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RACGP AFP/KFP > Cardio > Flashcards

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
What is the definition & treatment of Hypertesnive Emergency/crisis?
* 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
Symptoms of possible causes of secondary hypertension?
* 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
Initial investigations for ALL patients with newly diagnosed hypertension?
* 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
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?
* 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
General lifestyle advice and recommendations for patients with hypertension?
30
First line anti-hypertensive classes? (bonus marks for an example and dose range)
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
Antihypertensive combos to avoid/use with caution?
32
Effective antihypertensive drug combos?
33
How to decide when to initiate treatment of antihypertensives? \*assuming accurate readings and persistently elevated BP
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
What is eligibility criteria for absolute CVD risk assessment?
* 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
Physical exam findings of secondary HTN or end organ damage?
36
Contraindications to ACEI/ARBs?
* Compelling * Pregnancy * Angioedema * Hyperkalaemia * Bilateral renal artery stenosis * Possible * Women with child bearing potential
37
Contraindications to CCBs (dihydropyridines)?
* No compelling * Possible * Heart Failure
38
Contraindication to thiazide diuretics?
* Compelling * Gout * Age (risk of DM onset) * Possible * Glucose intolerance * Metabolic syndrome * Hypercalcaemia * Hypokalaem*a*
39
Contraindication to beta blockers?
* 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
Review frequency and drug treatment strategy to reach BP target in a newly diagnosed hypertensive patient?
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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