Cardiology Flashcards
Define malignant hypertension. What are some symptoms?
BP >180/120, associated with signs of retinal haemorrhages and/or papilloedema on fundoscopy.
- Red flag symptoms of malignant HTN:
- Headache
- Visual disturbances
- Seizures
- Nausea & vomiting
- Chest pain
What are blood pressure targets in those under & over 80 years old with hypertension?
- <80 years old → clinic BP < 140/90
- > 80 years old → clinic BP <150/90
What medication is given in any patient with diabetes for their hypertension?
ACE inhibitor
What are the two main types of HF?
- HF with reduced ejection fraction (HFrEF)
- Weakness of heart muscle, resulting in impaired ventricular emptying.
- Ejection fraction <50%
- HF with preserved ejection fraction (HFpEF)
- Poor contractility of myocardium, resulting in impaired ventricular filling.
- Ejection fraction >50%
- Diastolic dysfunction
- Poor contractility of myocardium, resulting in impaired ventricular filling.
What is the key blood test used in suspected heart failure? What do the results mean?
- N-terminal pro-B-type natriuretic peptide (NT-proBNP)
- Should be measured in all patients presenting with symptoms & clinical signs of HF to inform type & urgency of further investigations
- <400 ng/L → HF unlikely
- 400-2000 → refer routinely for specialist assessment & echo within 6 weeks
- > 2000 → refer urgently for specialist assessment & echo within 2 weeks.
What medications are started in someone with Chronic Heart Failure? What is added if symptoms fail to be controlled?
- Furosemide if fluid overloaded.
- ACEi + BB
- Aldosterone antagonist if symptoms are still bothersome (spironolactone, eplerenone)
What classification system is used to determine the severity of Chronic Heart Failure?
New York Heart Association’s Classification System:
- Class 1 → no symptoms during ordinary PA
- Class 2 → slight limitation of PA by symptoms
- Class 3 → less than ordinary PA leads to symptoms
- Class 4 → inability to carry out any activity without symptoms.
What are the difference between arterial & venous leg ulcers?
- Arterial → due to ischaemia secondary to inadequate blood supply
- Smaller & deeper than venous ulcers
- Well defined borders → punched-out appearance
- Occur peripherally → eg, on the toes
- Have reduced bleeding
- Are painful
- Venous → due to impaired drainage & pooling of blood in the legs
- Occur after minor injury
- Larger & more superficial than arterial ulcers
- Irregular, gently sloping borders
- Affect the gaiter area of the leg → mid-calf down the ankle
- Less painful
- Occur with other signs of chronic venous insufficiency → haemosiderin staining & venous eczema
What is the key investigation for peripheral arterial disease? What is a normal vs PAD result?
- Ankle-brachial pressure index
- Ratio of systolic BP in the ankle compared with the arm → readings are taken manually using a doppler probe
- Ankle:arm ratio
1-1.4: normal
<0.9: PAD
<0.5L severe & limb-threatening ischaemia
How is intermittent claudication managed?
- Lifestyle changes → stop smoking, more PA
- Medical treatments
- Atorvastatin 80mg
- Clopidogrel 75mg OD
- Naftidrofuryl oxalate → peripheral vasodilator
- Surgical
- Endovascular angioplasty & stenting
- Endarterectomy
- Bypass surgery
How often is a AAA screened for?
Start age 65 - if normal (<2cm) then discontinue
If 3-4.4cm: screen annually
If 4.5-5.4cm: screen every 3 months
When is an AAA surgically repaired?
If:
- symptomatic
- >5.5cm
- >4cm & rapidly growing >1cm per year
What are the causes of AF?
SMITH:
- Sepsis
- Mitral valve pathology
- Ischaemic heart disease
- Thyrotoxicosis
- Hypertension
- Also, alcohol & caffeine are lifestyle causes.
When is rate control offered to people with atrial fibrillation?
1st line in all apart from the following:
- A reversible cause of AF
- New onset AF → <48hrs
- Heart failure caused by AF
- Symptoms persistent despite being effectively rate controlled
What are the rate control options for AF?
- 1st line → Beta-blocker (eg, atenolol, bisoprolol)
- 2nd line → calcium-channel blocker (diltiazem, verapamil)
- 3rd line → digoxin (only in sedentary people with persistent AF, as requires monitoring & there is a risk of toxicity)
When is rhythm control offered to people in AF?
- Offered to patients with:
- A reversible cause for their AF
- New onset AF → <48hrs
- Heart failure caused by AF
- Symptoms despite being effectively rate controlled
What are the rhythm control options for people in AF?
- Cardioversion
- Immediate
- If AF has been present <48hrs, or is causing life-threatening haemodynamic instability
- Pharmacological option
- Flecainide
- Amiodarone → indicated if there is structural heart disease as there is a risk of sudden cardiac death in those with heart disease.
- Electrical option → defibrillator under sedation & GA
- Delayed
- If present >48hrs & patient is stable
- Electrical cardioversion is recommended, and amiodarone may be considered before & after to prevent recurrence.
- Patient should be anticoagulated for at least 3 weeks before delayed cardioversion. They are rate-controlled in the meantime.
- Immediate
- Long-term rhythm control
- Beta-blockers 1st line
- Dronedarone → 2nd line for maintaining NSR where patients have had successful cardioversion
- Amiodarone → in patients with heart failure or LVD
How is paroxysmal AF managed?
- Pill-in-the-pocket approach
- When symptoms start they take a pill
- Must have infrequent episodes without structural heart disease
- Flecainide 1st line
- Require anticoagulation based on CHA2DS-VASc score
What are the features of digoxin toxicity?
- Generally unwell, lethargic
- nausea & vomiting
- anorexia
- confusion
- yellow-green vision
- arrhythmias (AV block, bradycardic)
- gynaecomastia
What are the precipitating factors of digoxin toxicity?
- hypokalaemia (K binds in same place, so less competition if hypokalaemic)
- increasing age
- Renal failure
- MI
- amiodarone, verapamil, spironlactone
How is digoxin toxicity managed?
Digibind
Correct arrythmias
Monitor potassium
What medical management is given for stable angina?
-
Immediate symptomatic relief
- Sublingual glyceryl trinitrate (GTN)
- Spray or tablets
- Causes vasodilation, improving blood flow to the myocardium
- Advice → when angina begins, stop activity & take the GTN. Take a second dose after 5 mins if symptomatic. Take a third dose after 5 mins if still symptomatic & call for an ambulance. 3 sprays means 999.
- Side effects → headaches & dizziness
- Sublingual glyceryl trinitrate (GTN)
-
Long-term symptomatic relief (either one)
- 1st line → Either a Beta blocker OR Calcium-channel blocker
- Titrate up after 2-4 weeks if still symptomatic
- If unable to take a BB/CCB, then can use a long-acting nitrate, such as isosorbide mononitrate
- 1st line → Either a Beta blocker OR Calcium-channel blocker
What surgical interventions are offered to those with severe angina?
Offered for patients with severe disease & where medical treatments do not control symptoms.
- Percutaneous coronary intervention
- Angioplasty to areas of stenosis through dilating a balloon or inserting a stent. Arteries approached by inserting a catheter into the brachial or femoral artery under x-ray guidance.
- Has a faster recovery rate & lower rate of strokes than CABG, however there is a higher rate of repeat revascularisation with further procedures.
- Coronary artery bypass graft
- Offered to patients with severe stenosis. Midline sternotomy incision is done, where a graft vessel is attached to the affected coronary artery, bypassing the stenotic area. Options for the graft are saphenous vein, internal thoracic artery, radial artery.
What secondary prevention is given to those with angina?
- Aspirin 75mg OD
- Atorvastatin 80mg OD
- ACE inhibitor (if diabetes, HTN, CKD, or HF are also present)
- Already on a beta-blocker
