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GENERAL MEDICINE ILO'S > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What are the stages of Hypertension

A

Stage 1: 135-150
Stage 2: 150-180
Stage 3: 180<

  • 120-140 is classed as pre-hypertension
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2
Q

Risk Factors for Hypertension

A

Modifiable: Salt intake/ general diet, alcohol, mental and physical health.

Non-Modifiable: Age, Race, Gender, Genetics.

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3
Q

Symptoms and major complications of HTN

A
  • Usually asymptomatic however can present with headaches.
  • Major complications include cerebral infarct, LV hypertrophy…
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4
Q

HTN Treatment

A
  • Should be started when patient becomes pre-hypertensive. Start with general lifestyle advice such as diet changes, more exercise, Stress reduction…
  • Pharmacological treatment:

If under 55 and non-black give ACEi/ARB’s or Beta blockers, ( commonly used if HTN is stress induced).

If over 55 or black give Amlodipine or a Diuretic.

If either of these groups of people progress to stage 2 HTN, give A/B + C/D in dual drug therapy. If that still doesn’t work and patient progresses to Stage 3 give A/B + C + D.

If still resistant after triple drug therapy, it’s classed as resistant HTN and needs triple drug therapy + Aldosterone antagonist such as Spironolactone.

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5
Q

What are the ACS’s

A
  • Unstable angina, NSTEMI and STEMI
  • Caused by rupture of plaque in a blood vessel, worsened with thrombosis around this plaque.
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6
Q

Describe the change in troponin levels after an MI

A
  • Raised 4 hours after an episode and stays raised for 2 weeks.
  • Above 34 indicates necrosis in men and above 16 indicates necrosis in women
  • Higher troponin changes indicate acute events rather than chronic presentation of ACS’s.
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7
Q

Causes of false positive rises in troponin levels.

A

Renal failure, pulmonary embolism, congestive heart failure and myocarditis.

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8
Q

ECG changes for NSTEMI and Unstable angina

A
  • Transient ST depression or elevation, T wave flattening/inversion, and occasionally pseudonormalization of the T wave.

This is when an inverted T wave flips back around to become normal and often indicates the re-occlusion of a previously blocked artery. ECG change often starts as a peaked T wave.

  • Often ECG appears normal
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9
Q

STEMI Management

A
  • Refer to catheter lab immediately and gain IV access unless uncertain of the diagnosis.
  • M: Morphine
    O: Oxygen
    N: Nitrates
    A: Aspirin ( 300mg loading dose with 75 oral dose for life).
  • Prasugrel used for PPCI patients, ( Clopidogrel used for patients above 75, below 60kg, or have had a previous TIA or stroke
  • PCI: Primary therapeutic measure as 95% of the time restores blood flow to the affected artery therefore relieving symptoms.
  • Ongoing medications:
    . Beta blockers, 1.25mg oral dose ( avoid in hypotension or shock).
    . Ramipril, 2.5mg ( avoid in kidney failure).
    . Statins, 80mg, ( aim to reduce non- HDL’s
    by 40%).
  • Ongoing lifestyle management such as control of diabetes, diet, HTN, and to stop smoking.
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10
Q

NSTEMI and Unstable Angina management

A
  • Pain relief with morphine
  • Aspirin, ( 300mg loading and 75mg ongoing).
    -Enoxaparin for 48 hours
  • Repeat ECG
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11
Q

Risk factors for stable angina

A

Smoking, HTN, diabetes, hypercholesterolaemia, and family history.

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12
Q

Causes of angina

A
  • Most common is coronary artery disease. With angina try and assess the likelihood of this progressing into something more morbid.
  • Aortic stenosis, hypertensive heart disease, and hypertrophic cardiomyopathy.
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13
Q

Screening of CAD

A

Use table provided by trust to calculate the Coronary Artery Disease risk, if the percentage chance of complication is 61-90% offer invasive therapy, if it’s 31-60% offer imaging and if it’s below 30% do a CT calcium scoring. If 0 there is very small likelihood of significant coronary disease.

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14
Q

Drug treatment for Stable Angina

A
  • 75mg OD of aspirin, give Clopidogrel if aspirin contra-indicated.
  • Prescribe sublingual GTN spray and instruct on when to use it. Can give long term nitrates but be aware of nitrate sensitivity.
  • Beta blockers for rate limitation and symptom control. Give Ivabradine if Propranolol is contra-indicated but don’t give either if the heart rate is below 70bpm.
  • Should give statins to reduce overall cardiovascular risk.
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15
Q

Causes of Heart Failure

A

IHD, Hypertension, Valvular Heart Disease, Atrial Fibrillation, Cardiomyopathy, (e.g. hypertrophic heart or dilated ventricles).

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16
Q

What are the 2 types of Heart Failure

A
  • HFReF: Due to a systolic issue therefore investigate problems with pumping.
  • HFPeF: Due to a filling issue therefore check for changes in the heart structures or any valvular issues.
  • Diagnose between the two by using an echocardiogram
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17
Q

Symptoms of Heart Failure

A

SOB, Fatigue and weakness, Swelling in the legs, inability to exercise, rapid or irregular heartbeat.

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18
Q

Investigations for HF

A

Renal function (check for reason of fluid retention), FBC, LFT’s, TFT’s,

  • BNP: Identifies patients with LV dysfunction. A value below 100 should rule out acute heart failure. However values above this don’t point directly to the diagnosis. Can be caused by general chamber strain or Atrial Fibrillation.
  • Can perform Cardiac MRI if the echocardiogram is inconclusive as focus in more on the RV and scar tissue formation.
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19
Q

CXR Findings for HF

A

Cardiomegaly, Pleural effusions, Perihilar consolidations, Alveolar oedema…

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20
Q

HF Management

A
  • Lifestyle: Stop smoking and drinking, salt restriction and general fluid restriction especially with general hyponatraemia.
  • Medication:
    1) Diuretics. 40-500mg of Furosemide is the first line treatment. Can add thiazide diuretic if needed. If the patient becomes hypokalaemic you can add ACEi (often added anyway to bring BP down), if still persists you can add Spironolactone.
    2) ARB’s can be used instead of ACEi if hypokalemia isn’t a problem.
    3) Beta blockers if systolic BP is over 100 with a resting heart rate of over 60. Start Bisoprolol at 1.25mg for one week and increase by 1.25 every 1-4 weeks, (look at workbook for exact values). At the end you should be on 10mg OD.

IVABRADINE if beta blockers contra-indicated, also slows down the HR. Ensure the patient has a sinus rhythm first.

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21
Q

Symptoms of Aortic Stenosis

A

Angina, Heart Failure and Syncope.

22
Q

Common causes of Aortic Stenosis

A

Ageing, Congenital bicuspid valve, CKD, and previous rheumatic fever.

  • MURMUR: Systolic murmur heard around the 2nd ICS on the RHS radiating to the carotid area.
23
Q

Indications for surgery

A
  • Depends on severity of aortic stenosis which is found out on an echocardiogram.
  • Any symptoms should be treated with surgery.
  • If asymptomatic but LV systolic dysfunction or abnormal exercise test should perform surgery.
  • Give a TAVI ( transcatheter aortic valve implantation) through the femoral artery.
24
Q

Symptoms of Aortic Regurgitation

A
  • Often remains asymptomatic for long times as LV hypertrophy progresses due to the increased workload.
  • Most common initial symptom is lack of exercise tolerance.
  • Again investigated with echocardiography
25
Q

Causes of Aortic Regurgitation

A

Idiopathic dilatation or aorta therefore pulling the leaflets apart, calcific degeneration, rheumatic disease, infective endocarditis, or Marfan’s syndrome.

  • MURMUR: Diastolic murmur heard at the left sternal edge which sounds like a blowing.
26
Q

Indications for surgery

A
  • Symptomatic
  • Asymptomatic with evidence of LV dysfunction or any severity with aortic root dilatation
26
Q

Common causes of Mitral Regurgitation

A
  • Prolapse is the most common cause and is common in Marfan’s patients.
  • Rheumatic heart disease, IHD, Endocarditis, drugs, ruptured chordae or papillary muscle.
26
Q

Mitral Regurgitation symptoms

A

Mainly asymptomatic and less likely to cause symptoms then AR.

Most people with chronic mitral regurgitation won’t ever need surgical intervention and the disease will stay dormant forever.

27
Q

Which assessments should be carried out for MR

A
  • Echocardiography
  • LV function and size and checking how to the blood is jetting out of the valve.
27
Q

Indications for surgery in Mitral Regurgitation

A
  • Can repair as well as replace the mitral valve, replacement is much safer.
  • Surgical intervention only indicated in severe MR. Only if symptomatic or have mild-moderate LV dysfunction.
28
Q

Medical therapy of MR

A
  • Diuretics is the major controlling measure.
  • ACEi only used in ischaemic MR, ( dilated or ischaemic cardiomyopathy).
  • If LV dysfunction is present treat with ACEi and Beta blockers.
  • Cardiac resynchronization therapy can also help if necessary.
29
Q

What are the signs and symptoms of Bradycardia

A
  • Below 60bpm is considered slow, however below 40 is absolute bradycardia. Can also be classified if heart rate is slow when compared to haemodynamic state.
  • Other signs: systolic BP <90, poor perfusion or poor urine output.
30
Q

Sinus node Bradycardia

A
  • Shows as slow on ECG, however every P wave is followed by a QRS complex.
  • Often asymptomatic, symptoms would indicate that a pacemaker is needed.
31
Q

AV node Bradycardia

A

CLASSIFIED BY DEGREE OF DYSFUNCTION

1st degree: Large PR interval ( over 0.2 seconds). Check for offending medications, if all normal keep monitoring the heart.

2nd degree Type 1: Progressive lengthening of the PR interval until a QRS complex is missing. Quite common and rarely progresses to complete heart block.

2nd degree Type 2: Same PR interval length then a sudden drop of a QRS complex. Often proceeds complete heart block. Often occurs after a coronary event, if happens out of nowhere, permanent pacing should be arranged.

3rd degree: Complete heart block. No conduction between the atria and the ventricles. Blockage can occur above His Region ( narrow complex), or below the AV node ( wide complex). Wide complex isn’t tolerated as well as narrow. Caused by drug toxicity, often digoxin. Also common after STEMI’s and with hyperkalaemia. Urgent pace making is necessary.

32
Q

Atrial fibrillation

A
  • Most common arrhythmia and increases in prevalence with age. Also obese patients and those with sleep apnoea are more at risk.
  • Often shows no symptoms.
  • Can be paroxysmal (intermittent), or can be permanent.
33
Q

Complications of AF

A

Acute coronary syndrome, CCF, cardioembolic stroke.

  • Most AF is found with screening tests towards targeted groups.
34
Q

Diagnosis and Assessment of AF

A
  • Manual pulse checks for irregularity accompanied by symptoms of AF such as breathlessness, palpitations, syncope and chest discomfort.
  • Confirmed with an ECG, (wavy baseline).
35
Q

Management of AF

A
  • Anticoagulation, ( Apixaban is the current favourite as doesn’t need monitoring like warfarin does). to prevent a stroke, rate and rhythm control to try and control the hearts movement.

Check bleeding risk before commencing this treatment, this shouldn’t contra-indicate anticoagulation but it should make you more ready for if something goes wrong so you can be ready to deal with it. Also control other variables such as HTN, other medications, and alcohol consumption.
- If the AF is paroxysmal then try long term cardiac monitoring and potentially and echocardiogram to see if there are any structural problems which could be causing symptoms.

36
Q

Most common cause of Supraventricular Tachycardia

A

AV Nodal re-entry tachycardia. Next most common is Atrio-Ventricular re-entry tachycardia.

37
Q

First line treatment for SVT

A

-Vagal manoeuvres as long as patient is haemodynamically stable.

-Major ones are breath holding and carotid massage in younger patients.

38
Q

Medication approach if vagal manoeuvre’s don’t work.

A
  • IV Adenosine or CCB
  • Adenosine blocks AV node conduction, given as a rapid IV bolus. Can give feeling of chest pain, flushing, SOB and feeling that your heart has stopped. Short half life and deals with 90% of tachycardias.
  • If still not stopped after AV blockade measures, rhythm is almost certainly atrial tachycardic or flutter.
39
Q

What should you do for patients who are contra-indicated to medications. ( Have chest pain, pulmonary oedema or hypotension).

A

Synchronised cardioversion following sedation. Shock the heart to stop start it back into rhythm.

40
Q

Ventricular Tachycardia

A
  • Rapid broad complex tachycardia, often follows a STEMI.
41
Q

Management of VF

A
  • Can be suppressed with B blockers or Amiodarone however this shouldn’t be used if the patient is hypotensive or has significantly impaired LV function.
  • If any contra-indications are present, administer synchronised cardioversion.
42
Q

What is a hypertensive crisis?

A

Increase in blood pressure which if sustained over next few hours will lead to irreversible end organ damage.

EMERGENCY: High blood pressure related to a critical event, for example AKI, MI…

URGENCY: High blood pressure without critical illness, however may include malignant hypertension. Usually diastolic is above 130 and retinal changes often appear.

43
Q

Treatment for a hypertensive emergency

A
  • Aim is to get the BP to 110 systolic within 3-12 hours for emergency or 24 hours for urgency.
  • Sodium nitroprusside: Strong vasodilator used to immediately lower blood pressure.
  • Labetalol: Non selective Beta blocker
  • Esmolol: Selective Beta blocker to the B1 adrenoreceptor.
  • GTN: Similar action to sodium nitroprusside, ( 1-10mg/hr).
44
Q

Treatment for hypertensive urgency

A
  • Aim is to gradually reduce blood pressure to below 100 diastolic over the coming 48-72 hours.
  • Give oral treatment of one of the following; Amlodipine, Dilitiazem, Lisinopril.
45
Q

What is the classic triad of symptoms in Phaeochromocytoma

A

Episodic headache, sweating and tachycardia.

  • Most common sign of phaeochromocytoma is paroxysmal hypertension.
46
Q

Diagnosis of phaeochromocytoma

A
  • Measurement of urinary and plasma catecholamines.
  • If comeback positive then do a CT/MRI of abdomen and pelvis to detect for adrenal tumours.
47
Q

Treatment of phaeochromocytoma

A
  • Control of hypertension achieved by combining alpha and beta adrenergic blockade. PHENOXYBENZAMINE.
48
Q

Identifying Cushing’s

A

Physical appearance of buffalo hump, purple striations, moon face…

Also will have very high urine cortisol. Also can use low dose dexamethasone test to diagnose if the body is producing cortisol independently to ACTH.

49
Q
A

GENERAL MEDICINE ILO'S (2 decks)

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