Cardiology Flashcards
Blood pressure causes for elevations (8)
- Non compliance
- Whitecoat
- Recent weight gain
- drugs (methamphetamines)
- Renal failure
- Anxiety
- Wrong cuff size
- Smoking
- OSA
- Sedentary lifestyle
HOCM major symptom
Exertional Dyspnoea
ECG findings in HOCM
High voltage QRS
ST changes and T wave repolarisation abnormalities
May be hard to distinguish from athletic young person
HOCM ECHO findings (and what they are assessing for)
- LV thickness >11mm raises concern
Looking for
- LV function
- LVOT
- Pattern and degree of LVH
- Presence and degree of mitral regurg
Investigations for HOCM
- ECHO
- Stress ECHO (looking for exercise induced LVOT)
- ECG
- 24 hour holter monitor
- Cardiac MRI
Investigations for HOCM
- ECHO
- Stress ECHO (looking for exercise induced LVOT)
- ECG
- 24 hour holter monitor
- Cardiac MRI
Diagnosis of CCF
Transthoracic ECHO
BNP
CCF management (general)
- ACEi low dose (perindo 2.5-5mg)
- Spironolactone (25mg)
- Frusemide (up to 40mg)
- Cardio-selective beta blocker (bisoprolol 1.25mg) (NOT in decompensated HF)
- Low salt diet (<5g)
- Fluid restrict 1-1.5L
- Daily weights
- Review 48 hours
- Cardiac rehab
How much exercise per week
150-300 mintues moderate intensity/week
Angina episodic treatment
GTN spray 400mcg
Repeat every 5 min up to 3 doses
(note: if pain persists >10mins despite 2 doses –> ED)
Pharmacological management to prevent angina (broad categories)
USE TWO FROM DIFFERENT CLASSES
-Beta blocker (Metoprolol tartrate)
-Long acting nitrate (GTN 14 hour patch)
-Nondihydropyridine CCB (Diltiazem, verapamil)
-Dihydropyridine CCB (Amlodipine, nifedipine)
Pharmacological management to prevent angina: Betablocker dose.
Beta blocker:
Metoprolol tartrate 25mg BD (max 100mg BD)
(HFREF: use bisoprolol or metoprolol succinate)
Pharmacological management to prevent angina: Non-dihydropyridine calcium channel blocker
Diltiazem MR 180mg daily (up to 360mg)
OR
Verapamil MR 120mg daily ( up to 480mg)
Cautions with nondihydropyridine calcium channel blocker
Do not use with beta blocker (severe bradycardia and HF)
Avoid with ejection fraction <40 %
Do not use with dihydropyridine CCB (amlodipine or nifedipine)
Pharmacological management to prevent angina: Dihydropyridine calcium channel blocker
Amlodipine 2.5mg (up to 10mg)
Nifedipine MR 30mg (up to 60mg)
Pharmacological management to prevent angina: Long acting nitrate
Glyceryl trinitrate 5mg patch (14 hours/day)
max dose 15mg
Pharmacological management to prevent angina - refractory angina
Nicorandil 5mg BD
Max dose 20mg BD
History for HOCM
- Exertional dyspnoea
- non- exertional dyspnoea
- Chest pain
- palpitations
- Presyncope
Rule out differentials
- Wheeze
- Cough or coryzal symptoms
- Fever
- VTE: immobilisation, calf pain
HOCM management following diagnosis
- URGENT referral to cardiologist
- Stop competitive sport (high intensity) until cardiology review
- Any chest pain, presyncope to attend ED
- Family will need testing
Metabolic syndrome diagnostic criteria
- Waist circumference >88
(>80 for asian, african, mediterranean) - Triglycerides >1.7
- HDL-C <1
(1.3 in women) - HTN: >130 or >85
- Fasting glucose >5.5
Most common cause of Mitral Stenosis
Rheumatic heart disease
Clinical features of MITRAL STENOSIS (general and murmur findings)
- Mitral Facies: flushed cheeks
- Crackles due to pulmonary oedema
- Advanced: RHF
Murmur:
- Opening snap
- Low pitched diastolic rumble
- At APEX
- Best heard with bell with patient lying on left side (held expiration)
What makes you Automatic CVD high risk ?
HINT 6
- Diabetes & >60
- Diabetes & microalbuminuria (ACR >2.5men/3.5women)
- Mod-severe CKD
- Familial hypercholesterolaemia
- SPB >180 or diastolic >110
- Total cholesterol >7.5
4 first line betablockers in HFrEF
Bisoprolol 1.25 daily (inc to 10mg)
Carvedilol
Metoprolol succinate 23.75mg daily
Nebivolol 1.25 daily (up to 10mg)
Contrindications to stress testing
- Unstable angina
- Severe AS
- AMI/ new LBBB
- Unstable HF
- Haemodynamic instability
- Uncontrolled arrhythmia
Atrial Fibrillation management (non-pharmalogical)
- Smoking cessation
- etOH <3 std/week
- Aerobic exercise 210/week
- Weight loss to BMI <27
Cut off for diagnosis of HTN for ambulatory BP
ABPM over 24 hrs >130
LDL-C not sufficiently reduced on statin… What to add?
- Ezetimibe
- Bile acid binding
Triglycerides not sufficiently reduced on statin… What to add?
- Fenofibrate 145mg (90 if EGFR <60) *
- fish oil 2-4g **
- Triglygcerides >4
** Triglygcerides >10
HFrEF when to change ACEi to ARNI ?
If at 3 -6 monthly ECHO the LVEF <40 then change
Additional treatment options for HFrEF?
- Cardiac device therapy (<35%)
- Ivabradine if sinus rhythm >70 BPM and LVEF <35%
- If ACEi,ARB and ARNI not tolerated then use nitrates or hydralazine
- Consider nitrates and digoxin if refractory symptoms
Causes of Hypertension (Secondary)
OSA
Renal parenchymal disease
Primary aldosteronism
Renal artery stenosis
NSAIDS
Corticosteroids
stimulants
Phaeochromocytoma
Cushing’s syndrome
Resistant hypertension options
Indapamide 2.5mg Max
Atenolol 25mg
or Metoprolol 25mg BD
Spironolactone 12.5mg
Valvular AF: what conditions constitute this?
- Mitral valve stenosis (mod-severe)
- mechanical heart valve
Valvular AF anticoagulation
WARFARIN
Metabolic syndrome qualifiers
Waist circ
high triglycerides >1.7
reduced HDL <1
BP >130
Impaired fasting glucose >5.5
Moderate CVD Risk: which features makes medications necessary
ATSI
BP persistently >160
Family hist of premature CVD
Premature CVD age cut offs
F <55
M < 60
Mobitz type 1 action
If asymptomatic, nothing
Mobitz type 2 action
Referral for pacing and pacemaker insertion
When is it suitable to do a precordial thump?
Monitored pulseless VT (not VF) when defib not readily available
Examples of broad complex tachycardia (three)
- VT
- AF with BBB
- Torsades de pointes
Examples of narrow complex tachycardia (three)
Hint: Irregular & regular
Irregular:
- AF
Regular
- WPW
- SVT
- AT
- AF
- SInus tachy
Conscious VT & haemodynamically stable - what to do ?
- Amiodarone 300mg IV over 10-20mins mins, then 900mg over 24hrs
Narrow complex & regular QRS what to do?
Vagal manoeuvres
then ADENOSINE CHALLENGE 6mg rapid bolus
A) ?
B) ?
Atrial flutter
Atrial fibrillation
What to suspect with narrow complex tachycardia at 150BMP
FLUTTER with 2:1 block
Best analgesic for acute coronary syndrome
Fentanyl
(morphine reduces absorption of antiplatelet agents)
Complication of inferior STEMI
3rd degree heart block
Wide QRS (more than three squares) what does this usually indicate
BBB
Investigations for HTN for all people
- UA
- Urine ACR
- Fasting BGL
- Fasting Cholesterol
- EUC
- Hb
- ECG
Post AMI medication regime
- Perindopril 2.5-5mg
- Atorvatstatin 80mg
- Bisoprolol 1.25- 2.5mg
- aspirin 100mg
- clopidogrel (12months) 75mg
Driving restriction post AMI ?
2 weeks
3 types of options for SVT cardioversion before you get to adenosine
- Modified valsalva maneouver
- Unilateral carotid sinus massage
- Immersion of the face in cold water
SVT 2nd line
Adenosine 6mg IV stat push
