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Y3 Core Conditions > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What is atrial fibrillation (AF)?

A

Atrial fibrillation is an arrhythmia. It is caused by irregular, disorganised electrical activity in the atria. This leads to ineffective atrial contractions, and the AV node receives more electrical impulses than it can conduct, resulting in irregular ventricular rhythm.

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2
Q

In untreated AF, what does the ventricular rate often average, in beats per minute?

A

160-180bpm

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3
Q

What are the 3 categories of AF?

A
  1. Paroxysmal AF - episodes lasting longer than 3- seconds, but less than 7 days (often less than 48 hours) and are self-terminating and recurrent
  2. Persistent AF - episodes lasting longer than 7 days
  3. Permanent AF - AF that fails to terminate using cardioversion or that relapses within 24 hours. It can also be longstanding AF - longer than 1 year, in which cardioversion has not been indicated or attempted
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4
Q

What % of people have lone AF? (where there is no identifiable cause)

A

11% - it is often paroxysmal AF

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5
Q

What are the most common causes of AF? (4)

A
  1. Ischaemic heart disease
  2. Hypertension
  3. Valvular heart disease
  4. Hyperthyroidism
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6
Q

In addition to the common causes of AF, what other factors are thought to be causative or associated with AF? (14)

A 
Cardiac related:
1. Rheumatic heart disease
2. Wolff-Parkinson-White syndrome 
3. Heart failure
4. Other cardiac conditions (cardiomyopathy, pericarditis, myocarditis, congenital heart disease etc) 
Non-cardiac:
5. Drugs e.g. thyroxine
6. Acute infection
7. Electrolyte depletion
8. Lung cancer
9. Pulmonary embolism 
10. Thyrotoxicosis 
11. Diabetes
12. Excessive caffeine intake
13. Excessive alcohol intake 
14. Obesity
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7
Q

What is the main complication associated with AF?

A

Stroke and thromboembolism

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8
Q

In addition to stroke, what other complications are associated with AF? (3)

A
  1. Heart failure
  2. Tachycardia-induced cardiomyopathy and critical care ischaemia
  3. Reduced quality of life - reduced exercise tolerance and impaired cognitive function
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9
Q

Why can heart failure occur in people with AF?

A

Due to the disorganised electrical conduction in the atria. It results in ineffective ventricular filling. The cardiac output can be reduced by as much as 10-20%, pushing an already compromised ventricle into failure.

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10
Q

What are the symptoms of AF? (6)

A
  1. Irregular pulse
  2. Breathlessness
  3. Palpitations
  4. Chest discomfort
  5. Syncope/dizziness
  6. Reduced exercise tolerance, malaise, or polyuria
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11
Q

In suspected AF, if an irregular pulse is palpated, what investigations should be carried out? (1)

A
  1. 12 lead ECG

* If paroxysmal AF is suspected - an event recorder ECG (7-day Holter monitor)

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12
Q

How would the ECG graph appear with AF? (3)

A
  1. Absent P waves
  2. A chaotic baseline
  3. Irregular ventricular rate
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13
Q

What may be the different diagnoses for AF? (6)

A
  1. Atrial flutter
  2. Atrial extrasystoles - common and may cause an irregular pulse
  3. Ventricular ectopic beats
  4. Sinus tachycardia - more than 100bpm (sinus rhythm)
  5. Supraventricular tachycardias - Wolff-Parkinson-White syndrome
  6. Multifocal atrial tachycardia
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14
Q

What is the rate-control treatment for all people with AF (including paroxysmal AF)?

A

Beta-blocker or rate-limiting calcium-channel blocker (i.e. verapamil or diltiazem)

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15
Q

What is the rhythm-control treatment for AF, which may be appropriate for some people?

A

Cardioversion

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16
Q

When would cardioversion be an appropriate rhythm-control treatment for people with AF?

A
  1. When the AF is a new onset
  2. In people whose AF has a reversible cause (e.g. chest infection)
  3. Who have heart failure thought to be caused/worsened by AF
  4. With atrial flutter
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17
Q

How is the risk of stroke calculated, not just in someone with AF, but in anyone?

A

CHADSVASc

CHA2DS2VASc

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18
Q

In addition to rate and rhythm treatment, what other treatment should someone with AF be started on?

A

Anticoagulation (warfarin or NOAC/DOAC)

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19
Q

When would it be appropriate to admit someone with AF to hospital? - what symptoms/signs would they be displaying? (3)

A
  1. A rapid pulse (>150bpm) and/or low blood pressure (<90mmHG systole)
  2. Loss of consciousness, severe dizziness, ongoing chest pain, or increasing breathlessness
  3. A complication of AF, such as stroke, TIA or acute heart failure
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20
Q

What investigations could be carried out to assess for and manage the underlying cause of AF?

A
  1. ECG
  2. FBC, TFTs, U&Es, blood sugars
  3. CXR
21
Q

If a person with newly diagnosed AF needs rate-control treatment, but has asthma, which drug should be prescribed? (and which shouldn’t)

A

CCB should be prescribed, as BB are contraindicated for asthma

22
Q

If a person with newly diagnosed AF needs rate-control treatment, and has heart failure, which drug should be prescribed? (and which should be avoided)

A

BB can be prescribed, and CCB are contraindicated.

23
Q

Which NOAC’s are indicated for use in people with a high risk of stroke? (3)

A
  1. Dabigatran
  2. Rivaroxaban
  3. Apixaban
24
Q

What is the CHADVASc score/what does each letter stand for?

A 
CHADVASc assesses risk of stroke
C - congestive heart failure = 1
H - hypertension = 1
A - age older than 74 years = 2
D - diabetes (fasting glucose >6) = 1
S - stroke/TIA/thromboembolism = 2
V - vascular disease (MI etc.) = 1
A - age 65-74 years = 1
S - sex category (female) = 1 
(total 9 - (due to age appearing twice))
25
Q

What is the HAS-BLED score/what does each letter stand for?

A 
HAS-BLED tool identifies people at high risk of bleeding 
H - hypertension (uncontrolled >160mmHG)
A - abnormal liver function
A - abnormal renal function
S - stroke 
B - bleeding
L - labile international normalized ratios (INRs)
E - elderly (>65)
D - drugs (NSAIDs/antiplatelet agents) 
H - harmful alcohol consumption
26
Q

What is hypertension?

A

A persistently raised arterial blood pressure. This equates to a systolic blood pressure above 140mmHg, or a diastolic blood pressure above 90mmHg.

27
Q

What are the stages of severity of hypertension? (3)

A
  1. Stage one hypertension - 140/90mmHg
  2. Stage two hypertension - 160/100mmHg
  3. Stage three - severe hypertension - 180/110mmHg
28
Q

What is the prevalence of hypertension in adults in England?

A

In 2015, approximately 31% of men and 26% of women had hypertension - it is also estimated that for every 10 people diagnosed with hypertension, a further 7 remain undiagnosed.

29
Q

What are the risk factors associated with hypertension? (6)

A
  1. Age - increasing age
  2. Sex - up to age 65, women have lower BP, between 65-74, women have higher BP
  3. Ethnicity - black african and black caribbean origin more likely to be diagnosed with high BP
  4. Genetic factors - people from the most deprived areas in England 30% more likely
  5. Lifestyle
  6. Anxiety and emotional stress - due to increased adrenaline and cortisol levels
30
Q

Which lifestyle factors contribute to hypertension? (5)

A
  1. Smoking
  2. Excessive alcohol consumption
  3. Excess dietary salt
  4. Obesity
  5. Physical inactivity
31
Q

What are the complications associated with hypertension? (6)

A
  1. Heart failure
  2. Coronary artery disease
  3. Stroke
  4. CKD
  5. Peripheral arterial disease
  6. Vascular dementia
32
Q

When should someone be started on medication for hypertension before obtaining an ambulatory blood pressure monitor reading/home blood pressure monitor reading?

A

When they present with severe hypertension - 180/110mmHg

33
Q

If someone presents with severe hypertension, what investigation should be performed straight away?

A

Fundoscopy - for evidence for hypertensive retinopathy, i.e. papilloedema and/or retinal haemorrhage.

34
Q

What condition might be suspected, if a patient presents with severe hypertension, headache, palpitations, pallor, diaphoresis?

A

Phaeochromocytoma

35
Q

In all people with confirmed hypertension, what risk assessment needs to be carried out?

A

Cardiovascular risk - QRISK assessment tool : this estimates the person’s 10-year risk of developing cardiovascular disease.

36
Q

In people with confirmed hypertension, what investigations should be carried out to establish if there is any organ damage and if there are secondary causes of the hypertension? (2)

A
  1. 12-lead ECG

2. FBC, U&Es, eGFR, plasma glucose, creatinine, urine dipstick - haematuria

37
Q

What lifestyle advice is offered with regards to hypertension? (4)

A
  1. Diet and exercise - discourage excessive consumption of coffee and other caffeine rich products. Encourage a low sodium diet.
  2. Stress management
  3. Smoking cessation
  4. Alcohol consumption reduction
38
Q

When should people with stage 1 hypertension be started on antihypertensive treatment? (5)

A

If they have any of the following:

  1. Target organ damage
  2. Established CVD
  3. Renal disease
  4. Diabetes
  5. QRISK score >20%
39
Q

If a patient has stage 2 or stage 1 hypertension with complications, what treatment is recommended?

A
  1. Under 55 years of age –> ACE inhibitors
  2. If ACE inhibitors aren’t tolerated –> ARBs
  3. If pregnant/child-bearing age –> beta-blockers
  4. If under 55 but of black afro-caribbean ethnicity –> calcium channel blockers
  5. Over age of 55 –> calcium channel blockers
  6. If calcium channel blocker is not tolerated –> thiazide diuretic e.g. chlortalidone or indapamide
40
Q

What is step 2 in the treatment ladder for hypertension? (3)

A
  1. Offer a combination treatment with a CCB and either an ACE inhibitor or an ARB.
  2. If CCB is not suitable - e.g. due to heart failure, offer a thiazide-like diuretic
  3. For people of black afro-caribbean ethnicity - offer CCB with ARB rather than ACE inhibitor.
41
Q

What is step 3 in the treatment ladder for hypertension? (2)

A
  1. Review existing medication to establish if the doses are optimal/correct
  2. Combination of ACE inhibitor or ARB, with CCB and thiazide-like diuretic
42
Q

What is step 4 in the treatment ladder for hypertension?

A
  1. Low-dose spironolactone (25mg once daily)
  2. Higher-dose thiazide-like diuretic
  3. Alpha or beta-blocker if diuretic therapy is contraindicated/not tolerated
43
Q

If after step 4 on the treatment ladder for hypertension, the blood pressure remains uncontrolled, what is the next course of action?

A

Refer for specialist treatment if haven’t already done so

44
Q

Renal disorders are the most common secondary causes of hypertension. What do they include? (6)

A
  1. Chronic pyelonephritis
  2. Diabetic nephropathy
  3. Glomerulonephritis
  4. Polycystic kidney disease
  5. Obstructive uropathy
  6. Renal cell carcinoma
45
Q

What are the 2 vascular causes of secondary hypertension?

A
  1. Coarctation of the aorta

2. Renal artery stenosis

46
Q

What are the endocrine disorders that cause hypertension? (6)

A
  1. Primary hyperaldosteronism
  2. Phaeochromocytoma
  3. Cushing’s syndrome
  4. Acromegaly
  5. Hypothyroidism
  6. Hyperthyroidism
47
Q

What causes an MI?

A

Caused by coronary artery atherosclerosis. Occlusion of the coronary artery leads to ischaemia and infarction of the myocardium, causing irreversible damage. The fibrous cap of the atherosclerotic plaque ruptures/erodes, leading to the formation of a platelet rich clot - and vasoconstriction as the clot releases serotonin and thromboxane A2.

48
Q

How does an MI present?

A 
Central crushing chest pain which may radiate to the jaw/neck and down the arms. 
The pain may be associated with:
1. Breathlessness
2. Sweating
3. Vomiting and nausea

Y3 Core Conditions (19 decks)

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