Cardiovascular Flashcards
What is the threshold for hypertension?
140/90 mmHg
What is the target BP for someone with hypertension and diabetes?
130/80 mmHg
What is hypertension a risk for?
Stroke, MI, HF, CKD, AF, hypertensive retinopathy, vascular dementia
How does hypertension cause atherosclerosis?
Thickens media of muscular arteries
What is the threshold for malignant hypertension?
200/130 mmHg
Which renal diseases cause hypertension?
Glomerulonephritis, polycystic kidneys, systemci sclerosis
Which endocrine diseases cause hypertension?
Cushing’s, acromegaly, Conn’s
Which drugs cause hypertension?
Steroids, amphetamines, cocaine
Coarctation of the aorta can cause hypertension. What is a sign of this?
Weak femoral pulse
What Ix’s would you do to diagnose hypertension?
- 24 hour ambulatory BP monitoring
- blood glucose to rule out diabetes
- U&E and urinalysis to exclude renal disease
- Ophthalmoscopy : retinal haemorrhage
- ECG :LV hypertrophy
What lifestyle changes can reduce hypertension?
- Exercise
- Stop smoking
- Low fat diet
- Reduce salt
- Reduce alcohol
If a patient is under 55 years old, which drug do you give them for hypertension?
ACEi or ARB
If a patient is >55 or of Afro-Caribbean origin of any age, which drug would you give them for hypertension?
CCB
After initial treatment of hypertension, you can combine ACE/ARB with CCB. If the BP is still not controlled, what drug would you prescribe?
Thiazide diuretic
What drugs would you prescribe for resistant hypertension?
- Spironolactone if K+ <4/5 mmol/L
- alpha blocker or beta blocker if K+>4.5 mmol/L
How many stages of hypertension are there?
3.
stage 1: 140/90 mmHg
stage 2: 160/100 mmHg
stage 3: 180/120 mmHg
Which test would you do to assess CV disease risk?
Qrisk3.
What does Qrisk3 predict?
Risk of having a heart attack or stroke in next 10 years
Which extra conditions/medications does Qrisk3 ask for compared to Qrisk2?
- Erectile dysfunction
- Migraine
- Severe mental illness
- Anti-psychotic medication
- Steroids
Which non-modifiable factors does Qrisk 3 ask for?
- Age
- Sex
- Ethnicity
- UK postcode
Which conditions do both Qrisk2 and Qrisk 3 ask about?
- Smoking status
- Diabetes
- Angina or heart attack in 1st degree relative <60
- CKD
- AF
- Hypertension
- RA
- BMI
- Cholesterol/HDL ratio
What is the target BP for someone with hypertension <80 years old?
<135/85 mmHg
What is the target BP for someone with hypertension >80 years old?
<145/85 mmHg
Name an ACE inhibitor
Ramipril
Name an ARB
Losartan
Name a CCB
Amlodipine
Name a thiazide diuretic
Indapamide
Name an alpha blocker
Doxazosin
Name a beta blocker
Atenolol
Name symptoms and signs of malignant hypertension
- Retinal haemorrhage
- Papilloedema
- New onset confusion, chest pain
- Signs of AKI
What are the risk factors for atherosclerosis?
- Age
- Smoking
- High serum cholesterol
- Obesity
- Diabetes
- Hypertension
- FH
Which coronary arteries are most likely to develop atherosclerosis?
- Circumflex
- Left anterior descending
- Right coronary
Which cells in the artery are damaged due to plaques?
Endothelial cells
What can atherosclerosis lead to?
- Coronary artery disease
1. Angina
2. MI
3. HF
Which drugs can be used to treat atherosclerosis?
- Statins - inhibits enzymes which make cholesterol
- Clopidogrel - inhibits P2Y12 ADP receptor on platelets
- Aspirin - irreversible inhibitor of platelet cyclo-oxygenase
- Canakinumab injections - inhibit IL-1
Which surgery can be done to treat atherosclerosis?
Stent made out of steel and cobalt chromium
Which conditions does acute coronary syndrome consist of?
- STEMI
- NSTEMI
- Unstable angina
Which chemical is released when myocardial cells die?
Troponin
What are the features of a STEMI on an ECG?
- ST elevation
- New LBBB
- Pathological Q wave
What does a Q wave represent?
Septal depolarisation . This shows on the ECG due to it not being masked by ventricular wall depolarisation, due to the ventricular wall being dead - i.e. from an MI
Which conditions cause a raised troponin?
- MI
- Aortic dissection
- Hypertrophic cardiomyopathy
- Severe anaemia
- Heart failure
- Sepsis
- Stroke
- Renal failure
- Subarachnoid haemorrhage
Name the 2 main types of MI
- Spontaneous - due to plaque rupturing/occlusion of artery
- Secondary to ischaemia
Other types include those instigated by stents and bypass
Name the clinical features of ACS
- Chest pain, radiating to arms, back or jaw
- Pain >15 minutes
- Nausea + vomiting
- Sweating
- Breathlessness
What is the initial management of an MI?
- 12 lead ECG
- Morphine
- Oxygen
- Glyceryl trinitrate
- Aspirin 300mg
- Rapid acting antiplatelet e.g. Ticagrelor
What is ST elevation a sign of in the artery?
Complete occlusion of epicardial coronary artery
What is the gold standard treatment for a STEMI?
PCI: primary percutaneous intervention UP TO 12 hours after onset of pain
(thrombolysis is no longer first line due to significant bleeding risks)
What is a NSTEMI a sign of in the artery?
Partial coronary occlusion
What are the features of a NSTEMI on an ECG?
- ST depression
- T wave inversion
- No Q wave
Which test can be done to distinguish between a NSTEMI and unstable angina?
Troponin - a rise indicates NSTEMI
Which troponins are most specific to the heart?
I and T
Which drugs are given in the management of a NSTEMI?
- Beta blocker
- ACE inhibitor
- Atorvastatin 80mg OD
The same treatment is given for unstable angina.
Which score is used to predict mortality after a NSTEMI?
GRACE score
Which surgical treatment is used for high risk or young NSTEMI patients?
Coronary angiography, with subsequent PCI if required
Which drugs are given in the management of an MI?
- Dual antiplatelet therapy for 1 year, usually aspirin + clopidogrel
- Anticoagulate to inhibit fibrin formation e.g, fondaparinux
- Beta blocker
- ACE inhibitor
- Atorvastatin 80mg OD
Which lifestyle changes would you suggest after an MI?
- Stop smoking
- Treat diabetes, hypertension, hyperlipidaemia
- Healthy, low fat diet
- Daily exercise
Unstable angina is ACS without a rise in troponin. What are its features?
- Angina >20 mins at rest
- New onset of severe angina
- Angina that occurs after recent MI
What are the differentials of an MI?
- Myocarditis
- Pericarditis
- PE
- Aortic dissection
- Arrhythmias
- Sepsis
- Cardiotoxic agents
- Pneumothorax
- Pneumonia
- Reflux
When does troponin rise after an NSTEMI?
2-3 hours after onset of chest pain
What are the complications of a MI?
- Heart failure
- Arrhythmias - BBB, sinus brady/tachy, heart block, AF, VF
- Pericarditis
- Depression
- Cardiac tamponade
- Mitral regurgitation
What is the definition of angina?
Symptomatic reversible myocardial ischaemia
What causes angina?
Atherosclerosis leading to restricted coronary blood flow
What are the clinical features of angina?
-Heavy/constricting pain in chest, jaw, shoulders or arms
-Symptoms brought on by exertion and relieved by rest or GTN
Typical angina = all 3 features
Atypical angina = 2 features
Name the 5 types of angina.
- Stable
- Unstable - occurs on minimal exertion, increasing severity
- Decubitus - happens when lying flat
- Prinzmetal - caused by coronary artery spasm
- Microvascular - syndrome X
Name the supply related precipitant factors of angina.
- Anaemia
- Hypoxaemia
- Polycythaemia
- Hypothermia
- Hypovolaemia
Name the demand related precipitant factors of angina.
- Emotional stress
- Hypertension
- Hyperthyroidism
- Tachyarrhythmia
- Hypertrophic cardiomyopathy
- Cold weather
- Heavy meals
Which Ix’s would you do to diagnose angina?
- Exercise stress treadmill test - look for ST depression
- Stress echo
- 12 lead ECG, ST depression, inverted T wave
- SPECT
Which drugs are given to treat angina?
- Aspirin 75mg OD
- Statin
- Beta blocker - contraindicated in Prinzmetal angina
- GTN spray
- CCB
What are the side effects of beta blockers?
- bradycardia
- erectile dysfunction
- cold hands and feet
- fatigue
Beta blockers are -ve chronotropes and -ve inotropes. What does ths mean?
- ve chronotrope = reduces HR
- ve inotrope = reduces contractility
How does GTN work?
Dilates systemic veins to reduce preload on heart.
How do CCBs work?
Dilates systemic arteries to lower BP and afterload on heart.
What is the surgical management of angina (high risk or when medication fails)?
- PCI
2. CABG
What are the pros and cons of PCI?
Pros:
- Less invasive
- Repeatable
Cons:
- Risk of stent thrombosis
- Risk of re-stenosis
- Requires dual antiplatelet therapy
What are the pros and cons of CABG?
Pros:
-Deals with complex disease
Cons:
- Invasive
- Risk of stroke and bleeding
- Cannot be done on frail patients
- Long procedure
- Need time for recovery
What is the infarct site when there is ST elevation V1-V3?
Anterior
What is the sign on an ECG of an inferior infarct?
ST elevation II, III, AVF
What is the infarct site when there is ST depression V1-V3, Dominant R wave and ST elevation V5-6?
Posterior
What is the sign on an ECG of a lateral infarct?
I, AVL, V5-V6
What is chronic heart failure?
Reduced cardiac output due to impaired cardiac contraction
How do you calculate cardiac output?
Heart rate x Stroke volume
Name factors which reduce cardiac output
- lower HR
- lower preload
- lower contractility
- higher afterload
Name the cardiac causes of heart failure
- MI
- AF
- Valve disease
- Hypertension
- Cardiomyopathy
Name the non cardiac causes of heart failure
- Hypo and hyperthyroidism
- Diabetes
- Cushing’s
- Sepsis
- RA
- SLE
- Renal failure
- Nephrotic syndrome
- Hepatic failure
Which medications can cause heart failure?
- Beta blockers
- Anti-arrhythmics
- Calcium antagonist
What are the clinical features of heart failure?
- Dyspnoea on exertion
- Fatigue
- Orthopnoea - sleeps with several pillows
- Paroxysmal nocturnal dyspnoea
- Nocturnal cough
- Pre-syncope
Which social risk factors are associated with heart failure?
- Smoking
- Excess alcohol
- Recreational drug use
What the signs of heart failure you might find on examination?
- Tachycardia at rest
- Hypotension
- Narrow pulse pressure
- Raised JVP
- Displaced apex beat
- Right ventricular heave
- Gallop rhythm
- Murmurs
- Pedal and ankle oedema
- Tachypnoea
- Stony dullness on percussion (pleural effusion)
- Bibasal end-inspiratory crackles and wheeze
- Hepatomegaly
- Ascites
What are the ECG findings of heart failure?
- Tachycardia
- AF
- Left axis deviation due to hypertrophy
- P wave abnormalities
- Prolonged PR interval (AV block)
- Wide QRS complex
What blood tests are included in a cardiomyopathy screen?
- Serum iron and copper to rule out haemochromatosis and Wilson’s
- Rheumatoid factor
- ANCA/ANA
- Serum ACE to rule out sarcoidosis
- Serum free light chains to rule out amyloidosis
Which blood test is gold standard for heart failure?
Serum NT-proBNP
What is the threshold value of NT-proBNP which suggests heart failure?
> 400 ng/L
Which other conditions present with raised NT-proBNP?
- Left ventricular hypertrophy
- Tachycardia
- Liver cirrhosis
- Diabetes
- Renal disease
Which echo is needed to diagnose heart failure?
Transthoracic
What are the CXR signs of congestive heart failure?
A -alveolar oedema (bat wings) B - kerley B lines (interstitial oedema) C - cardiomegaly D - dilated upper lobe vessels E - effusion (blunted costophrenic angle)
Name the classification system for heart failure
New York Heart Association classification system
Class I: no symptoms during ordinary physical activity
Class II: slight limitation of physical activity by symptoms
Class III: less than ordinary activity leads to symptoms
Class IV: inability to carry out any activity without symptoms
What is the ejection fraction in systolic HF?
EF < 40%
What is the ejection fraction in diastolic HF?
EF >40%
Name conditions which cause high output heart failure
- Anaemia
- Pregnancy
- Hyperthyroidism
What are the complications of heart failure?
- Renal dysfunction
- Rhythm disturbance
- Systemic thromboembolism
- DVT
- LBBB
- Hepatic dysfunction
- Depression
What is ejection fraction?
% of blood ejected out of LV with each beat (should be 70%)
What lifestyle management is advised for heart failure?
- Fluid and salt restriction
- Regular exercise
- Smoking cessation
- Reduced alcohol intake
Which medications can worsen heart failure?
- CCB
- Tricyclic antidepressants
- Lithium
- NSAIDs
- Corticosteroids
Which medications are prescribed to treat heart failure?
- Diuretics - relieve symptoms of fluid overload
- ACE inhibitors (measure U&E to check hyperkalaemia)
- Beta blockers
- ARB if cannot tolerate ACEi
Which medications are prescribed for resistant heart failure?
- Spironalactone
- Ivabradine
Which surgical treatments can be used for heart failiure?
- CABG
- Valve surgery
- ICD
- Heart transplant
What is AF?
Chaotic irregular rhythm 300-600 bpm
What are the causes of AF?
- Post surgery
- Heart failure
- Hypertension
- Mitral valve disease
- Pneumonia
- Hyperthyroidism
- Caffeine and alcohol
- Hypokalaemia
What are the triggers of AF?
- PE
- Ischaemia
- Thyroid disease
- Alcohol
- Sepsis
- Sleep apnoea
What are the symptoms of AF?
- Asymptomatic
- Chest pain
- Palpitations
- Dyspnoea
- Dizziness
- Collapse
What are the signs of AF?
- Irregularly irregular pulse
- Tachycardia
How will an ECG present in AF?
- Absent P wave
- Irregular, narrow QRS complex
Which other Ixs (other than ECG) can you do for AF?
- CXR
- Echo
- Bloods: U&E, thyroid function, FBC
How would you manage acute AF?
- ABCDE
- Cardioversion
- Amiodarone to control rhythm
- Beta blocker to control HR
- Heparin
- Correct electrolyte imbalance
- Treat precipitating factors
- Fluids
How would you manage chronic AF?
- Beta blocker or CCB
- Flecainide to control rhythm
- Warfarin (anticoagulation to prevent stroke from emboli)
Which score calculates risk of stroke?
CHA2DS2-VASc
Which score calculates risk of bleeding?
HAS-BLED
What term is given to AF when the episodes are intermittent and stop within 48 hours?
Paroxysmal AF
What are the risk factors of developing chronic AF from paroxysmal AF?
- Age
- Hypertension
- Obesity
