Cardiovascular Flashcards
Define HYPERTENSION.
Hypertension is clinically defined as a systolic blood pressure > 140mmHg and diastolic blood pressure > 90 mmHg, in a patient > 18 years of age.
Outline the grades of HTN.
NORMAL - SBP < 120 mmHg; DBP < 80 mmHg
HIGH NORMAL - SBP 120- 139 mmHg; DBP 80 - 89 mmHg
GRADE I HTN - SBP 140 - 159 mmHg; DBP 90 - 99 mmHg
GRADE II HTN - SBP 160 - 179 mmHg; DBP 100 - 109 mmHg
GRADE III HTN - SBP > 180 mmHg; DBP > 110 mmHg
ISOLATED HTN - SBP > 140 mmHg but DBP < 90 mmHg
Identify causes of SECONDARY HYPERTENSION.
MERC
M - MEDICATIONS
✔️ NSAIDS
✔️ corticosteroids
✔️ oral contraceptive pill
E - ENDOCRINE ✔️ primary hyperaldosteronism (Conn's Syndrome) ✔️ phaeochromocytoma ✔️ Cushing's Syndrome ✔️ hyperthyroidism
R - RENAL
✔️ renal artery stenosis
✔️ polycystic kidney disease
C - CARDIOVASCULAR
✔️ coarctation of the aorta
Define the ABSOLUTE CARDIOVASCULAR RISK assessment.
Absolute cardiovascular risk assessment is a tool used to stratify the risk that an individual will experience an adverse cardiovascular event within the next FIVE YEARS.
It should be calculated every TWO years in adults > 45 years of age (>35 years of age if ATSI).
The components that make up the ACR include both modifiable and non-modifiable factors, such as: ✔️ age ✔️ gender ✔️ ATSI status ✔️ diabetes mellitus ✔️ smoking status ✔️ blood pressure ✔️ HDL: total cholesterol ratio ✔️ LVH on ECG
Based on the calculations, risk is classified as either:
- mild (<10% risk)
- moderate (10-15% risk)
- high (>15%)
The ACR is used to guide management of both hypertension and dyslipidemia.
How is HYPERTENSION diagnosed?
Hypertension requires two seperate readings on two seperate occasions of BP > 140 / 90 mmHg.
Methods for measurement include:
- clinic readings
- home readings
- ambulatory / 24 hour halter monitor
Outline some investigations appropriate for HYPERTENSION.
BEDSIDE Ix
✔️ ECG
✔️ urine dipstick (for proteinuria)
✔️ random BGL
LABORATORY Ix ✔️ FBC + WCC ✔️ inflammatory markers ✔️ UECs + eLFTs ✔️ fasting lipids ✔️ fasting BGL ✔️ TFTs ✔️ iron studies + B12 + folate
IMAGING / FUNCTIONAL Ix
✔️ echocardiogram
✔️ ambulatory monitoring / halter monitor
✔️ exercise stress test
✔️ coronary angiogram
✔️ fundoscopy
✔️ abdominal / pelvic CT (to view renal artries and the kidney).
Identify the aim blood pressure for patients with HTN.
< 140 / 90 mmHg (if no renal disease or end-organ complications).
< 130 / 80 mmHg in the following patient groups: ✔️ diabetes mellitus ✔️coronary artery disease ✔️ chronic kidney disease ✔️ proteinuria > 300 mg per day ✔️ stroke / TIA
< 125 / 75 mmHg if proteinuria > 1g per day
For LOW RISK patients, outline the appropriate management of hypertension.
✔️ offer lifestyle advice
✔️ commence pharmacotherapy is BP consistently > 160 / 100mmHg
✔️ re-check blood pressure in TWO MONTHS if > 140 to 159 mmHg SBP
BP to be monitored every TWO YEARS.
For MODERATE RISK patients, outline the appropriate management of hypertension.
✔️ offer intensive lifestyle advice
✔️ commence pharmacotherapy if BP > 160 / 100mmHg
✔️ commence pharmacotherapy if history of premature CVD, ATSI, South Asian, Maori or Middle Eastern descent
✔️ consider pharmacotherapy if SBP between 140 to 159 mmHg or DBP between 90 to 99 mmHg
✔️ review BP in SIX MONTHS if SBP between 130 to 139 mmHg or DBP between 80 to 89 mmHg
BP to be monitored every 6 to 12 months
For HIGH RISK patients, outline the appropriate management of hypertension.
✔️ offer intensive lifestyle advice
✔️ commence pharmacotherapy
BP to be monitored every 6 to 12 weeks.
Which populations are automatically HIGH RISK for ABSOLUTE CARDIOVASCULAR RISK?
✔️ diabetes mellitus > 60 years ✔️ ATSI patients > 74 years ✔️ moderate or severe CKD ✔️ diabetes mellitus with proteinuria ✔️ familiar hypercholesterolemia ✔️ serum cholesterol > 7.5 mmol / L ✔️ previous CKD, stroke or IHD / MI
Outline lifestyle advice for management of hypertension.
✔️ smoking cessation ✔️ reduced / appropriate alcohol consumption ✔️ optimise BMI / weight loss ✔️ physical activity 30 mins per day ✔️ high fibre diet ✔️ reduce salt intake < 4 g per day
Outline appropriante pharmacological management of hypertension.
First line pharmacotherapy:
✔️ ACE-i or ARB
✔️ thiazide diuretic
✔️ calcium channel blocker
Second line pharmacotherapy:
✔️ beta-blocker
All patients with HTN should be commenced on ACE-i or ARB (given no contraindications).
If blood pressure remains uncontrolled, introduce CCB. Titrate up dose of one or both medications.
If blood pressure still remains controlled, consider adding thiazide diuretic.
✔️ ACE-I / ARB + CCB –> appropriate for management of HTN and dyslipidemia
✔️ ACE-I / ARB + thiazide diuretic –> appropriate for heart failure and post-stroke
✔️ ACE-I / ARB + beta-blocker –> appropriate for post MI and congestive cardiac failure patients
Contraindications for ACE-I / ARBs?
✔️ pregnancy ✔️ hyperkalaemia ✔️ angiooedema ✔️ bilateral renal artery stenosis ✔️ renal function eGFR < 30
Define ATRIAL FIBRILLATION.
AF is a supra-ventricular arrhythmia characterised by (1). absence of P waves (2). irregularly irregular rhythm
What are some causes for ATRIAL FIBRILLATION?
P - pulmonary causes (e.g. COPD, chronic PE, OSA)
I - ischemia (e.g. IHD, CAD)
R - rheumatic heart disease / valvular pathologies (e.g. aortic stenosis)
A - anaemia
T - thyrotoxicosis
E - endocrine abnormalities (e.g. hypokalaemia)
S - sick sinus syndrome
Classification of AF?
✔️ paroxysmal AF - episodes last < 1 week
✔️ persistent AF - episodes last > 1 week
✔️ long-term persistent - episodes last > 12 months
✔️ permanent AF - resistant to cardioversion
Outline management protocol for AF?
RACE
R - rate control
A - anticoagulation
C - cardioversion or flecanide / amiodarone
E - etiology / underlying cause
What are options for RHYTHM CONTROL in the management of AF?
There are three options for rhythm control in AF: 1. medications ✔️ flecanide ✔️ sotalol ✔️ amiodarone 2. catheter ablation 3. electrical cardioversion
What are some options for RATE CONTROL in the management of AF and when should rate control be considered over rhythm control?
Rate control should be considered in the following circumstances: ✔️ younger patients ✔️ severe CHF ✔️ significant symptoms ✔️ paroxysmal / persistent AF
Options for rate control include: 1. medications ✔️ beta-blockers ✔️ calcium channel blockers 2. AV node ablation 3. permanent pace-maker
What are the components that make up the CHADSVASc score and how should it be interpreted?
C - congestive heart failure H - hypertension A - age > 75 years (2 points) D - diabetes mellitus S - stroke / TIA (2 points) V - vascular disease A - age > 64 years Sc - sex category (female)
CHADSVASc is used to stratify risk of a patient with AF experiencing a stroke, and therefore, whether it is appropriate for them to commence on pharmacotherapy .
Score 0 - no need for anticoagulation
Score 1 - consider anticoagulation
Score 2 - commence anticoagulation with warfarin (valvular AF) or a NOAC (non-valvular AF)
What components make up the HASBLED score?
H - hypertension
A - abnormal liver or renal function tests
S - stroke
B - bleeding history
L - labile INR
E - elderly (>65 years or age)
D - drugs (e.g. antiplatelets, NSAIDs, clopidogrel)
Define CONGESTIVE HEART FAILURE.
CHF occurs when cardiac output is insufficient to meet metabolic demands.
It is characterised by:
✔️ insufficient forward flow –> ischemic symptoms
✔️ black flow –> fluid overload symptoms
SYSTOLIC HEART FAILURE
✔️ ejection fraction
✔️ mechanism / pathology
✔️ aetiology
EJECTION FRACTION < 40%
MECHANISM - insufficient contraction of myocardium during systole results in cardiac output less than metabolic demands of the body; reduced forward flow results in “back flow” symptoms
AETIOLOGY ✔️ ischemic heart disease ✔️ essential hypertension ✔️ diabetes mellitus ✔️ valvular pathologies ✔️ cardiomyopathies ✔️systemic disease (e.g. scleroderma)
