Cardiology Flashcards
What is the treatment for heart failure?
HF due to LVSD:
1st: ACEi/ARB (Ramipril)+ beta-blocker (Bisoprolol) + diuretic: 80mg Furosemide (if periph/pulm oedema)
2nd: Aldosterone antagonist (spironolactone) or Hydralazine w/nitrate
3rd: Digoxin or resynchronisation therapy
Consider implantable defib at any stage if appropriate
HF w/preserved EF:
Manage comorbidities: HTN, secondary prevention of MI, T2DM
How is hypertension managed in those <55yo?
Lifestyle advice
1) ACEi: 1.25-10mg PO Ramipril
2) ACEi + CCB: Amlodipine PO 5-10mg/Diltiazem 60-300mg PO
3) ACEi + CCB + Thiazide: Indapamide PO 1.25-5mg
4) ACEi + CCB + Thiazide + Spironolactone (K+ <4.5) PO 25mg /alpha: Doxazosin 1-16mg PO/beta blocker: PO Bisoprolol 5-20mg
How is hypertension managed in those >55yo?
OR Afro-carribbean
Lifestyle advice
1) CCB: Amlodipine PO 5-10mg/Diltiazem 60-300mg PO
2) ACEi + CCB + Thiazide: Indapamide PO 1.25-5mg
3) ACEi + CCB + Thiazide + Spironolactone (K+ <4.5) PO 25mg /alpha: Doxazosin 1-16mg PO/beta blocker: PO Bisoprolol 5-20mg
Who is risk assessed for IHD?
>40 with RFs for developing IHD (Diabetics) T1DM CKD Smokers FHx HTN
What do the Q-risk scores correlate to?
Risk of developing CVD in the next 10years
>10% high risk
How is hyperlipidaemia risk reduced?
Full lipid profile then start:
Atorvastatin 20mg if Qrisk >10%
Atorvastatin 80mg if known CVD
What are the different stages of hypertension?
Stage 1: 140/90 ABPM: >135
Stage 2: 160/110 ABPM: >150
How is acute pulmonary oedema treated?
Sit up 15L/min Catheterise Morphine- ARDS Furosemide 40mg IV
What blood test needs to be done before starting: ACEi Beta blocker Furosemide Aldosterone
ACEi: U&E- Hyperkalaemia (contraindication for Rampiril), Creatinine, electrolytes, eGFR at initiation, after dose increase, then every 3m
Beta: HR, BP, clinical status after every dose increase (start low & go slow- all patients w/LVF <40%)
Furosemide: Weight, U&Es
Aldosterone: Potassium, eGFR, Creatinine
What pathology can cause AF?
Cardiac: CAD, LVHF, MI, HTN, mitral valve disease, congenital (cardiomyopathies)
Pulm: PE, pneumonia, bronchocarcinoma
Metabolic: Hyperthyroid, OH-, sepsis, caffeine, antiarrhythmics, HyperMg, HypoK, acidosis, infection, bronchodilators
What are the signs & symptoms of AF?
Asymptomatic Palpitations Chest pain Dyspnoea Dizziness/syncope Embolic event: Stroke/TIA
What is the pathophysiology of AF?
Irregular atrial rhythm 300-600bpm
AV node unable to transmit beats as quickly as this
Results in irregular ventricular rhythm
Reduced CO by 20%
How is AF investigated?
Pulse: Irregularly irregular
ECG: No p-waves, irregular (narrow) QRS but normal shape, variable ventricular rate, no isoelectric baseline
Bloods: U&Es, TFTs, Cardiac enzymes
ECHO
How is AF managed?
Tx cause & associated Heart failure
1) Rate: Beta blocker/CCB (Diltiazem), Digoxin if sedimentary & non-paroxysmal
Poor monotherapy compliance then dual therapy
2) Rhythm: If rate control unsuccessful- Flecainide (pill in the pocket) & Amiodarone
Anticoagulant: Heparin
3) DC Cardioversion: >48hrs, Amiodarone 4w before & 12m after
Long-term Rhythm: Beta blocker
Pill in the pocket: Infrequent paroxysmal
What are the different types of AF?
Acute: Onset within 48hours
Paroxysmal: Self-terminating in 7 days
Recurrent: >2 episodes (paroxysmal or persistent)
Lone/idiopathic: Absence of disease
Persistent: Cardioverted or >7days
Permanent: Cardioversion/SR not possible >1yr
What are ectopic beats?
Extra beats
25% of the blood is expelled from the heart
The next ‘normal’ beat is the beat a patient complains about
This beat ‘recalibrate’ the heart to expel all the blood left
How is atrial flutter managed?
Beta blockers
Best = ablation
Longstanding untreated can lead to dilated cardiomyopathy (reversible)
What drug used by cancer patients and IVDUs can cause bradycardia?
Methadone
What is the CHADS-VASc Score?
Assessing risk of stroke in AF C- Congestive HF H-HTN 140-90 or on meds A- Age >75 (/2) D- DM S- Prior stroke/TIA/VTE (/2) V- Vascular disease A- Age 65-74 Sc- Sex (Female)
What is the HAS BLED Score?
Risk of bleeding on anticoagulation therapy H-HTN Uncontrolled 160 A- Abnormal LFTs & U&Es S-Prior Stroke B- History of bleeding L- Labile INR E- Elderly >65 D- Drugs NSAIDS, anti platelets, OH- consumption harmful
What does the scoring system for CHADS-VASc relate to?
0 for Men 1 for women= LOW risk, No anticoagulant therapy but consider daily aspirin
1 for men= Consider anticoagulation (Aspirin or Warfarin)
>2= Anticoagulation treatment commenced (Warfarin/NOAC), INR: 2-3
What co-morbidities are common with AF?
HTN HF CAD Valvular DM Obesity CKD
What order is AF medication given in?
Rate control
THEN
Rhythm Control
Unless AF has a reversible cause
Which anticoagulants should be offered & when in AF?
Apix/Rivaroxaban: Prev stroke/TIA, >75, DM, HTN, HF
Dabigatran: Prev stroke/TIA/embolism, NY Class 2+ HF, >75 or >65 + DM/CAD/HTN
What medications should not be given to people with structural heart disease or IHD?
Class 1c antiarrhythmics: Flecainide or Propafenone
How is acute AF treated?
Life-threatening Haem instability: Emergency cardioversion
Non-life threatening Haem instability: Rate/rhythm control if <48hrs or rate control if >48hrs & anticoagulation min 3w before cardioversion
How is hypertension diagnosed?
Clinical BP from both arms (take highest reading)
If >140/90: ABPM or HBPM
Severe: Do not wait, treat immediately
If not diagnosed: Measure BP every 5years
How does ABPM & HBPM work?
ABPM: BP over 24hours
At least 2readings/hr between 8am-10pm
Diagnosis confirmed by average of 14 readings
HBPM: 2 measurements 1 min apart whilst seated
Record BP twice daily in am & pm for 4-7days
Discard measurement on 1st day & average the rest
What are the indications for giving antihypertensive medications?
All people <80 w/stage 1 HTN plus: target organ damage, DM, renal disease, QRISK >10%, CVD
Any age w/stage 2 HTN
<55 ACEi
<40 refer to specialist
What are the blood pressure targets for clinic BP?
<80: <140/90
>80: <150/90
What is the NY Heart Association Classification for HF?
1: No limitations
2: Slight limitations of physical activity- mild HF
3: Marked limitations of physical activity- moderate HF
4: Symptoms of HF present at rest- severe HF
