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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
Q

Target INR of 2.5

A
  • Non-recurrent VTE
  • AF
  • Cardioversion
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26
Q

Target INR of 3.5

A
  • Recurrent VTE

- Mechanical heart valves

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27
Q

Duration of anticoagulation following VTE

A
  • 3 months for provoked VTE

- > 3 months for unprovoked –> long-term may be required

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28
Q

Warfarin + major bleeding

A
  • Stop warfarin
  • IV vitamin K
  • Prothrombin complex concentrate (or FFP if PCC not available)
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29
Q

Warfarin + INR > 8.0 + minor bleeding

A
  • Stop warfarin
  • IV vitamin K
  • Repeat dose of vit K is INR still high in 24h
  • Restart warfarin when INR < 5.0
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30
Q

Warfarin + INR > 8.0 + no bleeding

A
  • Stop warfarin
  • Oral vitamin K
  • Repeat dose of vit K is INR still high in 24h
  • Restart warfarin when INR < 5.0
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31
Q

Warfarin + INR 5.0-8.0 + minor bleeding

A
  • Stop warfarin
  • IV vitamin K
  • Restart warfarin when INR < 5.0
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32
Q

Warfarin + INR 5.0-8.0 + no bleeding

A
  • Withhold 1-2 doses

- Reduce maintenance dose

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33
Q

Warfarin pre-op - elective surgery

A
  • Stop 5 days before surgery
  • Consider bridging with LMWH until 24 hours before surgery
  • Vitamin K the day before surgery if INR > 1.5
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34
Q

Warfarin pre-op - emergency surgery

A
  • Vitamin K + delay 6-12h if possible

- Prothrombin complex concentrate if delay not possible

35
Q

Indications for unfractionated heparin

A
  • STEMI

- Patients with high risk of bleeding - easier to reverse than LMWH

36
Q

Advantage of LMWH vs unfractionated hepatin

A

Lower risk of heparin-induced thrombocytopenia

37
Q

Indications for aspirin

A

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
Q

Side effects of aspirin

A
  • Dyspepsia
  • Haemorrhage
  • Nausea and vomiting
  • Bronchospasm
39
Q

Symptoms of aspirin toxicity

A
  • Hyperventilation
  • Tinnitus
  • Vasodilation
  • Sweating
40
Q

Contraindications to aspirin

A
  • NSAID allergy
  • Breast-feeding
  • Severe liver impairment
  • Severe renal impairment
  • AKI
41
Q

Adverse effects of heparin

A
  • Haemorrhage
  • Heparin-induced thrombocytopenia (more likely with unfractionated heparin)
  • Hyperkalaemia (due to inhibition of aldosterone secretion)
42
Q

Mechanism of action of dabigatran

A

Direct thrombin inhibitor

43
Q

Sequelae of hypertension

A
  • Stroke
  • MI
  • Heart failure
  • CKD
  • Cognitive decline
44
Q

Risk factors for hypertension

A
  • Increased age
  • Social deprivation
  • Smoking
  • Obesity
  • Alcohol excess
  • Poor diet
  • High dietary sodium intake
  • Stress and anxiety
  • High caffeine intake
  • FHx
45
Q

Non-pharmacological management of hypertension

A
  • Weight loss
  • Management of stress and anxiety
  • Healthy diet
  • Reduce alcohol intake
  • Reduce dietary sodium intake
  • Reduce caffeine intake
  • Smoking cessation
46
Q

Features that raise suspicion of pheochromocytoma in a patient with hypertension

A
  • Postural hypotension
  • Headache
  • Palpitations
  • Pallor
  • Abdominal pain
  • Diaphoresis
47
Q

Target BP (SIGN)

A

<140/90

or < 135/85 if high cardiovascular risk and target organ damage

48
Q

Investigations in newly-diagnosed hypertension

A
  • HbA1c
  • U&Es including eGFR
  • Lipids
  • Urine dip for proteinuria and haematuria
  • ECG
  • Fundoscopy to look for retinal disease
49
Q

Hypertension + T2DM

A
  1. ACEi (or ARB)
  2. Add calcium-channel blocker (or thiazide)
  3. ACEi (or ARB) + calcium channel blocker + thiazide
  4. Seek specialist advice
50
Q

Hypertension, under 55, not black

A
  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
Q

Hypertension, no T2DM, over 55

A
  1. Calcium-channel blocker
  2. Add ACEi or ARB or thiazide
  3. Calcium channel blocker + ACEi/ARB + thiazide
  4. Seek specialist advice
52
Q

Hypertension, no T2DM, black

A
  1. Calcium-channel blocker
  2. Add ACEi or ARB or thiazide
  3. Calcium channel blocker + ACEi/ARB + thiazide
  4. Seek specialist advice
53
Q

Mechanism of action of ACE-inhibitors

A
  • 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
Q

Contraindications to ACE-inhibitors (most are relative and increase risk of hyperkalaemia)

A
  • Pregnancy
  • Poor renal function
  • AKI
  • NSAIDs
  • Potassium-sparing diuretics
  • Severe renal artery stenosis
55
Q

Indications for beta-blockers

A
  • 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
Q

Side effects of beta-blockers

A
  • Bronchospasm
  • Hypotension
  • Bradycardia
  • Fatigue
  • Cold hands and feet
  • Sleep disturbance and nightmares
  • Hypo- or hyperglycaemia, or may mask symptoms
  • GI upset
57
Q

Contraindications to beta blockers

A
  • 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
Q

Side effects of calcium channel blockers

A
  • Abdo pain
  • Nausea and vomiting
  • Dizziness
  • Drowsiness
  • Flushing
  • Headache
  • Peripheral oedema
59
Q

Mechanism of thiazide diuretics

A
  • Block Na/Cl symporter to reduce reabsorption of sodium and calcium in the DCT
  • This reduces water reabsorption in the kidneys
60
Q

Medical conditions exacerbated by thiazides

A
  • Gout
  • Diabetes
  • SLE
61
Q

Examples of thiazide diuretics

A
  • Bendroflumethiazide

- Indapamide

62
Q

Side effects of ACEi

A
  • Hypoglycaemia in diabetes
  • First-dose hypotension
  • Cough
  • GI upset and diarrhoea
  • Tinnitus
  • Headache
63
Q

Non-modifiable cardiovascular risk factors

A
  • Male
  • FHx
  • South Asian ethnicity
  • Age > 50 and especially > 85
64
Q

Modifiable cardiovascular risk factors

A
  • Hypertension
  • Hyperlipidaemia
  • Obesity
  • Diabetes
  • Depression, anxiety, social isolation
  • Low levels of physical activity
  • Poor diet
  • Smoking
  • Alcohol excess
65
Q

Calculation of cardiovascular risk

A
  • QRISK score

- ASSIGN score (SIGN)

66
Q

Primary prevention of cardiovascular disease

A
  • Antihypertensive therapy (if BP >140/90)

- Statin - if >10% 10-year QRISK or CKD , and some T1DM patients

67
Q

Secondary prevention of cardiovascular disease

A
  • Antiplatelet - low-dose aspirin
  • Antihypertensive therapy (if BP >140/90)
  • Statin
  • Manage psychological risk factors - SSRI
68
Q

Definition of heart failure

A
  • Progressive clinical syndrome
  • Caused by structural or functional heart disease
  • Results in reduced cardiac output
69
Q

Symptoms of heart failure

A
  • SOB
  • Reduced exercise tolerance
  • Cough
  • Peripheral oedema
  • Fatigue
70
Q

Signs of heart failure

A
  • Raised JVP
  • Pulmonary oedema
  • Ankle swelling
  • Reduced heart sounds
  • Displaced apex beat
71
Q

Complications of heart failure

A
  • CKD
  • Sudden cardiac death
  • AF
  • Depression
72
Q

Types of heart failure

A

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
Q

Classification of heart failure

A

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
Q

Aims of heart failure management

A
  • Reduce mortality
  • Relieve symptoms
  • Improve exercise tolerance
  • Reduce incidence of exacerbations
75
Q

Non-pharmacological management of heart failure

A
  • 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
Q

Pharmacological management of heart failure with reduced ejection fraction

A
  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
Q

Mechanism of potassium-sparing diuretics (aldosterone agonists - spironolactone)

A
  • 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
Q

Side effects of statins

A
  • GI symptoms - nausea, constipation, discomfort
  • Headache
  • Myalgia
  • Sleep problems
79
Q

Pharmacological management of stable angina

A
  • 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
Q

Treatment of unstable angina and NSTEMI

A
  • 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
Q

Treatment of STEMI

A
  • 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
Q

Indications for thiazide diuretics

A
  • Oedema in chronic heart failure

- Management of hypertension

83
Q

Indications for loop diuretics

A
  • Pulmonary oedema due to LV failure

- Chronic heart failure

84
Q

Mechanism of loop diuretics

A
  • Inhibit reabsorption from the ascending limb of loop of Henle

MBChB 5 (7 decks)

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