Cardiology Flashcards
Acute chest pain DDx (7)
ACS Aortic dissection PE Pneumothorax Coronary artery spasm Oesophageal rupture/spasm Pericarditis
Acute Cardiac Chest pain - immediate management (meds + doses)
O2 if Sats <94% Aspirin 300mg PO Stat GTN spray (400-800mcg s/l, or tab 300-600 mcg s/l) every 5 mins, up to 3 doses (IF HAEMODYNAMICALLY STABLE) 2x large bore IV access IV Morphine 2.5-5mg, every 5-10 minutes
Already high CVS risk groups (7)
- Diabetes + age .60
- Diabetes w/ microalbuminuria (ACR >2.5)
- Mod CKD (eGFR <45)
- Familial hypercholesterolaemia
- TChol >7.5
- BP >180/>110
- ATSI age >74 y.o
Other 2ndary causes of HTN (5)
- Primary aldosteronism (Conn’s syndrome)
- Cushing’s disease
- Phaeochromocytoma
- Renovascular disease
- OSA
Treatment failure considerations ○ Non-adherence ○ Undiagnosed secondary conditions ○ Other meds causing hypertensive effects ○ OSA ○ Use of eTOH/illicit drugs ○ High salt intake ○ White coat ○ Volume overload (esp. w/ CKD)
AAA risk factors (6)
- Peripheral vascular disease
- Smoking
- HTN
- COPD
- Marfans
- First-degree relative
Metabolic syndrome diagnostic criteria (5)
- Elevated waist circumference
- Elevated triglyceride levels >1.7
- Reduced HDL <1.0 (<1.3 in women)
- Elevated BP >130/85
- Elevated fasting glucose >5.5
Other causes of elevated troponin apart from ACS (9)
- Cardiac surgery
- Post-ablation or PPM insertion
- HOCM
- Tachyarrhythmias
- Infiltrative disease (sarcoid, amyloid)
- Myocarditis
- PE
- Renal failure
- Rhabdo
Who is coronary calcium scoring suitable for?
Low -intermediate CVS risk people who are asymptomatic
Heart failure definitions
HFrEF = symptoms/signs and LVEF <50%
HFpEF = symptoms/signs and LVEF >50% and
–objective structural heart disease (LV hypertrophy, atrial enlargement)
–diastolic dysfunction
Heart failure specific symptoms (4) and signs (4)
Symptoms: -Dyspnoea -Orthopnoea -PND -Fatigue Signs -Elevated JVP -Hepatojugular reflex -3rd heart sound -Laterally displaced apex beat
HFpEF Rx (2)
-Diuretics + HTN management (MRA, ACEi/ARB preferred)
heart failure Acute decompensation causes (9)
- AMI
- Hypoxia
- Arrhythmia (AF/VE’s)
- Pericardial tamponade
- Infections
- Anaemia
- Thyroid disease
- Acute renal failure
- New meds
HFrEF medical management algorithm
- Congested vs. euvolaemic
- How often to uptitrate meds
- When to repeat TTE
- Other options
- Uptitrate meds every 2-4 weeks
- Repeat TTE in 3-6 months
- Change ACEi/ARB to ARNI if persistent HFrEF <40%
- Consider ivabradine or device therapy if LVEF <35% and sinus rhythm >70bpm
Approach to managing Heart Failure comorbidities:
- HTN
- Coronary artery disease
- AF
- Hyponatraemia
- COPD
- Arthritis
-HTN
• Avoid diltiazem/verapamil/moxonidine in HFrEF
• HFpEF –> MRA +/- ACEi/ARB
-Coronary artery disease
• Ivabradine if sinus HR >70bpm and LVEF <35%
-AF
• B-blockers and digoxin preferred for rate control
-Hyponatraemia
• Restrict fluid
• Reconsider need for diuretics
-COPD
• B-blockers are safe for most w/ COPD
-Arthritis
• Avoid NSAIDs if ↓severe LVEF or hyponatraemia
AF anticoagulation doses & dose reduction criteria
Apixaban 5mg BD
–Dose reduce if 2 of, age >80, weight <60kg, Creat >133
Rivaraoxaban 20mg daily
–Dose reduce 15mg daily if CrCl 30-49 AND/OR combo w/ DAPT
Dabigatran 150mg BD
–Dose reduce to 110mg BD if age >75 OR CrCl 30-50 OR combo w/ DAPT
- Bleeding risk scores should not be used to avoid anticoagulation in pts w/ AF - net benefit always favours stroke prevention > major bleeding
- NOACs preferred to warfarin (even reasonable to change to NOAC from warfarin)
- If antiplatelet agents indicated (e.g post-ACS or stent), only use clopi+aspirin for up to 12 mths
- If Crl <30, use warfarin
AF Risk Factors (8)
-Heart failure
-HTN
-Valvular heart disease
-T2DM
-Obesity
-OSA
-Alcoholism
-Hyperthyroidism
AF risk factors for bleeding (6)
-HTN
-Labile INR
-Excess eTOH
-Anaemia
-Renal/liver impairment
-Frailty and falls
AF Rhythm control - preferred in who?
-Younger, physically active people, highly symptomatic
-Paroxysmal/early persistent
-Presence of Left Ventricular dysfunction
-No severe L) atrial enlargement
-Adequate rate control difficult
AF acute rhythm control options (3)
-Synchronised DC cardioversion (defer for 3/52 of OAC or TTE if AF >48 hours)
-Fleicainide
-Amiodarone
AF long-term rhythm control options
-If no LV dysfunction
-If LV dysfunction
-Alternative
If no LV dysfunction or CAD - flecainide 50mg BD sotalol 40mg BD
If LV dysfunction - amiodarone 200mg TDS –> wean
-Catheter ablation (continue anticoag EVEN AFTER procedure if high stroke risk)
AF long-term rate control options (4)
-Beta-blockers (atenolol 25mg daily, metoprolol 25mg BD)
-Non-DHP CCBs (Diltiazem/verapamil 180mg MR daily) - avoid if LV dysfunction
-Add digoxin to above (2nd line)
-Add amiodarone to above - 200mg daily
DVT risk factors (6)
○ PHx of DVT
○ Sudden immobility/extended travel (within four weeks)
○ Surgery/medical illness (within three months)
○ Hormonal contraception
○ Pregnancy
○ FHx of venous disease
DVT - blood tests before starting anticoagulation (4)
-FBE
-UEC/LFT
-Coags
-Beta-hcg (confirm not pregnant)
DVT anticoagulant dosing
-Rivaroxaban 15mg BD for 3/52 –> 20mg daily
-Apixaban 10mg BD for 1/52 –> 5mg BD
CrCl needs to be >30
Dabigatran & warfarin need concurrent clexane as well
Clexane if pregnant
