Cardiac revision cards Flashcards
What are some of the cardiac risk factors for Atrial Fibrillation?
Hypertension
Ischaemic heart disease
Structural heart disease
What are some of the non-cardiac risk factors for Atrial fibrillation?
Diabetes melluitis
Increased alcohol consumption
Thyrotoxicosis
COPD
Difference between chronic and acute AF?
Acute- started within 48 hours
Chronic - longer than 48 hours
What are the three types of AF?
Paroxysmal- intermittent AF, in between patient has normal sinus rhythm
Persistent- successfully converted by treatment
Permanent- failed or unsuitable treatment
What is an alternative for stroke prevention if anti-coagulants are contraindicated?
Left atrial appendage occlusion
A small sac in the left atrium which is responsible for the formation of most clots within the heart in AF patients is sealed off, preventing blood flow and stasis there.
When would rate control not be the first line management for AF patients?
When there is a reversible cause (treat the cause such as infection)
Heart failure has been caused by underlying AF (Beta blockers can worsen HF)
New onset acute AF (started within the last 48 hours) - non-pharmacological such as DCCV is first line
Outline briefly the rhythm control management for AF.
First line - direct current cardioversion
Second line- Standard beta blockers
Third line - Amiodarone and Dronedarone
When is Amiodarone used in preference to Dronedarone?
In patients with heart failure with underlying AF. Dronedarone has been shown to worsen HF.
What is the appropriate pharmacological management of Paroxysmal AF?
Patients with intermittent AF:
‘Pill in pocket strategy’ patient is encouraged to take medication when they experience an AF attack only (Flecainide)
If more frequent, preventative therapy is required: Back to conventional therapy
Not Digoxin due to increasing the frequency, and cause rapid and persistent paroxysms
Abstinence from alcohol and caffeine due to increasing the frequency
Antithrombotic
If conventional treatment for AF has failed?
Left atrial ablation - radioactive materials used at a point in the left atrium where arrythmia is generated
Pace and ablate - radiofrequency ablation of the AV node and pacemaker inserted
Briefly outline the process of direct current cardioversion.
Electrical shock is conducted across the chest wall which allows the SA node to regain control of the heart rate
Patient is briefly anaesthetised
What is one of the main risk associated with DCCV?
Risk of thromboembolism
To reduce risk patient is anti-coagulated 3 weeks before and 4 weeks after (to ensure sinus rhythm is restored)
What happens in ablation?
Electro-frequency studies identify the exact myocardial tissue responsible for generation of the arrythmia.
An electrode is guided to that point and effectively the tissue is destroyed, conduction pathway is disrupted.
What are the principals of internal cardioversion defibrillators?
Delivers rapid rate impulses when detects patient is entering a ventricular tachycardia (faster than the arrhythmia to try and regain the control and then slows heart rate.
If this fails they will deliver an electrical shock.
Which patients are implanted with ICDs?
High risk patients with resistant VTs (have suffered a cardiac arrest previously)
When should QRISK3 be used to determine CVD risk?
Patients aged 25-84 years for primary prevention of CVD
Patients aged 25-84 years with Type 2 diabetes for primary prevention of CVD
When should QRISK3 not be used to determine CVD risk?
Type 1 diabetes
Chronic kidney disease with eGFR below 60mL/min/1.73m2
Over 85 years
Familial hypercholesterinaemia
Primary prevention of Atorvastatin 20mg should be offered in all of these groups (most Type 1 DM) as they are considered HIGH RISK.
Which Type 1 DM should be offered primary CVD prevention?
Patients over 40
Type 1 DM for over 10 years
Diabetic nephropathy
Has other CVD risk factors
Considered in all
What other factors should be taken into consideration with QRISK score?
Taking treatment which causes dyslipidaemia (immunosuppressants, corticosteroids or antipsychotics)
Severe mental health illnesses
Treatment for HIV
Recent changes in risk factors (bp, lipids, quit smoking)
Systemic inflammatory disorders (SLE)
Non-diabetic hyperglycaemia
High fasting triglycerides
Severe obesity (over 40kg/m2)
What is the statin therapy management for patients with CKD (less than 60mL/min/1.73)?
For PRIMARY and SECONDARY prevention:
20mg Atorvastatin OD
Appropriate management for CKD patient if there is not a 40% reduction in non-HDL cholesterol after 3 months?
Dose increase if eGFR is greater than 30mL/min/1.73m2
If below, refer to specialist
Which are some add on therapies if patients non-HDL does not achieve a 40% reduction with maximum tolerated dose of statin?
Ezetimibe 10mg daily
Reassess after 3 months
If still inadequate: +180mg Bempedoic acid
LDL-cholesterol remains above 2.5mmol/L
Considered injectable therapies (Inclisiran or PCSK9 inhibitors)
What is the initial monitoring parameters for statins?
Blood pressure
LFTs - ALT and AST
Renal function
Full lipid profile - TG, HDL, LDL, Total cholesterol
Smoking status
Urea and electrolytes
TSH - hypothyroidism
Diabetes status
BMI
Alcohol consumption
When would Atorvastatin 80mg not be considered for use in the secondary prevention of CVD?
Patients with CKD (20mg Atorvastatin)
Patient’s preference
High risk of experiencing an adverse effect
Drug interactions
Which drugs interact with Atorvastatin?
Drugs that increase the exposure:
Ciclosporin
Diltiazem
Dronedarone
Verapamil
Conazoles
Monitor and adjust dose
Macrolides (stop during course +1 days)
‘Parins’ increased risk of hepatoxicity
Colchicine increased risk of rhabdomyosis
What is the therapeutic target for statin treatment?
40% reduction in non-HDL cholesterol at 3 months
HDL greater than 1mmol/L
What monitoring is required for statin therapy?
Initial monitoring/prior to use
At 3 months:
Full lipid profile - TG, non-HDL, HDL, TC
LFTs- ALT, AST
Repeat at 12 months and then annually or at 3 months after every up titration
What is the appropriate management for raised LFTs?
ALT/AST above three times the upper limit of normal do not initiate a statin or discontinue it and repeat in one month
Raised but less than 3 times the upper limit of normal, continue statin and repeat in a month
If they continue raised but still less than three times the upper limit of normal, continue repeat in six months
What are some symptoms of statin induced muscle pain?
Symmetrical pain and/or weakness
Large proximal muscles
Worsened on exercise
Elevated creatine kinase
Improvement on discontinuation
Explain the statin intolerance pathway (muscle aches).
- De-challenge
Measure Creatine kinase if it appears elevated and patient has intolerable symptoms
Stop for 4-6 weeks
Consider other potential causes of muscle pains - Re-challenge
Has creatine kinase normalised?
Has the patient been symptom free for 2 weeks?
Offer lower dose or alternative statin (more hydrophilic)
This should be a low or moderate dose of a high intensity statin (Atorvastatin 10/20mg or Rosuvastatin 5-10mg) - Consider alternative or twice weekly dosing
Both Atorvastatin and Rosuvastatin have a long half life - Statin intolerance confirmed
Switch to Ezetimibe 10mg
When should statin therapy be stopped according to intolerance pathway?
In severe myopathy or rhabdomyosis
Creatine kinase is measured at 10x or greater the upper limit of normal
Under what circumstances would you consider offering anti-hypertensive in acute management of stroke patients?
To meet blood pressure requirements for fibrinolytics (below 185/110 mmHg)
In a hypertensive crisis one or more of the following:
Intracerebral haemorrhage with a systolic blood pressure above 220 mmHg
Aortic dissection
Hypertensive HF/MI
Hypertensive nephropathy
Hypertensive encephalopathy
Pre-eclampsia
Which anti-hypertensives should be used if blood pressure needs to be lowered in acute stroke?
Calcium channel blockers such as Amlodipine such is safe for NG tube administration
Parental Beta blockers such as Labetalol
What is the recommended management of VTE prophylaxis in stroke patients?
Intermittent pneumatic compressions within 3 days of admission
Graduated stockings are deemed ineffective and LMWH should not be used due to risk of intracerebral haemorrhage
What is the blood pressure target for a patient who has suffered a stroke?
Aim to achieve a systolic blood pressure below 130 mmHg
When should anti-hypertensives be initiated post-stroke?
Prior to the transfer out of secondary care or after 2 weeks whichever is soonest.
May be initiated sooner if patient has stabilised but blood pressure remains high
When should statin therapy be offered?
Not within the first 48 hours post stroke due to the risk of haemorrhagic transformation.
What is the target of patients post stroke with evidence of atherosclerosis?
Aim to reduce LDL cholesterol to under 1.8 mmol/L within 4-6 weeks.
If this is not achieved speak about adherence, timing of dose, diet and lifestyle
Consider adding Ezetimibe 10mg to Atorvastatin 80mg.
When should anti-coagulants not be given to cardioembolic patients?
Intracranial haemorrhage identified on imaging
Blood pressure above 180/120 mmHg
What ORBIT scores considered a patient to be high, medium and low risk of bleeding?
Used as a guide only but:
0-2 is considered low risk
3 is medium risk
4-7 high risk
Attempt to modify risk factors for bleeding, if it remains high DO NOT give Aspirin as an alternative
When should stroke patients receive supplemental oxygen?
Oxygen saturation drops below 95%
What are some of the risk factors for an ischaemic stroke?
Age
Hypertension
Family history of TIA or stroke
Previous TIA or stroke
Coagulable status
Migraine
Diabetes
Dyslipidaemia
Obesity
Smoking
Illicit drug use / excess alcohol
Physical inactivity
Increased age
Male
Cardiac disease
Carotid artery stenosis
What are some of the risk factors for an haemorrhagic stroke?
Head injury
Illicit drug use
Diabetes
Anti-coagulant therapy
Hypertension
Age
Male
Smoking
What are some of the cardiac conditions that increase your risk of stroke development?
Atrial fibrillation
Structural abnormalities
Valvular AF
HF
Mitral stenosis
Atrial and ventricular enlargement
All cause blood stasis within the heart increasing the risk of emboli formation
What are some of the additional tests used in stroke diagnosis?
Blood glucose
Clotting (APTT, PT and INR)
ECG
Fasting lipids
Blood culture
Full blood count
Urea and electrolytes
Glasgow coma scale
Are CT scans recommended for TIA patients?
Not routinely used however may be considered if:
Area of the brain affected is unknown
Atypical symptoms
Detect haemorrhage (if patient is already on anti-coagulants)
If these factors will influence treatment (carotid surgery)
Explain the different NIHSS scores.
0 - no stroke
1-4 - minor stroke
5-15 - moderate stroke
16-20 - moderate/severe stroke
21-42 - severe stroke
What does eligibility for a thrombectomy depend upon?
This is a mechanical clot removal, eligibility depends upon:
Area of brain and location of occlusion
Neurological deficit
Consideration of quality of life before and after the stroke
What are some causes of systolic Heart failure?
Ischaemic heart disease
Cardiomyopathies
Infection and viruses
Inflammation
Diffuse fibrosis
Arrhythmias
Excess alcohol
Post myocardial infarction
What is systolic heart failure?
Systolic heart failure also known as pump failure is the inability of the heart to contract effectively to pump blood out of the ventricles into the peripheral circulation.
What is diastolic heart failure?
Diastolic heart failure is when the myocardium specifically the left ventricular wall becomes stiff, can’t relax properly during diastole and hence cannot accept an adequate blood flow during diastole. This type of heart failure is known as HF with a preserved ejection fraction.
What are the different factors that contribute to diastolic heart failure?
Excessive preload
Excessive afterload
What are some of the factors that contribute to excessive preload?
Caused by hypervolemia such as:
Renal failure (increased reabsorption, hence fluid retention)
Excessive IV infusions
NSAIDS, Steroids
Polycythaemia
What are some of the factors that contribute to excessive afterload?
Pulmonary hypertension
Peripheral hypertension
Valvular dysfunction
What are some of the factors that contribute to excessive demand?
Anaemia (O2 carrying capacity is reduced)
Hyperthyroidism and Thyrotoxicosis
Tachycardia, Bradycardia
Widespread vasodilation
Valve dysfunction
What are some of the precipitating factors for HF?
Arrhythmias
Anaemia
Hyperthyroidism
Pregnancy
Obesity
Infective endocarditis
Pulmonary infection
Poor therapy compliance to diuretics
Treat underlying cause here
What are some of the symptoms of hypoperfusion associated with HF?
Fatigue and exercise intolerance
Cold and pale extremities
Fluid and electrolyte retention
Tachycardia and Tachypnoea
What are some of the symptoms specifically associated with left sided HF?
Due to pulmonary congestion / backlog:
Pulmonary oedema
(Dyspnoea, Orthopnea, Paroxysmal nocturnal dyspnoea)
Cough/wheeze
Central cyanosis
Tiredness
Breathlessness
What are some of the symptoms specifically associated with right sided HF?
Peripheral oedema
Raised jugular vein
Peripheral cyanosis
Hepatomegaly
Fluid and electrolyte retention
What are the four factors that contribute to changes in the heart?
Cardiac enlargement
Arterial constriction
Increased sympathetic drive
Salt and water retention
What is one of the key biological markers for HF and how is it associated?
Atrial natriuretic peptide
Cardiac output is reduced during HF resulting in a drop in systemic blood pressure and resulting in reduced tissue perfusion including that through the kidney. In attempt to increase the blood pressure, RAAS system is activated, resulting in aldosterone release. This results in sodium and water retention increasing the preload (hypervolemia effect). ANP is a hormone released from the right atrium is response to an increase in ECF causing stretch of the atrial wall, it aims to reduce ECF volume by promoting sodium excretion in the kidneys.
What are some of the tests used in the diagnosis of HF?
Attempt to identify and treat underlying causes of HF
Assessment of symptoms:
Raised jugular vein, Lung sounds, Peripheral oedema
Test BNP and NTproBNP via blood test
Main: Echocardiogram for EF
Others:
Chest X-ray
Heart rate, rhythm, sounds
Electrocardiogram
Blood pressure
Blood tests
What do the main pharmacological interventions for HF aim to achieve?
Depending on the cause (systolic or diastolic) either
Increase inotropy (the force of contraction) or
Reduce preload or afterload
What are the short and long term doses for Metolazone?
Atypical thiazide diuretic is used for exacerbation of HF to eliminate oedema, when furosemide has not been effective (120mg BD)
STAT and short term 2.5-5mg
Long term 2.5/5mg 2 or 3 times weekly
What are the patient risk factors for DVT?
Age
Male
Pregnancy and puepartam
Immobility
Long journeys (more than 4 hours)
Varicose veins
Previous VTE
Obesity
What are some of the condition risk factors for DVT?
Trauma or surgery
Malignancy (chemotherapy or radiotherapy)
CCF, including recent MI
Infection
Hormone therapy - COC or HRT
Inherited thrombophilia
Vasculitis
What is used in the diagnosis of DVT?
Wells clinical score based on clinical presentation and risk factors
D-dimer assay
Diagnostic imaging:
Venography
Duplex sonography
MRI
What are the categories of the Wells clinical score?
0 - low probability
1-2 intermediate probability
3 or more - high probability
What are the limitations of using the D-dimer assay?
High negative predictive value
Can be raised in other conditions such as haemorrhage, sepsis, trauma, surgery, pregnancy
Result is also affected by position of clot, elderly, heparin use
What are some of the side effects of unfractionated heparin?
Haemorrhage
Thrombocytopenia (monitor platelets > 5 days)
Hyperkalaemia
Osteoporosis, alopecia
What therapeutic monitoring parameter is used for unfractionated heparin and what is the therapeutic range?
APTT (activated partial thrombin time)
APTT ratio:
patients APTT at a given time/ reference
Target is: 80-100 seconds
or the ratio: 1.5-2.5 seconds
What therapeutic monitoring parameter is used for LMWH?
If needed anti-Xa assay
