Cardiology 1 Flashcards
Stage 1 HTN HBPM versus clinic BP
Stage 2 HTN
Severe HTN
135/85 >= or 140/90
150/95 >= or 160/100
Clinic >=180 or 110
When do you treat stage 1 and stage 2 HTN?
What age should you consider specialist referral?
Stage 1 Rx if <80yo only treat medically if: diabetic, renal disease, QRISK2 >10%, established coronary vascular disease, or end organ damage. Otherwise lifestyle.
Consider if under 60 with stage 1 HTN and QRISK <10%
Stage 2 - everyone
For patients < 40 years consider specialist referral to exclude secondary causes.
Treatment of HTN
<55yo or diabetic: A –> A+C or A+D
> 55 and not diabetic, or black: C –> C+A or C+D
Third line A+C+D
(D indapamide or chlortalidone may be preferred over bendroflumethiazide)
Step 4 <=4.5 –> spiro >4.5 alpha blocker or BB
If not controlled on four drugs then refer to secondary care.
What are the blood pressure targets? Clinic versus home
<80 <140/90 or 135/85
> 80 <150/90 or 145/85
Pan systolic murmur
RF: female, low BMI, previous MI, collagen disorders
Name the valvular disease
Mitral regurgitation
Name the causes of mitral regurgitation (5)
- Infective endocarditis
- Post MI
- Mitral valve prolapse
- Rheumatic fever
- Collagen
Mitral regurg mumur description
Where is it best heard? Where does it radiate to?
Pan systolic
Blowing
Best heard at the apex and radiates to the axilla
DVLA requirements:
Angioplasty
ACS
CABG
Angina
Pacemaker
Aortic aneurysm
Angioplasty 1 week
ACS 4 weeks
CABG 6 weeks
Angina cease if symptomatic
Pacemaker 1 week
Aortic aneurysm 6cm inform DVLA and for annual review. 6.5cm not allowed to drive
Statin
Common side effects (2)
Not recommended for patients with which condition?
Contraindicated (2)
- Myopathy
- Liver impairment
Not recommended if has BG of intra-cerebral haemorrhage
CI - pregnancy and macrolides
Who should receive a statin? (4)
Anyone with CVD (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
QRISK >= 10%
T2DM patients should have QRISK calculated
T1DM if dx >10 years ago OR >40yo OR nephropathy
NICE recommendations of statins
Primary prevention: choice of drug and dose
Secondary prevention: choice of drug and dose
Atorvastatin 20mg
Atorvastatin 80mg
ACE inhibitor SE (3)
Monitoring
Acceptable changes in creatinine and K+
Cough, hyperkalaemia, angiodema
U+E to be checked prior to starting and after increasing the dose.
Acceptable changes:
Creatinine increased up to 30% baseline
K+ up to 5.5
Mx
All acute (4)
Type 1
Pre op
Post op
If PCI can be done within 2 hours
If PCI cannot be done within 2 hours
Mx
All
Aspirin 300mg, oxygen if sats <94%, morphine if in pain, nitrates IV/SL
Type 1
- pre op prasugrel, post op unfractionated heparin
PCI if within 12 hrs onset of sx AND PCI can be delivered within 2hrs
give an anti-thrombin (fondaparinux) pre op, post op ticagrelor
- fibrinolysis if onset of sx within 12 hours and PCI cannot be delivered within 2 hrs (repeat ECG after 1hr, if persistent ischaemic changes then for PCI)
Mx Type 2 ACS
Mx
Aspirin 300mg
Fondaparinux if no immediate PCI planned
GRACE score
<3% ticagrelor
>3% ticagrelor or prasugrel with unfractionated heparin and PCI within 72 hours
In Type 2 Mx - who gets FU PCI?
Immediate: if clinically unstable
Within 72 hours if GRACE >3%
Acute pericarditis sx (7)
CP (pleuritic)
Relieved by sitting forward
Perciardial rub
High HR
High RR
Flu like symptoms
Non productive cough
ECG changes in acute pericarditis (3)
Mx (2)
Widespread ST elevation
Saddle shaped ST elevation
PR depression
Mx NSAIDS + colchicine
Adverse effects of amiodarone (8)
Long QT
Pneumonitis
Thyroid dysfunction
Liver fibrosis/ hepatitis
Corneal deposits
Slate grey appearance
Bradycardia
Peripheral neuropathy
Angina Mx
All patients should received which two drugs?
Symptom mx (1)
First line treatment (2)
Single agent choice examples
Dual agent choice examples
If unable to tolerate dual therapy then give? (three examples)
Aspirin and statin
GTN
BB or CCB (if single agent then verapamil or diltiazem)
If combo then long acting such as nifedipine
Long acting nitrate e.g ivabradine, nicorandil or ranolazine
Antiplatelet Summary:
1st and 2nd line mx
ACS
PCI
TIA
Ischaemic stroke
Peripheral arterial disease
ACS
- aspirin (lifelong), ticagrelor (12 months)
- if aspirin CI then clopi lifelong
PCI
- aspirin (lifelong), ticagrelor or prasurgrel (12 months)
- if aspirin CI then clopi lifelong
TIA + ischaemic stroke
- clopi lifelong
- asp + dipydridamole lifelong
Peripheral arterial disease
- clopi lifelong
- aspirin lifelong
Name 5 features of aortic dissection
Help:
Describe the pain, pulse, valvular disease, RF and ECG changes
CP radiating to the back
Weak/ absent pulse
Aortic regurg
HTN
Non specific ECG changes or no changes
Aortic dissection
Type A
Type B
A - ascending aorta 2/3 of cases typically CP
B - descending aorta, typically back pain
Name six features of aortic regurg
Early diastolic murmur
Collapsing pulse
Wide pulse pressure
Quincke’s (nail bed pulsation)
De Musset’s (head bobbing)
Austin Flint murmur
Name four causes of LBBB
MI
Aortic stenosis
Cardiomyopathy
HTN
Chronic heart failure mx
1st line
2nd line
1st line ACE + BB
2nd line aldosterone antagonist e.g spiro/ eplenerone
3rd line tx for chronic heart failure (5)
Should be initiated by a specialist
ivabradine
criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%
sacubitril-valsartan
criteria: left ventricular fraction < 35%
digoxin
for symptomatic relief and is strongly indicated if there is coexistent atrial fibrillation
hydralazine in combination with nitrate
this may be particularly indicated in Afro-Caribbean patients
cardiac resynchronisation therapy
indications include a widened QRS (e.g. left bundle branch block) complex on ECG
Heart failure vaccinations (2)
Annual flu vaccine and one off pneumococcal vaccine
If BP >180/120 but no eye signs of life threatening sx then what investigations would you request? (3)
When would you start BP meds without waiting for the results of ABPM or HBPM?
What would you do if that is not the case?
bloods, urine ACR, ECG
If end organ damage
Repeat clinic blood pressure measurement within 7 days
What is ambulatory blood pressure monitoring (ABPM)?
at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)
use the average value of at least 14 measurements
What is home blood pressure monitoring (HBPM)?
for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
BP should be recorded twice daily, ideally in the morning and evening
BP should be recorded for at least 4 days, ideally for 7 days
discard the measurements taken on the first day and use the average value of all the remaining measurements
Provoked VTE
Unprovoked VTE mx length of time
Choice of anticoagulant (2)
If renal impairment (what creat clearance?) what would you give?
3 months
6 months
Apixaban or rivaroxaban
Unless there is renal impairment creat clearance <15ml then LMWH
Aortic stenosis features (6)
ejection systolic murmur
narrow pulse pressure
slow rising pulse
soft/ absent S2
S4
thrill
Causes of AS (4)
Degenerative calcification >65yo
<65yo bicuspid aortic valce
HOCM
post-rheumatic disease
Aortic stenosis Mx
Asymptomatic
Symptomatic
Types of surgery
Asymptomatic - observe
Symptomatic - valve replacement
If asymptomatic but valvular gradient >40mmgHG with features of systolic dysfunction then can consider surgery
AVR - young/ low/medium risk patients. Co-existent CVD.
Balloon valvuplasty in children with no calcification.
Difference between persistent and paroxysmal AF
<7 days = paroxysmal
AF mx
1st line and 2nd line
1st line - BB or rate limiting CCB such as diltiazem
If not effective
Then combi therapy with any two of the following:
BB, diltiazem or digoxin
AF mx
When to pick rhythm? (3)
<48 hours mx options rate or rhythm
>48 hours mx options rate or rhythm
(not the details)
<48 hours of symptoms (and haemodynamically unstable) OR have been anticoagulated for a period of time prior to attempting cardioversion
OR if rate control hasn’t worked
<48 hours rate or rhythm
>48 hours - rate control
CHA2DVAS2Sc
Congestive heart failure
HTN
Age >75, 60-74
T2DM
Valvular disease
Stroke TIA versus stroke
Sex - female
What is the ORBIT score used for?
Factors considered (5)
Results interpretation
Bleeding risk
(previously HASBLED)
Hb <130 M <120 F (2)
Age >75 (1)
Bleeding hx (2)
Renal impairment (1)
Tx with antiplatelet agents (1)
0-2 - low risk
3 - medium risk
4-7 high risk
Cardioversion Mx
<48 hours
Give ? and then can electrocardiovert
How long should you anticoagulate for after this?
OR
Pharmacological - structural (1)/ non structural (2)
> 48 hours
anticoag for ? weeks
OR
? then ?+?
If high risk of cardioversion failure then give ? or ? for ? weeks prior to cardioversion
How long should you anticoagulate for following this
<48 hours
- heparinised
- electrical DC cardioversion - if this then further anticoagulation is unnecessary.
OR
- pharmacological with amiodarone if has structural heart disease. OR flecainide or amiodarone if no structural heart disease.
> 48 hours
- anticoagulate for 4 weeks prior
OR
- TOE to exclude thrombus and then can be heparinised and cardioverted immediately.
- electrical cardioversion rather than pharmacological.
If high risk of cardioversion failure (previous failure or recurrence of AF) then to have 4 weeks or amiodarone or sotalol prior to electrical cardioversion. - 4 weeks minimum of anticoagulation following this.
Anticoagulation of choice if a pt develops a stroke/ TIA with AF
When do you start anticoag in acute stroke patients?
Warfarin - anticoag of choice
In acute stroke patients, in the absence of haemorrhage, anticoag therapy should be commenced after 2 weeks.
When to use digoxin in AF?
only be considered if the pt does no or very little exercise as is no as good at controlling HR during exercise.
Catheter ablation
When is it used?
When to anticoagulate?
Complications (3)
For those with AF who have not responded to or wish to avoid, anti-arrhythmic medication
4 weeks before and after
Tamponade, stroke, pulmonary vein stenosis
Atrial flutter underlying atrial rate
300/min
