Cardio - HTN, AF

Question 1

HTN - what is it?

Answer 1

BP that is 140/90 in clinic
OR
BP that is 135/85 with ambulatory or home readings

Question 2

HTN - what is primary and secondary HTN?

Answer 2

Primary - 90% of cases, causes include obesity, alcohol, DM, genetics

Secondary - specific cause, such as kidney disease, pre-eclampsia, co-arctation of aorta

Question 3

HTN - how do you diagnosis?

Answer 3

Patients with clinic blood pressure between 140/90 mmHg and 180/120 mmHg should have 24 hour ambulatory blood pressure or home readings to confirm the diagnosis

Question 4

HTN - what is the pharmacological stepwise management?

Answer 4

A - ACEi or Angiotensin receptor blocker (ARB)
C - Calcium Channel Blocker
D - Thiazide-like diuretic

Question 5

HTN - what is a hypertensive emergency, what is an example of one, and what is the management?

Answer 5

HTN emergencies occur when high BP results in acute end-organ damage

BP >180/120 with signs of papilloedema and/or retinal haemorrhage - condition results in neurological, renal and cardiac damage, requires admission + immediate management.

IV Nitroprusside (nitric oxide releasing drug), labetalol and glyceryl trinitrate infusions

Question 6

AF - what is AF?

Answer 6

It is uncoordinated atrial activity and irregularly iregular rhythm

Question 7

AF - pathophysiology

Answer 7

Uncoordinated electrical activity from SAN across atria

Causes fragmented impulses all over atria

Muscle fibres all contract at different times

Question 8

AF - causes? ATRIALE PIBI

Answer 8

A - Alcohol +caffeine
T - Thyrotoxicosis
R - Rheumatic fever + mitral valve
I - Ischaemia heart disease
A - Atrial myxoma
L - Lungs, pulmonary HTN
E - Electrolyte disturbances

P - Pharmacological
I - Iatrogenic
B - BP
I - Infections

Question 9

AF - what is the clinical presentation?

Answer 9

Asymptomatic

SoB
Palpitations
Syncope
Fatigue

Sign - irregularly irregular pulse

Question 10

AF - what are the investigations?

Answer 10

1st line - 12 lead ECG, irregularly irregular rhythm, absent P waves

Bloods - identify underlying cause, FBC (infection), U&Es (hypoK+), TFTs

Echo

Question 11

AF - what are the complications?

Answer 11

Blood stasis, clot formation, thrombus

Leads to:
TIA, stroke
Acute limb ischaemia
Acute mesenteric ischaemia

Question 12

AF - management of acute AF?

Answer 12

Haemodynamic instability - emergency electrical cardioversion
Haemodynamic stability - rate or rhythm control

AF < 48h:

1. Anticoag with Heparin
2. Possible cardioversion (rhythm control), pharmacologically with flecainide in absence of structural heart disease, amiodarone if structural heart disease present, or electrical cardioversion

AF > 48h or unknown time:

1. Increased risk of embolism after cardioversion
2. Delay cardioversion until maintained on anticoag for at least 3 weeks, rate control in meantime

Question 13

AF - management of chronic AF?

Answer 13

1st line - Rate Control (avoid in patients with HF):

1. Beta blocker (Bisoprolol)
2. CCB (Verapamil/Diltiazem) rate limiting
3. Digoxin - preferred choice in patients who have coexistent HF

Rhythm control (aims to restore normal sinus rhythm, preferred if patient has HF or younger)

1. Pharmacological - Beta blocker, Flecianide, Amiodarone
2. Electrical DC cardioversion

Anticoagulation:

1. Balance risk of thromboembolic event vs bleeding risk
2. Warfarin - target INR 2 to 3
3. NOACs - Rivaroxaban, Apixaban (Factor Xa inhibitors), Dabigatran (Direct thrombin inhibitors), avoid in patients with valvular disease