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RACGP AFP/KFP > Cardio > Flashcards

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1
Q

General investigations for diagnosing heart failure?

A
  • ECG
  • CXR
  • BNP -> if uncertain dx
  • TT
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2
Q

General managment for acute heart failure?

A
  • O2 if SpO2 <94%
  • NIV if acute HF with assocaited pulm congestion + hypoxic despite O2
  • IV loop diuretics if consolidation
  • IV vasodilators i.e. GTN (if SBP >90)
  • IV inotropes if periph hypoperfusion
  • Ix/Mx the precipitating factor/cause i.e. -> ACS, hypertensive crises, arrhythmia, mechanical catastrophe (ruptured interventricular septum, mitral papillary muscles or LV free wall, acute valvular regurgitation) & pulmonary embolism
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3
Q

Diagnostic criteria for HFrEF?

A
  • Symptoms +/- signs of heart failure, AND
  • LVEF <50%
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4
Q

Diagnostic criteria for HFpEF?

A
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5
Q

Symptoms of heart failure?

A
  • Typical
    • Dyspnoea (esp exertional)
    • Orthopnoea
    • Paroxysmal nocturnal dyspnoea
    • Fatigue
  • Less typical
    • Nocturnal cough
    • Wheeze
    • Abdo bloating
    • Anorexia
    • Confusion (elderly)
    • Depression
    • Palpitations
    • Dizziness
    • Syncope
    • Bendopnoea
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6
Q

Signs of heart failure?

A
  • Specific
    • Elevated JVP
    • Hepatojuglar reflux
    • 3rd heart sound
    • Laterally displaced apex beat
  • Less specific
    • Weight gain (>2kg/week)
    • Weight loss (advanced HF)
    • Perpheral oedema (ankles, sacrum)
    • Pleural effusions
    • Cardiac murmur
    • Tachycardia
    • Tachypnoea
    • Cheye-stokes respiration
    • Ascites
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7
Q

Describe the 4 classes of NYHA functional classification of heart failure

A
  • Class I
    • No limitation of ordinary physical activity
  • Class II
    • Slight limitation of physical activity
    • No symptoms at rest
  • Class III
    • Marked limitation of physical activity
    • No symptoms at rest
  • Class IV
    • Symptoms on any physical activity or rest
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8
Q

General work up of patient with suspected heart failure?

A
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9
Q

General management of patient with HFrEF?

A
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10
Q

When to use ACEI in chronic heart failure?

A
  • ACEI
    • Recommended in ALL pts w/ HFrEF + mod-severe LVEF reduction (≤40%)
      • Decrease mortality + hospitalisation
    • Consider if HFrEF + mild LVEF reduction (41-49%), unless not tolerated
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11
Q

When to use beta blockers in heart failure? Also which ones?

A
  • Beta Blockers
    • ALL pts w/ HFrEF + mod-severe LVEF reduction (≤40%)
      • Once stabilised w/ no/minimal congestion on physical exam
      • Bisoprolol, carvedilol, metoprolol(CR, ER) or nebivolol
    • Consider if HFrEF + mild reduction LVEF (41-49%), also once stabilised
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12
Q

When to use MRAs in CHF?

A
  • Mineralocorticoid receptor antagonists (MRAs) i.e. spironolactone
    • ALL pts HFrEF + mod-severe LVEF (≤40%)
    • Consider in HFrEF + mild reduction (41-49%),
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13
Q

When to use diuretics in CHF?

A
  • Consider in pts with HF + clinical signs/symptoms of congestion ->improves symptoms but no change in mortality
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14
Q

When to use ARBs in CHF?

A
  • Angiotensin receptor blockers (ARBs)
    • Recommended if HFrEF + LVEF mod reduced ≤40% + cant have ACEI
    • Consider if HFrEF + mild LVEF reduction (41-40%) + not tolerating ACEI (or CI’d)
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15
Q

Other less common drugs for CHF?

A
  • Angiotensin receptor neprilysin inhibitor (ARNI) i.e. valsartan/sacubitril (entresto)
    • Replacement of ACEI or ARB in pts w/ HFrEF + LVEF ≤40% despite maximal ACEI/ARB therapy AND beta blocker, with or w/o MRA
      • Concomitant use of ACEI + ARNIs CONTRAINDICATED -> should not be administered within 36hrs -> increased risk of angioedema
  • Ivabradine
    • Consider in pts w/ HFrEF + LVEF ≤35% AND SR 70 BPM or higher, despite max tolerated ACEI/ARB AND a beta blocker, with or w/o MRA
      • Decrease CV mortality and heart failure
      • Direct sinus node inhibitor
  • Hydralazine plus nitrates
    • Consider if pts w/ HFrEF if ACEI/ARB not tolerated or CI’d
    • Also consider in black pts of African descent with HFrEF despite receiving max ACEI/ARB + beta blocker with or w/o MRA
  • Digoxin
    • Consider in pts w/ HFrEF + sinus rhythm + mod-severe symptoms (NYHA Class 3-4) despite max ACEI/ARB
      • Weak evidence
    • Increases cardiac contractility
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16
Q

Indications for implatable cardioverter difibrillators in CHF?

A
  • Secondary prevention following resuscitated cardiac arrest, sustained VT with HD compromise, VT associated w/ syncope and LVEF <40%
  • Primary prevention in pts w/ HFrEF at least 1 mth post MI associated w/ LVEF ≤30%
  • Primary prevention in pts w/ HFrEF associated with IHD + LVEF ≤35%
  • Consider as primary prevention in pts w/ HFrEF with dilated cardiomyopathy
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17
Q

Antihypertensives to avoid in patients with HFrEF?

A
  • Diltiazem
  • verapamil
  • moxonidine
18
Q

Causes of heart failure? (general categories then sub groups)

19
Q

Red flags for early referral of Heart Failure? (symptoms, signs, investigation results)

20
Q

Definition of grade 1 (mild) HTN?

A

SBP 140-159 AND/OR DBP 90-99

21
Q

Definition of Grade 2 (moderate) HTN?

A

SBP 160-179 AND/OR DBP 100-109

22
Q

Definition of grade 3 (severe) HTN?

A

SBP >180 AND/OR DBP >110

23
Q

Definition of isolated systolic HTN?

A

SBP >140 AND DBP <90

24
Q

What is the definition & treatment of Hypertensive Urgency?

A
  • BP >180/110 that is not immediately life threatening BUT is associated with EITHER symptoms (i.e. headache, vision disturbance) OR moderate target organ damage
  • Treatment with oral drugs and F/U within 24-72 hrs recommended
25
Q

What is the definition & treatment of Hypertesnive Emergency/crisis?

A
  • BP >220/140 and acute target organ damage/dysfunction present (heart failure, APO, AMI, aortic aneurysm, acute renal failure, major neurological changes, hypertensive encephalopathy, papilloedema, cerebral infarction, haemorrhagic stroke)
  • Need hospitalisation (ICU), close BP monitoring and parenteral drug therapy
26
Q

Symptoms of possible causes of secondary hypertension?

A
  • Phaeochromocytoma: frequent headaches, sweating, palpitations
  • Sleep apnoea: obesity, snoring, daytime sleepiness
  • Complementary and/or recreational drug intake
  • Hypokalaemia: muscle weakness, hypotonia, muscle tetany, cramps, arrhythmias
  • Symptoms of thyroid disease
27
Q

Initial investigations for ALL patients with newly diagnosed hypertension?

A
  • Urine dip for blood -> if abnormal send for microscopy
  • Albuminuria & proteinuria status
    • Recommended for ALL pts, MANDATORY for those w/ diabetes
    • First void spot urine preferable, but random okay
    • If in the maroalbuminuria range -> recommend 24 hr protein level
      • Proteinuria = >500mg/day excretion rate
  • Blood tests
    • Fasting glucose
    • Fasting serum total chol, LDL, HDL, triglycerides
    • Serum urea, EUC w/ eGFR
    • Hb + HCt
  • 12 Lead ECG
    • Detect AF, LVH, prev evidence of IHD
28
Q

If you have a patient with newly diagnosed hypertension, other than the standard (bloods/ECG/urine dip) what are some specific Ix for patients with other co-morbidities?

A
  • CVD
    • Echocardiography (TTE) -> To dx LVH, or where left atrial dilatation & concomitant heart disease is suspected
    • Carotid US -> of arteries ?asymptomatic atherosclerosis esp in older adults
  • CKD
    • Renal artery imaging
    • Renal artery duplex US, renal nuclear med +/- CT angiography
    • For Ix of renovascular causes of HTN (e.g. fibromuscular dysplasia in young females with HTN, older pts who may have atherosclerotic renal artery disease & pts with a renal and/or femoral bruit
  • Peripheral arterial disease
    • ABI (Ankle Brachial Index) -> in ALL w RFs for PAD; inc hypertensive pts w/ DM, vascular bruit, older age and/or smokers
    • Index <0.9 diagnostic for PAD
  • Other
    • Plasma aldosterone/renin ration
      • Primary aldosteronism occurs 5-10% of pts w/ HTN and is NOT excluded by normal serum K
      • Consider in pts w/ HTN, esp those with mod-severe OR treatment resistant HTN, and those with hypokalaemia
      • Referral to specialist for Ix recommended when primary aldosteronism suspected as interpretation is difficult in treated pts
      • Refer to clinical practice guideline: case detection, diagnosis and treatment of patients with primary aldosteronism (ref 42)
    • Metanephrine & normetanephrine excretion (with creatinine) and/or plasma catecholamine, metanephrine and normetanephrine concentration, 24 hr urinary catecholamine
      • Indicated when symptoms of episodic catecholamine excess and/or episodic HTN (suggestive of phaeochromocytoma)
29
Q

General lifestyle advice and recommendations for patients with hypertension?

30
Q

First line anti-hypertensive classes? (bonus marks for an example and dose range)

A
  1. ACEI -> i.e. perindopril arginine 5-10mg daily
  2. ARB -> candesartan 8-32mg daily
  3. CCB -> amlodipine 2.5-10mg daily
  4. Thiazides -> Hydrochlorothiazide 12-25mg daily
31
Q

Antihypertensive combos to avoid/use with caution?

32
Q

Effective antihypertensive drug combos?

33
Q

How to decide when to initiate treatment of antihypertensives? *assuming accurate readings and persistently elevated BP

A
  1. Absolute CVD Risk
    • High risk >15% -> start immediately
    • Medium risk 10-15%
      • Immediately if BP >160/100, FHx of premature CAD OR ATSI
      • Otherwise review BP next visit
    • Low risk <10%
      • Start immediately if SBP >160/100
      • Otherwise review in 2/12
  2. Not eligible for CVD Risk (i.e. <45y.o. etc)
    • Assess for
      • target organ damage
      • Relevant co-morbidities
      • Any know vascular disease
    • Decision to treat depends on this + BP readings
34
Q

What is eligibility criteria for absolute CVD risk assessment?

A
  • Eligible
    • Adults >45 (>35 ATSI)
    • WITHOUT known pmhx of CVD or other co-morbidities
  • Ineligible
    • Adults <45 (ATSI < 35)
    • Existing CVD
      • Prior MI, stroke/TIA, PAD, heart failure, AF, Aortic disease
      • End-stage kidney disease on dialysis
35
Q

Physical exam findings of secondary HTN or end organ damage?

36
Q

Contraindications to ACEI/ARBs?

A
  • Compelling
    • Pregnancy
    • Angioedema
    • Hyperkalaemia
    • Bilateral renal artery stenosis
  • Possible
    • Women with child bearing potential
37
Q

Contraindications to CCBs (dihydropyridines)?

A
  • No compelling
  • Possible
    • Heart Failure
38
Q

Contraindication to thiazide diuretics?

A
  • Compelling
    • Gout
    • Age (risk of DM onset)
  • Possible
    • Glucose intolerance
    • Metabolic syndrome
    • Hypercalcaemia
    • Hypokalaema
39
Q

Contraindication to beta blockers?

A
  • Compelling
    • Asthma
    • Bradycardia
    • AV block (2 or 3)
    • Uncontrolled heart failure
  • Possible
    • T1DM or T2DM
    • Metabolic syndrome
    • Glucose intolerance
    • Athletes or active patients
    • COPD
    • Depression
  • Also have an increased risk of developing DM
40
Q

Review frequency and drug treatment strategy to reach BP target in a newly diagnosed hypertensive patient?

A
  1. Start drug treatment with:
    • low-mod dose of 1st line drug
    • If doesn’t tolerate change to other 1st line
  2. If target not reached after 3 months
    • Add 2nd drug from different class at low-mod dose BEFORE increasing dose of 1st drug
  3. If target not reached after further 3 months:
    • increase dose of one drug incrementally to max dose BEFORE increasing dose of other drug
  4. Target not reached after further 3 months
    • 3rd drug class at low-moderate dose
    • Re-assess for non-adherence, secondary HTN and hypertensive effectos of other drugs
    • Consider OSA, EtOH, recreational drugs, high salt intake
  5. If remains elevated -> referral to cardiologist

Note:

Review every 4-6 weeks NOT 3 monthly (this is when to consider dose increases) -> more frequently if sig elevated BPs.

Max drug effect likely to be seen in 4-6 weeks

Life style advice for ALL patients

RACGP AFP/KFP (2 decks)

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