic BP is > 150/90
- Any age with stage 2 HTN = Treat
- Start Rx if under 80 with stage 1 HTN and one or more of the following
- Target organ damage
- Established CVD
- Renal disease
- Diabetes
- QRISK3 ≥10%
- Use QRISK3 if cardiovascular risk >10% offer lipid modification therapy with atorvastatin ??
Secondary HTN – History, examination and investigation findings
Renal:
- Haematuria, polyuria, proteinuria and elevated creatinine
Phaeochromocytoma:
- Rare tumour of the adrenal glands, specifically from the chromaffin cells
- Dysregulated release of adrenaline and noradrenaline
- Paroxysmal symptoms. Anxiety or panic attacks, palpitations, tremor, sweating, headache, flushing, nausea. Labile hypertension, tachycardia, bradycardia, orthostatic hypotension
Aortic coarctation:
- Radio-femoral delay, systolic ejection murmur, diminished lower extremity pulses, differential upper and lower extremity BP
Renal artery stenosis:
Abdominal or flank bruits, or a significant rise in serum creatinine when starting an ACE-inhibitor may indicate renovascular hypertension
Conn’s syndrome/ primary hyperaldosteronism:
Hypokalemia
Cushing’s syndrome:
Osteoporosis, truncal obesity, round face, purple striae, muscle weakness, easy bruising, hirsutism, hyperglycemia, hypokalemia and hyperlipidemia
Complications of HTN
Increases the risk of:
Heart:
- Coronary artery disease
- LVH
- Heart failure
- Arrhythmias –> Infarcts
Stroke:
- Infarction. Big vs small.
Small –> cognitive decline, vascular dementia
Tiny aneurysms –> Haemorrhage
Chronic kidney disease
Peripheral artery disease
Single biggest risk factor for CVD. Half of all heart attacks and strokes are associated with HTN
Define ABPM and HBPM and what it involves:
Ambulatory blood pressure monitoring (ABPM) - monitor blood pressure over a 24-hour period of at least two measurements per hour
Use the average value of at least 14 measurements to confirm a diagnosis of HTN.
Home blood pressure monitoring (HBPM) – monitor blood pressure twice daily ideally in the morning and evening.
For each blood pressure measurement, advise the patient to record two consecutive measurements taken at least one minute apart whilst seated.
The patient should record their blood pressure recording for at least four days but ideally for seven days.
After 7-14 days discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of HTN.
Diagnosis of HTN
3 THINGS:
Target organ damage:
12-lead electrocardiogram (ECG) for left-ventricular hypertrophy (LVH)
Renal function tests (U&Es) and urine tests (proteinuria or albuminuria, haematuria) for renal impairment.
Eye screening/ fundoscopy for hypertensive retinopathy
Assess cardiovascular risk:
Hba1C, cholesterol
Calculate person’s 10-year risk of developing cardiovascular disease (CVD) using QRISK3 assessment tool (age, sex, ethnicity, smoking status, diabetes? FHx of heart issues, renal impairment, bp Rx, RA, cholesterol)
Management for HTN - targets
Use clinic blood pressure to monitor BP unless they have white coat HTN in which case you would also use ABPM or HBPM
Measure standing and seated BP in people with T2DM/ symptoms of postural hypotension/ aged ≥80
Aim for <140/90 in people <80 (<135/85 if using ABPM or HBPM)
Aim for <150/90 in people >80 (<145/85 if using ABPM or HBPM)
Use clinical judgement for people with frailty or multimorbidity
Management – Targets - Exceptions
Type 1 Diabetes:
- <135/85
- <130/80 if there is albuminuria, or 2 or more features of the metabolic syndrome
Chronic Kidney Disease (CKD) not diabetic
- Urinary ACR <70 mg/mmol: clinic bp <140/90
- Urinary ACR ≥70 mg/mmol: clinic bp <130/80
CKD with diabetes
- < 130/80
Management - Lifestyle
Diet
– low calorie diets, reduced saturated fat intake
- Aim for ≤ 6g/day salt
Exercise
– aerobic exercise (brisk walking, jogging or cycling) for 30-60 minutes, 3-5 times a week.
Weight loss – achieve ideal body weight
Alcohol – 14 units/week spread over 3 days or more
Relaxation therapies
Coffee
Smoking cessation
Red flag symptoms of accelerated or malignant HTN
Headache
Visual disturbances
Seizures
Nausea and vomiting
Chest pain
History- Symptoms suggestive of kidney disease as a secondary cause of HTN include:
Haematuria
‘Frothy’ urine suggestive of proteinuria
Dyspnoea (pulmonary oedema)
Lower limb swelling (peripheral oedema)
Flank tenderness and pain
Weight loss is suggestive of renal cell carcinoma
History- Symptoms suggestive of coarctation of the aorta as a secondary cause of HTN include:
Headache
Epistaxis
Intermittent claudication
Lower limb weakness
Cold legs and feet
History- Symptoms suggestive of endocrine disease as a secondary cause of HTN include:
Muscle weakness, muscle spasms and paraesthesia are suggestive of hyperaldosteronism.
Severe headache, palpitations and sweating are suggestive of pheochromocytoma.
Weight gain particularly abdominal, facial and on the back of the neck and shoulders is suggestive of Cushing’s syndrome.
Tall statures, swelling of the hands and feet and deepening of the voice are suggestive of acromegaly.
Weight gain, cold intolerance and low mood are suggestive of hypothyroidism.
Weight loss, heat intolerance and palpitations are suggestive of hyperthyroidism.
What is Coarctation of the aorta?
it is a birth defect in which a part of the aorta, the tube that carries oxygen-rich blood to the body, is narrower than usual.
What clinical examination should patients undergo to see if they suffer from hypertensive retinopathy
fundoscopy
Urine albumin creatinine ratio (uACR) is an investigation to detect ?
albuminuria which suggests end-organ damage. Albuminuria is a sign of kidney disease
Relevant bedside investigations for hypertension:
Urinalysis: to look for haematuria and proteinuria which could suggest kidney disease.
Urine albumin creatinine ratio (uACR): albuminuria suggests end-organ damage.
ECG: to look for signs of cardiac arrhythmias and heart failure.
Observations
Blood pressure
Urinalysis
Urinary protein creatinine ratio (uPCR)
ECG
Direct ophthalmoscopy
Relevant laboratory investigations for hypertension:
Urea and electrolytes: derangement suggests a renal impairment.
HbA1c: indicates blood glucose concentration over the previous 3 months; high levels may suggest diabetes.
Lipid profile: useful to assess future cardiovascular disease risk.
What is QRISK3?
It is an online tool used to assess risk of Cardiovascular disease. It considers factors such as patient sex, age, ethnicity, smoking status and presence of comorbidities to generate an overall percentage that estimates the risk of a patient having a heart attack or stroke in the next 10 years.
Management: Blood pressure targets for less than 80
The target blood pressure for patients aged <80 years is a clinic blood pressure <140/90mmHg or ABPM/HBPM <135/85mmHg.
The complications of HTN:
Brain: stroke (both ischaemic and haemorrhagic) and vascular dementia
Eye: hypertensive retinopathy
Heart: coronary artery disease, peripheral vascular disease, cardiac arrhythmias and heart failure
Kidneys: chronic kidney disease
How do you diagnose HTN:
Target organ damage:
12-lead electrocardiogram (ECG) for left-ventricular hypertrophy (LVH)
Renal function tests (U&Es) and urine tests (proteinuria or albuminuria, haematuria) for renal impairment.
Eye screening/ fundoscopy for hypertensive retinopathy
Assess cardiovascular risk:
Hba1C, cholesterol
Calculate person’s 10-year risk of developing cardiovascular disease (CVD) using QRISK3 assessment tool (age, sex, ethnicity, smoking status, diabetes? FHx of heart issues, renal impairment, bp Rx, RA, cholesterol)
define palpitations
Palpitations are heartbeats that suddenly become more noticeable. This can involve the heart feeling like it’s pounding, fluttering or beating irregularly, often for just a few seconds or minutes.
define Arrhythmias
a condition in which the heart beats with an irregular or abnormal rhythm
what is atrial fibrillation
Atrial fibrillation is a condition that causes an irregular and often fast heartbeat.
A normal heart rate should be regular and between 60 and 100 beats a minute when you’re resting.
Symptoms of HTN:
Palpitations
Angina
Headaches
Blurred vision
New neurology (e.g. limb weakness, paraesthesia)
Signs of HTN:
New neurology (e.g. limb weakness, paraesthesia)
Retinopathy
Cardiomegaly
Arrhythmias
Proteinuria
Signs of HTN:
New neurology (e.g. limb weakness, paraesthesia)
Retinopathy
Cardiomegaly
Arrhythmias
Proteinuria
Bloods for HTN
FBC
U&Es
Fasting glucose
Cholesterol (CVS risk)
HbA1c
Examples of relevant pre-existing cardiovascular disease to palpitations
Arrhythmias (e.g. atrial fibrillation, atrial flutter, heart block)
Structural heart disease (e.g. aortic stenosis)
Coronary artery disease
Congestive heart failure
Cardiomyopathy
Congenital heart disease
categories of Atrial Fibrillation
AF can be categorised as either paroxysmal, persistent or permanent:
Paroxysmal: episodes last >30 seconds but <7 days and are self-terminating but recurrent
Persistent: episodes last less than or more than seven days but require electrical or chemical cardioversion
Permanent: episodes fail to terminate with cardioversion OR a terminated episode that relapses within 24 hours OR long-standing AF (usually >1 year) in which cardioversion has not been indicated or attempted
Causes of AF:
AF is most commonly associated with:2
Hypertension
Obesity
Alcohol
Other causes of AF can be split into cardiac and non-cardiac causes.2
Cardiac causes of atrial fibrillation include:
Heart failure (e.g. secondary to myocardial infarction)
Structural pathology (e.g. valve stenosis or valve regurgitation)
Congenital heart disease
Atrial or ventricular dilation
Atrial or ventricular hypertrophy
Pre-excitation syndromes (e.g. Wolff-Parkinson-White syndrome)
Sick sinus syndrome
Inflammatory conditions (e.g. pericarditis or myocarditis)
Infiltrative conditions (e.g. amyloidosis)
Non-cardiac causes of atrial fibrillation include:
Acute infection
Electrolyte imbalances (e.g. hypokalaemia or hyponatraemia)
Pulmonary embolism
Thyrotoxicosis or hypothyroidism
Diabetes mellitus
Risk factors for AF
- Male sex
- Caucasian ethnicity
- Increasing age
- Alcohol
- Cigarette smoking
- Obesity
- Co-morbidities (e.g. chronic kidney disease and obstructive sleep apnoea)
- Caffeine intake is not typically a risk factor although it is often blamed for palpitations.
Define Tachycardia
a heart rate over 100 beats a minute.
Normal heart rate:
Most adults have a resting heart rate between 60 and 100bpm
Typical symptoms of AF include:
Breathlessness
Chest discomfort
Palpitations
Light-headedness
Reduced exercise tolerance
Syncope: due to bradycardia, particular in paroxysmal AF when sinus rhythm is restored because the SAN can take a few seconds to wake up
Syncope
fainting or passing out
transient ischaemic attack
also called a “mini stroke”, is a serious condition where the blood supply to your brain is temporarily disrupted.
Clinical examination of AF
- Irregularly irregular pulse when palpating either the radial or carotid arteries or auscultating at the apex.
- Radial-apical deficit: this is important to assess because each ventricular contraction may not be sufficiently strong enough to transmit a pulse to the radial artery and palpating only the radial artery can miss tachycardia.
Some patients may have co-existing heart failure. Typical clinical findings of heart failure include:
- Raised jugular venous pressure
- Added heart sounds on chest auscultation (e.g. gallop rhythm)
- Crackles on chest auscultation
- Ankle swelling
Possible differential diagnoses in the context of suspected AF include
- Other supraventricular tachycardias: atrial flutter, atrial extrasystoles, multifocal atrial tachycardia, sinus tachycardia
- Ventricular ectopics
Relevant bedside investigations in the context of suspected AF include:
Basic observations (vital signs): to assess for haemodynamic instability suggested by tachycardia, hypotension and cool peripheries.
12-lead ECG: this is the diagnostic investigation for AF. Typical features of AF on an ECG include tachycardia (particularly in new-onset; as aforementioned heart rate depends on the rate of AVN conduction), irregularly irregular rhythm, absent P-waves, fibrillation waves (best seen in lead II and V1 and often confused with atrial flutter waves) and a chaotic (noisy) baseline.
Ambulatory ECG: this may be considered for patients with suspected paroxysmal AF to capture a symptomatic episode for diagnostic purposes. It can also be considered to assess the rate in persistent and/or permanent AF once a patient has been established on treatment. Ambulatory monitoring can be achieved using a 24-hour ECG monitor, a cardiac event recorder or a 7-day Holter monitor or in patients with infrequent symptoms an implantable loop recorder.
Relevant laboratory investigations in the context of suspected AF include:
Full blood count: to assess for a reversible cause such as acute infection (e.g. suggested by raised white cell count)
Urea & electrolytes: to assess for a reversible cause such as hypokalaemia or hyponatraemia
Liver function tests: to establish baseline hepatic function before giving anticoagulant drugs
Thyroid function tests: to assess for thyroid dysfunction. Raised T4 and low TSH levels indicate hyperthyroidism
CRP: to assess for a reversible cause such as acute infection. Raised CRP is suggestive of underlying infection
Clotting screen: to establish a baseline coagulation status before giving anticoagulant drugs
BNP: can be considered to assess for underlying heart failure but should be interpreted with caution based on the patient’s clinical presentation. AF in itself can cause a raised BNP without evidence of heart failure.
Relevant imaging investigations in the context of suspected AF include:
Echocardiogram: a transthoracic echo is used to assess for underlying structural or valvular disease and or left ventricular systolic dysfunction. NICE only recommends performing an echocardiogram if the result is likely to alter management for example AF could be the presenting feature of a cardiac condition such as a cardiomyopathy/valvular pathology.
Chest X-ray: to assess for changes associated with heart failure (e.g., alveolar oedema, Kerley B-lines, cardiomegaly, upper lobe diversion, pleural effusion, fluid in the lung fissures)
diagnosis of AF
Common ECG findings include irregular RR intervals and absent P-waves.
ABCDE assessment
Airway
Breathing
Circulation
Disability
Exposure
Management for AF
Anticoagulation is the primary consideration for AF patients. Following this, the management of AF can broadly be split into rhythm control and rate control.
Rhythm-control can be achieved either electrically or pharmacologically whereas rate-control is achieved by using drugs such as beta-blockers, rate-limiting calcium channel blockers and Digoxin.
Management of modifiable risk factors (e.g. alcohol, obesity) and comorbidities (e.g. hypertension) is particularly important to improve symptoms, prognosis and successful maintenance of sinus rhythm if a rhythm control strategy is considered.
What is NSR
Normal sinus rhythm (NSR) is the rhythm that originates from the sinus node and describes the characteristic rhythm of the healthy human heart.
what are antiarrhythmic drugs used for
Anti-arrhythmic drugs are designed to treat an abnormality of the heart rhythm
examples of antiarrhythmic drugs
Flecainide is a class 1c antiarrhythmic drug that blocks sodium channels within the heart and thereby raises the threshold for depolarisation. It should not be used in patients with evidence of structural or ischaemic heart disease because of the risk of sudden cardiac death. Flecainide can be given orally or intravenously.
Amiodarone is a class 3 antiarrhythmic drug that blocks potassium channels within the heart and thereby prolongs the refractory period of the myocardium. It can be used in patients with evidence of structural heart disease. Amiodarone may prolong the QT interval and should be avoided in patients with QT prolongation.
Pharmacological options for rate control include:
- Beta-blockers (e.g. bisoprolol)
- Rate-limiting calcium channel blockers (e.g. verapamil or diltiazem): appropriate for patients with good left ventricular function
- Digoxin: for patients who do little or no exercise or if other rate-control drugs are contraindicated. It can also be used as second-line therapy when a patient is already taking the maximum tolerated dose of a beta-blocker or rate-limiting calcium channel blocker.
What is Paroxysmal atrial fibrillation
Paroxysmal atrial fibrillation (PAF) is intermittent episodes of atrial fibrillation that terminate within seven days either spontaneously or with intervention
When are Class 1c antiarrhythmic drugs used
anticoagulation therapy involves:
a choice of either a direct-acting oral anticoagulant (DOACs) or a vitamin K antagonist such as warfarin.
DOACs are the first-line option. Examples of DOACs include apixaban, rivaroxaban, edoxaban and dabigatran. Apixaban, rivaroxaban and edoxaban inhibit factor Xa within the clotting cascade and thereby prevent thrombus formation. Dabigatran works by inhibiting the action of thrombin and therefore thrombus formation.
Warfarin is a vitamin K antagonist. Clotting factors 10, 9, 7 and 2 are vitamin K dependent factors meaning they require vitamin K for activation. Therefore, if the action of vitamin K is antagonised these factors will not be activated and hence thrombus formation is inhibited.
What is Left atrial ablation
A complex procedure that involves creating small scars within the myocardium of the left atrium to block abnormal electrical signals and restore sinus rhythm.
What is atrial flutter
In atrial flutter, the heart’s upper chambers (atria) beat too quickly. This causes the heart to beat in a fast, but usually regular, rhythm. Atrial flutter is a type of heart rhythm disorder (arrhythmia) caused by problems in the heart’s electrical system
What is atrial fibrillation
AF is a cardiac arrhythmia characterised by the disorganised electrical activity within the atria which results in ineffective atrial contraction and irregular ventricular contraction.
AF can be asymptomatic, however, common presenting symptoms include breathlessness, chest discomfort, palpitations, dizziness, syncope and reduced exercise tolerance.
Complications of AF include:
- Thromboembolic events: TIA and ischaemic stroke/systemic embolism
- Tachycardia-induced cardiomyopathy
- Decompensation of pre-existing cardiac disease: heart failure, valvular disease
- Cardiac ischaemia can be associated with poorly controlled AF with the high ventricular rate leading to angina and type 2 myocardial infarction
Clinical skills: Diagnosis for Hypertension
- Measure BP in both arms.
- If the difference is greater than 15mmHg, repeat.
- If the difference is still greater than 15mmHg , measure thesubsequent BPs in the arm with higher reading
- If BP is more than or equal to 140/90, take a 2nd reading.
- if it is substantially different, take a 3rd reading. Lower of the last 2 = clinic blood pressure.
- Suspect HTN = BP ≥ 140/90
- If clinic systolic BP at least 180 mmHg or clinic diastolic BP at least 120 mmHg:
Same day referral for accelerated HTN (retinal haemorrhage +/- papilloedema or suspected phaeochromocytoma or life threatening symptoms (new onset confusion, chest pain, signs of heart failure, AKI)
If no symptoms, carry out investigations for target organ damage ASAP.
Target organ damage = start treatment immediately
No target organ damage = repeat BP within seven days
What is Isolated systolic HTN:
When patient is older than 60yrs has a systolic pressure of at least 160 mm Hg and diastolic pressure below 90 mm Hg.
What is considered a hypertensive crisis?
Hypertensive crisis defined as systolic BP >180 or diastolic BP >120
What is Hypertensive Urgency?
When systolic BP >180 or diastolic BP >120 but there are no or minimal end-organ damage
What is a hypertensive emergency
When there is a presence of End organ damage
- Hypertensive encephalopathy
- intracranial haemorrhage
- aortic dissection
- acute coronary syndromes
- acute left ventricular failure with pulmonary oedema or pre-eclampsia.
Malignant/accelerated HTN if evidence of hypertensive neuroretinopathy
What is Hypertensive encephalopathy
“Encephalopathy” means damage or disease that affects the brain. It happens when there’s been a change in the way your brain works or a change in your body that affects your brain. Those changes lead to an altered mental state, leaving you confused and not acting like you usually do
What is intracranial haemorrhage
bleeding between the brain tissue and skull or within the brain tissue itself – can cause brain damage and be life-threatening. Some symptoms include headache; nausea and vomiting; or sudden tingling, weakness, numbness or paralysis of face, arm or leg
What is aortic dissection
a serious condition in which a tear occurs in the aorta
acute coronary syndromes
a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart.
Examples: Non-ST-elevation myocardial infarction (NSTEMI), ST-elevation MI (STEMI), and unstable angina
What is pulmonary oedema
an abnormal buildup of fluid in the lungs. This buildup of fluid leads to shortness of breath.
What is pre-eclampsia
a condition that causes high blood pressure during pregnancy and after labour
Aim of treatment for hypertensive crisis
The initial aim of treatment is to lower blood pressure in a rapid (within 2-4 hours), controlled but not overzealous way, to safe (not normal) levels – about 160mmHg systolic and 100mmHg diastolic, with the maximum initial fall in blood pressure not exceeding 25% of the presenting value. Too rapid a fall in pressure may precipitate cerebral or myocardial infarction, or acute renal failure.
How does Aortic Dissection occur
Atherosclerosis and constant exposure to high pressure leads to weakening of aortic wall –> intimal tear –> blood flows into this space
Symptoms of aortic dissection
- Sudden, severe pain (tearing in character, interscapula or anterior chest
- Nausea, vomiting, syncope, sweating
Management exceptions - must remember
- Using QRISK3 if cardiovascular risk ≥10% and patient under the age of 84 offer lipid-modification therapy with atorvastatin 20mg
- Elderly and black people of African Caribbean origin have low levels of renin and angiotensin II.
…Therefore drugs that block the renin-angiotensin system are not particularly effective.
ALSO The elevation in BP is more likely to be salt sensitive.
A Response to non pharmacological therapy (weight reduction) may be less pronounced
ALSO Better response with diuretic or calcium channel blocker
AND Does not mean ACE inhibitor is useless
Management using ACEi for HTN:
Side effects:
Cough, dizziness, drowsiness, taste disturbance, hyperkalaemia, hyponatremia, renal failure, etc.
Contraindications:
Allergy, pregnancy, breast feeding, etc.
Caution:
Reduced dose in renal impairment
On other medications such as diuretics
Peripheral vascular disease as risk of renal artery stenosis
Etc.
What are ACE inhibitiors
Angiotensin-converting-enzyme inhibitors are a class of medication used primarily for the treatment of high blood pressure and heart failure. They work by causing relaxation of blood vessels as well as a decrease in blood volume, which leads to lower blood pressure and decreased oxygen demand from the heart.
When are ACE inhibitors used?
- HTN
- heart failure
- prevention of cardiovascular events
- nephropathy (kidney disease)
ACEi ‘s Mechanism of Action:
Vasodilation, diuresis and natriuresis
What drugs should be avoided when taking ACEi?
ARBs, NSAIDs
What are ARBs
Angiotensin receptor blockers (ARBs), also known as angiotensin II receptor antagonists, are used to treat high blood pressure and heart failure
Monitoring of ACEi
Monitoring:
U&E before Rx
U&E 1-2 weeks after initiation and after each dose change
BP in 4 weeks
For people who are at higher risk of hyperkalaemia or deteriorating renal function (for example those with peripheral vascular disease, diabetes mellitus, or pre-existing renal impairment or older people), consider checking renal function and serum electrolytes sooner (within 1 week).
Urea and electrolytes
What is the ACEi agent for hypertension?
Ramipril 1.25 to 2.5mg OD. MAX: 10mg OD
OD-once daily
What are the ARBs agents for hypertension?
irbesartan, valsartan, losartan and candesartan
What are CCBs
Calcium channel blockers are medications used to lower blood pressure. They work by preventing calcium from entering the cells of the heart and arteries. Calcium causes the heart and arteries to squeeze (contract) more strongly. By blocking calcium, calcium channel blockers allow blood vessels to relax and open.
What are CCBs agents for hypertension?
Dihydropyridine CCB (amlodipine, felodipine, nifedipine)
Rate-limiting CCB (Diltiazem, verapamil)
In patients with HTN alone amlodipine is preferred on the basis of cost
What are the side effects of CCBs:
Oedema, headaches, flushing, gum hypertrophy, postural hypotension
What are the contraindications and cautions of CCBs:
- Verapamil and diltiazem contraindicated in heart failure.
- Amlodipine can be used cautiously in stable heart failure
- Second degree AV block
- Cardiac outflow obstruction
Management of CCBs
Dose and titration:
Start at 5mg OD and titrate upwards as intervals of 4 weeks until target BP met.
Measure BP 4 weeks after each change
What are Diuretics
help rid your body of salt (sodium) and water through an increase in production of urine
How do diurectics help with hypertension
they help your kidneys release more sodium into your urine. The sodium helps remove water from your blood, decreasing the amount of fluid flowing through your veins and arteries. This reduces blood pressure
Side effects of diurectics
- Hyponatremia
- hypokalemia
- gout
- Erectile dysfunction
- rash
- postural hypotension
- hyperglycaemia
- polyuria etc
What is Hyponatremia
means that the sodium level in the blood is below normal
What is hypokalemia
a lower than normal potassium level in your bloodstream.
What is gout
a common form of inflammatory arthritis that is very painful. It usually affects one joint at a time (often the big toe joint).
What is hyperglycaemia
where the level of sugar in your blood is too high
What is polyuria
a condition where the body urinates more than usual and passes excessive or abnormally large amounts of urine each time you urinate
Contraindications and cautions of diurectics:
Avoid people with
- severe renal failure,
- hyponatremia,
- hypercalcemia,
- Addison’s disease, etc.
What is hyponatremia
the sodium level in the blood is below normal.
What is hypercalcemia
a condition in which the calcium level in your blood is above normal.
Addison’s disease
an uncommon disorder that occurs when your body doesn’t produce enough of certain hormones. In Addison’s disease, your adrenal glands, located just above your kidneys, produce too little cortisol and, often, too little aldosterone.
What does diuretics interact with
ACEi, ARB, NSAIDs
Diurectics options for hypertension
Dose and titration
Indapamide now first choice. 2.5mg daily to be taken in the morning
Chlortalidone. Start 25mg daily to be taken in the morning, increase up to 50mg daily
Management options for Hypertension:
ACEi,
ARBs,
CCBs,
Diurectics
Beta blockers
Alpha blockers
Mechanism of action for BBs
- Heart: decrease HR, contractility, conduction velocity, and relaxation rate therefore reduces cardiac output
- Blood vessel: vasodilation
- Kidney: inhibit the release of renin by the kidneys
Side effects for BBs
Lethargy, achy muscles, vivid dreams, Erectile Dysfunction, exacerbation of asthma, intermittent claudication, dizziness, dry eye, peripheral coldness
Lethargy
a pathological state of sleepiness or deep unresponsiveness and inactivity.
What is Claudication
Claudication is pain in the legs or arms that occurs while walking or using the arms.
Management BBs agents :
Depends on co-morbidities
- HTN and HF: bisoprolol, carvedilol, or nebivolol
- HTN and angina: atenolol, bisoprolol, or metoprolol
- HTN and previous myocardial infarction (without heart failure): metoprolol (standard release), propranolol (standard release), timolol, or atenolol
Dose:
- Depends on which one of the above is used
- Bisoprolol initially 5mg OD
- Atenolol 25-50mg OD
How do alpha-blockers help treat HTN
They lower blood pressure by preventing a hormone called norepinephrine from tightening the muscles in the walls of smaller arteries and veins. As a result, the blood vessels remain open and relaxed. This improves blood flow and lowers blood pressure.
Examples of alpha-blockers to treat HTN:
Doxazosin (Cardura) Prazosin (Minipress) Terazosin.
What is Orthostatic hypotension
is a form of low blood pressure that happens when standing after sitting or lying down.
Orthostatic hypotension can cause dizziness or lightheadedness and possibly fainting
Investigations for Orthostatic hypotension
investigations: FBC, U&E, fasting glucose, ECG, ECHO?
Lying and standing BP:
First BP should be taken after lying for at least 5 minutes
Second BP should be taken after standing in the first minute
A third BP should be taken after standing for 3 minutes
Symptoms should be documented
Management:
