Cardiology Flashcards
What CHAD-VA score should anticoagulation be recommended for in pAF?
CHADVAS of 2 or over anticoagulation is recommended.
CHAD-VA of 1 you should CONSIDER anticoagulation
Note - CHAD-VA has now removed the gender point as women no longer considered at higher risk now we have more evidence
Also important to consider the ORBIT score to consider bleeding risk
When should Digoxin levels be taken?
Digoxin levels need to be taken at least 6 hours post-dose to allow time for it to be distributed throughout the body and reach steady state distribution
What is the UK screening programme for abdominal aortic aneurysm?
All men regardless of risk factors get an invite for a one-off abdominal ultrasound at aged 65 to screen for AAA.
If a AAA is detected then they are followed up from there.
If AA width is < 3cm = normal
If AA 3-4.4 = small aneurysm - recan every 12 months
If AA 4.5 - 5.4 - medium aneurysm - rescan every 3 months
If AA 5.5+ - large aneurysm - urgent referral to vascular to be seen within 2 weeks for probable surgical intervention
Also need an urgent 2-wk vascular referral if symptomatic or enlarging >1cm per year.
For patients that have had a previous TIA or stroke, they are recommended life long Clopidogrel. If they are allergic / unable to have Clopidogrel then what is the alternative for secondary prevention>?
lifelong Aspirin & Dipyridamole.
What timing is recommended for the dosing of standard release Isosorbide mononitrate when used in angina ?
NICE recommends asymmetrical timing of doses e.g 8am and 4pm so ensure a 10-14 period overnight that is nitrate free to reduce the risk of the patient developing nitrate tolerance
(this is not relevant for those on OD modified release isosorbide mononitrate)
Which group of antibiotics should be avoided for patients on statins?
MACROLIDES - do not give macrolides (erythromycin, azithromycin, clarithyromycin) alongside statins
They ^ the risk of rhabdomyolysis and statin-related myopathy
Need to stop statin therapy while on these abx if no alternatives possible.
Which PPI is safe to co-prescribe with Clopidogrel?
There is some evidence to suggest that some of the PPIs may reduce the efficacy of Clopidogrel
Lansoprazole seems to be the safest PPI to use if the patient’s on Clopidogrel
Which medication is associated with causing yellow-tinted vision (xanthopsia) when in toxic levels?
Digoxin
True or false - obesity can falsely lower NT-proBNP levels?
True!
So if strong clinical suspicion of HF in someone with BMI > 35 then refer to cardio anyway for echo, even if BNP normal
Which scoring system is now recommended by NICE to assess bleeding risk prior to commencing anticoagulation for atrial fibrillation?
ORBIT score
(now replaced the HAS-BLED)
How should ankle brachial pressure ratios be interpreted?
ABPI ratio 1 - 1.4 = normal
ABPI ratio 0.91-0.99 = may indicate peripheral limb ischaemia, consider further investigation if clinical suspicion is high
ABPI ratio 0.9 or less = peripheral arterial disease (if <0.5 may indicate limb-threatening ischaemia and so need urgent referral to vascular)
ABPI ratio > 1.4 = may indicate arterial calcification. If the value is > 1.5 then can’t always rely on the value as the valves may not be compressible
For patients with ischaemic limb pain AT REST, what is their risk of amputation in the ensueing year?
30% risk of limb amputation
& 25% risk of death in the next year
How should you calculate the mean home blood pressure when a patient submits a home BP diary?
Should be recorded for at least 4 days, preferably 7
You should DISCARD THE READINGS FROM THE 1ST DAY and then average the rest
What are the evidence-based lifestyle interventions for stage I hypertension?
Weightloss
Smoking cessation
Reduced caffeine and alcohol
Increased exercise
Stress management
REDUCED SALT DIET - just 1 wk of lower salt reduced BP by ~ 8mmHg in 75% of people (excess salt = > 1 tsp salt) and reduces risk of CVD
What decline in renal function would be concerning in a patient newly commenced on an ACEi?
A drop in eGFR of 25% or more or an increase in creatinine of 30% of more is indication to stop the ACEi and repeat renal function checks - consider investigation for renal artery stenosis
What lifestyle adaptions reduce the risk of AF?
Reduce alcohol consumption (aim for max 3 alcoholic drinks per week)
Optimise blood sugar levels
Structured exercise
Weightloss if overweight
Blood pressure control
What HR should be targeted when managing rate-control in AF?
For most, should aim for a HR < 110 bpm
However if remain symptomatic then should aim for HR < 80
Which patients should be referred to cardiology for consideration of rhythm-control in preference to rate control in AF?
Now evidence that rhythm-control is likely to lead to better outcomes in AF than just controlling the rate
Refer
Younger patients
Newly diagnosed AF
Those with HF suspected to be 2ndary to AF
In whom AF is thought to have a reversible cause.
What are the ECG diagnostic criteria for an STEMI?
ST elevation of 1mm or more in 2x or more anatomically contiguous leads or new LBBB
What are the Canadian Cardiovascular Guideline grades of angina
Grade I - Angina with strenuous or prolonged exertion only
Grade II - Slight limitation with ordinary activity e.g on walking uphill
Grade III - Marked limitation on ordinary activity e.g just walking up a few stairs will provoke symptoms
Grade IV - Inability to carry out any physical activity without symptoms OR symptoms at rest
What advice should you give patients on how to use sublingual GTN as part of the management of stable angina?
Can be used for symptom prevention (ie before planned exercise) or once symptoms arise.
If used when symptoms arise, then can be repeated after 5 minutes if symptoms still present. Advise them to call an ambulance if symptoms still present 5 minutes after the 2nd dose.
What drop in BP is diagnostic of postural hypotension?
Drop in 20mmHg or more of systolic or 10 mmHg of more of diastolic
How should you properly assess clinic blood pressure
Take BP on one arm first
If over 140 / 90 then repeat
If the 2nd reading is substantially different from the 1st then take a 3rd
Record the LOWEST of the readings as the clinic BP
If clinic BP between 140/90 - 180 /120 then offer home / ambulatory BP
Diagnose HTN if clinic BP > 140 / 90 AND home/AMBP > 135 / 85
What investigations should be performed on someone with newly diagnosed HTN?
Urine dip for haematuria and send off for A:Cr
12 lead ECG
Bloods inc cholesterol and HBA1C to allow for QRisk calculation
Examine the fundi for signs of hypertensive retinopathy
What BP range is classed as Stage 1 HTN ?
Clinic BP > 140 / 90 and home BP > 135/85
What BP range is classed as Stage 2 HTN?
Clinic BP > 160 / 100 and home BP > 150 / 95
What BP range is classed as Stage 3 HTN?
Clinic systolic > 180mmHg or clinic diastolic > 120 mmHg
Patients with HTN stage 2 and above should always be offered hypertensive medications, but what in circumstances should those with stage 1 HTN also be offered medical treatment (in addition to lifestyle advice?)
If under 80 and have any of the following:
Target organ damage
QRisk score of 10% or more
Established cardiovascular disease, renal disease or diabetes
Patients presenting with HTN under what age should be referred to secondary for further investigation?
Under 40
What are the target clinic blood pressures for those under 80 with HTN on treatment?
140/90 mmHg is the general BP target for those under 80 (even if type 2 DM!)
Should use clinic BP generally unless white coat HTN in which case home BP targets are 5mmHg less than the clinic targets
(UNLESS TYPE I diabetes or CKD AND a A:Cr > 70 in which case should aim for 130/80)
What is the target clinic blood pressure for those aged 80+ on BP treatment?
150 / 90
(UNLESS
If CKD and A:Cr < 70 then target is 140 / 90
If CKD and A:Cr is > 70 then target is 130 / 80)
How should you manage a patient with established HTN that subsequently gets diagnosed with type 2 DM?
Only change medications (e/g to ACEi) if poor control of HTN on current regime OR if current medication not appropriate due to microvascular or metabolic complications
What are the 1st line antihypertensives for people of different ages and ethnicities?
Type II diabetic of any age or ethinicity = ACEi or ARB (offer ARB first if black)
<55 & white = ACEi or ARB
Black not diabetic at any age = Ca channel blocker
> 55 = Ca channel blocker
If ACEi isn’t tolerated switch to ARB
If Ca channel blocker not tolerated switch to thiazide-like diuretic (ideally Indapamide)
What is the advised choice of antihypertensive to add in if BP not controlled on single agent?
If on ACEi / ARB then add in either Ca channel blocker OR thiazide-like diuretic
If on Ca channel blocker, then add in either ACEi/ARB OR thiazide-like diuretic
If BP not controllled on the above then can add in whichever agent is not yet being used
if a 4th agent is needed then = RESISTANT HTN , consider spironolactone if baseline potassium < 4.5, or consider an alpha or beta blocker if potassium > 4.5
If BP not controlled on 4 agents then refer to specialist
How should you manage a patient presenting with new HTN with a clinic BP > 180 / 120 mmHg who does NOT have signs or symptoms requiring same day admission?
Assess for signs of target organ damage as soon as possible
If target organ damage identified then start HTN treatment without waiting for home BP
If no target organ damage, then either repeat clinic BP in 7 days or arrange AMBP
For patients presenting with BP > 180 / 120, what are the features that would necessitate a same day admission?
Signs of phaochromocytoma (- epinephrine and norepinephrine secreting tumour of the adrenal medulla - labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis)
Signs of retinal haemorrhage or papillooedema
Signs of heart failure or chest pain, new confusion, AKI
