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MBChB 5 > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

Treatment of new onset AF, <48h history

A 
Rhythm control --> cardioversion
Pharmacological:
- Amiodarone
- (Flecainide only if no structural heart disease)
Electrical:
- Synchronised DC cardioversion
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2
Q

Treatment of new onset AF, >48h history

A

Rate control:

  • Beta blocker
  • Rate-limiting calcium channel blocker
  • Consider digoxin in heart failure/reduced LV function

Cardioversion electively after 3 weeks of anticoagulation

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3
Q

Adverse features in tachy- and bradyarrhythmias

A

Shock
Syncope
Heart failure
Myocardial ischaemia

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4
Q

Assessment for thromboprophylaxis in AF

A

CHA2DS2-VASc score:

  • CHD
  • HTN
  • Age >75
  • DM
  • Stroke hx (1 point if TIA hx)
  • Vascular disease
  • Age >65
  • Sex female

Score > 0 in men and > 1 in women –> need anticoagulation (DOAC)

HAS-BLED score gives bleeding risk

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5
Q

Treatment of paroxysmal SVT

A
  1. Valsalva manoeuvre
  2. Adenosine (or verapamil)
  3. Synchronised DC cardioversion
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6
Q

Treatment of recurrent SVT

A
  • Catheter ablation

- Rate-limiting calcium channel blocker

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7
Q

Treatment of symptomatic bradycardia

A

Atropine
Adrenaline if unstable/high risk of asystole
Transcutaneous pacing

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8
Q

Treatment of VT

A

Adverse features:

  1. Synchronised DC cardioversion
  2. Amiodarone
  3. Repeat cardioversion

No adverse features:

  1. Amiodarone
  2. Synchronised DC cardioversion

Non-acute/maintenance:

  • Catheter ablation
  • ICD
  • Beta-blocker
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9
Q

Treatment of torsades de pointes

A
  • Magnesium sulfate

- Beta-blocker

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10
Q

Indications for amiodarone

A
  • Rhythm control (pharmacological cardioversion) in AF
  • Broad-complex tachycardias
  • Long-term control of arrhythmias
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11
Q

Adverse effects of amiodarone

A
  • Hypo- and hyperthyroidism
  • Hepatotoxicity
  • Pulmonary toxicity
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12
Q

Indications for adenosine

A
  • SVT
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13
Q

Warning for patients before giving adenosine

A
  • Will make them feel terrible
  • Discomfort (chest, abdo, head)
  • Dizziness (hypotension)
  • Dyspnoea
  • Dry mouth
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14
Q

Actions of digoxin

A
  • Increases force of myocardial contraction

- Reduces AV node conductivity

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15
Q

Digoxin - side effects and symptoms of toxicity

A
  • Nausea
  • Diarrhoea
  • Dizziness
  • Confusion
  • Green-tinted vision
  • Scooped ST segment on ECG with chronic use
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16
Q

Things that increase the risk of digoxin toxicity

A
  • Hypokalaemia
  • Hypomagnesaemia
  • Hypercalaemia
  • Renal impairment
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17
Q

VTE risk factors

A
  • Reduced mobility
  • Obesity
  • Malignancy
  • Hx VTE
  • Thrombophilia
  • Age > 60
  • Pregnancy and postpartum period
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18
Q

Mechanical thromboprophylaxis

A
  • TED (anti-embolism) stockings

- Intermittent pneumatic compression

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19
Q

Contraindications for TED stockings

A
  • Peripheral vascular disease
  • Peripheral neuropathy
  • Severe peripheral oedema
  • Gangrene
  • Severe dermatitis
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20
Q

Rapid reversal of heparin

A

Protamine

only partially reverses LMWH

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21
Q

Management of TIA

A
  • Aspirin 300mg
  • Refer to TIA clinic
  • Secondary prevention
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22
Q

Thrombolysis in acute ischaemic stroke

A
  • Alteplase
  • Within 4.5 hours of symptom onset
  • Haemorrhage excluded on CT scan
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23
Q

Secondary prevention of ischaemic stroke

A
  • Clopidogrel or dipyridamole + aspirin
  • Atorvastatin
  • BP target of 130/80
  • Lifestyle changes
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24
Q

Management of haemorrhagic stroke

A
  • Surgery to remove haematoma and relieve ICP
  • BP lowering treatment (within 6h of onset)
  • Stop and reverse anticoagulants
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25
Target INR of 2.5
- Non-recurrent VTE - AF - Cardioversion
26
Target INR of 3.5
- Recurrent VTE | - Mechanical heart valves
27
Duration of anticoagulation following VTE
- 3 months for provoked VTE | - > 3 months for unprovoked --> long-term may be required
28
Warfarin + major bleeding
- Stop warfarin - IV vitamin K - Prothrombin complex concentrate (or FFP if PCC not available)
29
Warfarin + INR > 8.0 + minor bleeding
- Stop warfarin - IV vitamin K - Repeat dose of vit K is INR still high in 24h - Restart warfarin when INR < 5.0
30
Warfarin + INR > 8.0 + no bleeding
- Stop warfarin - Oral vitamin K - Repeat dose of vit K is INR still high in 24h - Restart warfarin when INR < 5.0
31
Warfarin + INR 5.0-8.0 + minor bleeding
- Stop warfarin - IV vitamin K - Restart warfarin when INR < 5.0
32
Warfarin + INR 5.0-8.0 + no bleeding
- Withhold 1-2 doses | - Reduce maintenance dose
33
Warfarin pre-op - elective surgery
- Stop 5 days before surgery - Consider bridging with LMWH until 24 hours before surgery - Vitamin K the day before surgery if INR > 1.5
34
Warfarin pre-op - emergency surgery
- Vitamin K + delay 6-12h if possible | - Prothrombin complex concentrate if delay not possible
35
Indications for unfractionated heparin
- STEMI | - Patients with high risk of bleeding - easier to reverse than LMWH
36
Advantage of LMWH vs unfractionated hepatin
Lower risk of heparin-induced thrombocytopenia
37
Indications for aspirin
75mg: - Secondary prevention of MI and stroke - Prevention of pre-eclampsia in moderate and high-risk women 300mg: - ACS - Acute TIA or stroke Other indications: - Pain/pyrexia (300-900mg) - Migraine (900mg) - Kawasaki disease
38
Side effects of aspirin
- Dyspepsia - Haemorrhage - Nausea and vomiting - Bronchospasm
39
Symptoms of aspirin toxicity
- Hyperventilation - Tinnitus - Vasodilation - Sweating
40
Contraindications to aspirin
- NSAID allergy - Breast-feeding - Severe liver impairment - Severe renal impairment - AKI
41
Adverse effects of heparin
- Haemorrhage - Heparin-induced thrombocytopenia (more likely with unfractionated heparin) - Hyperkalaemia (due to inhibition of aldosterone secretion)
42
Mechanism of action of dabigatran
Direct thrombin inhibitor
43
Sequelae of hypertension
- Stroke - MI - Heart failure - CKD - Cognitive decline
44
Risk factors for hypertension
- Increased age - Social deprivation - Smoking - Obesity - Alcohol excess - Poor diet - High dietary sodium intake - Stress and anxiety - High caffeine intake - FHx
45
Non-pharmacological management of hypertension
- Weight loss - Management of stress and anxiety - Healthy diet - Reduce alcohol intake - Reduce dietary sodium intake - Reduce caffeine intake - Smoking cessation
46
Features that raise suspicion of pheochromocytoma in a patient with hypertension
- Postural hypotension - Headache - Palpitations - Pallor - Abdominal pain - Diaphoresis
47
Target BP (SIGN)
<140/90 | or < 135/85 if high cardiovascular risk and target organ damage
48
Investigations in newly-diagnosed hypertension
- HbA1c - U&Es including eGFR - Lipids - Urine dip for proteinuria and haematuria - ECG - Fundoscopy to look for retinal disease
49
Hypertension + T2DM
1. ACEi (or ARB) 2. Add calcium-channel blocker (or thiazide) 3. ACEi (or ARB) + calcium channel blocker + thiazide 4. Seek specialist advice
50
Hypertension, under 55, not black
1. ACEi (or ARB) 2. Add non-rate limiting calcium-channel blocker (or thiazide) 3. ACEi (or ARB) + calcium channel blocker + thiazide 4. Seek specialist advice
51
Hypertension, no T2DM, over 55
1. Calcium-channel blocker 2. Add ACEi or ARB or thiazide 3. Calcium channel blocker + ACEi/ARB + thiazide 4. Seek specialist advice
52
Hypertension, no T2DM, black
1. Calcium-channel blocker 2. Add ACEi or ARB or thiazide 3. Calcium channel blocker + ACEi/ARB + thiazide 4. Seek specialist advice
53
Mechanism of action of ACE-inhibitors
- Inhibit angiotensin-converting enzyme - Prevents conversion of angiotensin I to angiotensin II - Prevents actions of angiotensin II to increase BP (upregulation of sympathetic NS, Na and Cl reabsorption and K and H2O excretion, aldosterone secretion, vasoconstriction, ADH secretion)
54
Contraindications to ACE-inhibitors (most are relative and increase risk of hyperkalaemia)
- Pregnancy - Poor renal function - AKI - NSAIDs - Potassium-sparing diuretics - Severe renal artery stenosis
55
Indications for beta-blockers
- Angina - Prevention of MI - Rate control in AF - SVT - Heart failure - Thyrotoxicosis - symptom control and pre-op to reduce vascularity of thyroid gland - Anxiety/panic disorder - Prophylaxis of migraine - Glaucoma - topical
56
Side effects of beta-blockers
- Bronchospasm - Hypotension - Bradycardia - Fatigue - Cold hands and feet - Sleep disturbance and nightmares - Hypo- or hyperglycaemia, or may mask symptoms - GI upset
57
Contraindications to beta blockers
- Asthma - Heart block - Severe or uncontrolled heart failure - Hypotension - Bradycardia - Severe peripheral artery disease - Diabetes with frequent hypoglycaemic episodes - Myasthenia gravis - Pregnancy - can cause IUGR and neonatal hypoglycaemia - Phaeochromocytoma without alpha-blocker - risk of hypertensive crisis - Rate-limiting calcium channel blockers
58
Side effects of calcium channel blockers
- Abdo pain - Nausea and vomiting - Dizziness - Drowsiness - Flushing - Headache - Peripheral oedema
59
Mechanism of thiazide diuretics
- Block Na/Cl symporter to reduce reabsorption of sodium and calcium in the DCT - This reduces water reabsorption in the kidneys
60
Medical conditions exacerbated by thiazides
- Gout - Diabetes - SLE
61
Examples of thiazide diuretics
- Bendroflumethiazide | - Indapamide
62
Side effects of ACEi
- Hypoglycaemia in diabetes - First-dose hypotension - Cough - GI upset and diarrhoea - Tinnitus - Headache
63
Non-modifiable cardiovascular risk factors
- Male - FHx - South Asian ethnicity - Age > 50 and especially > 85
64
Modifiable cardiovascular risk factors
- Hypertension - Hyperlipidaemia - Obesity - Diabetes - Depression, anxiety, social isolation - Low levels of physical activity - Poor diet - Smoking - Alcohol excess
65
Calculation of cardiovascular risk
- QRISK score | - ASSIGN score (SIGN)
66
Primary prevention of cardiovascular disease
- Antihypertensive therapy (if BP >140/90) | - Statin - if >10% 10-year QRISK or CKD , and some T1DM patients
67
Secondary prevention of cardiovascular disease
- Antiplatelet - low-dose aspirin - Antihypertensive therapy (if BP >140/90) - Statin - Manage psychological risk factors - SSRI
68
Definition of heart failure
- Progressive clinical syndrome - Caused by structural or functional heart disease - Results in reduced cardiac output
69
Symptoms of heart failure
- SOB - Reduced exercise tolerance - Cough - Peripheral oedema - Fatigue
70
Signs of heart failure
- Raised JVP - Pulmonary oedema - Ankle swelling - Reduced heart sounds - Displaced apex beat
71
Complications of heart failure
- CKD - Sudden cardiac death - AF - Depression
72
Types of heart failure
Reduced ejection fraction - LV loses the ability to contract normally, so ejection fraction is reduced to < 40% Preserved ejection fraction - LV loses the ability to relax normally so although ejection fraction is not significantly reduced, cardiac output is still low
73
Classification of heart failure
NYHA functional classification: 1. Normal functional status, no symptoms on exertion 2. Mild functional limitation, mild symptoms on exertion, comfortable at rest 3. Marked functional limitation, moderate symptoms with low-level exertion, only comfortable at rest 4. Severe functional limitation, severe symptoms on minimal exertion, symptomatic at rest
74
Aims of heart failure management
- Reduce mortality - Relieve symptoms - Improve exercise tolerance - Reduce incidence of exacerbations
75
Non-pharmacological management of heart failure
- Lifestyle changes - smoking cessation, reduce alcohol consumption, increase exercise, weight loss, increase fruit and vegetable intake, reduce saturated fat intake. - Monitor weight - daily at a set time, report gain of >2kg in 2 days - Fluid +/- salt restriction - Discuss contraception with women of childbearing potential - Cardiac rehab programme - psychosocial support, exercise - ICD or CRT-D
76
Pharmacological management of heart failure with reduced ejection fraction
1. ACEi (ramipril, enalapril, lisinopril) or ARB (candesartan, losartan, valsartan 2. add beta-blocker (bisoprolol, carvedilol) 3. add spironolactone 4. Consider amiodarone, sacubitril-valsartan, digoxin, ivabridine
77
Mechanism of potassium-sparing diuretics (aldosterone agonists - spironolactone)
- Inhibit aldosterone-sensitive Na/K exchange channels in the DCT. - These usually reabsorb sodium in exchange for potassium. - When inhibited, there is increased sodium loss and potassium retention
78
Side effects of statins
- GI symptoms - nausea, constipation, discomfort - Headache - Myalgia - Sleep problems
79
Pharmacological management of stable angina
- GTN as required - Lifestyle changes - Secondary prevention of cardiovascular disease 1. Beta blocker 2. Add calcium channel blocker 3. Add a long acting nitrate or ivabradine or nicorandil or ranolazine 4. Revascularisation - PCI or CABG ``` (Ivabridine = sinus node funny current inhibitor) (Nicorandil = vasodilates by acting on potassium channels) ```
80
Treatment of unstable angina and NSTEMI
- Oxygen only if hypoxic Pain relief: - Sublingual GTN - IV GTN - IV isosorbide dinitrate - IV morphine + metaclopramide if required - Aspirin - continue long term at low dose - Clopidogrel/ticagrelor - continued for 3 months - LMWH - Beta blocker (or calcium channel blocker if LV dysfunction) - continue long-term - ACEi if diabetic - continue long term - Assess need for long-term angina treatment and coronary angiography
81
Treatment of STEMI
- Oxygen only if hypoxic Pain relief: - Morphine + metaclopramide if required - Nitrates - sublingual/IV GTN or IV isosorbide dinitrate - Aspirin - continue long term at low dose - Clopidogrel/ticagrelor - continue for 3 months - PCI (or thrombolysis with alteplase if PCI not available within 90 minutes of diagnosis) - Unfractionated heparin - Beta blocker - continue long term - ACEi - continue long term
82
Indications for thiazide diuretics
- Oedema in chronic heart failure | - Management of hypertension
83
Indications for loop diuretics
- Pulmonary oedema due to LV failure | - Chronic heart failure
84
Mechanism of loop diuretics
- Inhibit reabsorption from the ascending limb of loop of Henle

MBChB 5 (7 decks)

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