Cardiovascular Flashcards
Aortic stenosis - replacement strategies
1) Over 65
2) Under 65
3) Not fit enough for surgery - temporary measures & monitoring
In symptomatic patients that are fit enough for surgery:
Biprosthetic aortic valve replacement - offered to those > 65 yrs OR younger patients NOT wishing to take lifelong anticoagulation. Biprosthetic valves advantage of NOT requiring lifelong anticoagulation.
Mechanical aortic valve replacement is typically offered to YOUNGER patients ( under 65 with longer life expectancy therefore more at risk of degeneration of biprosthetic valve). Requires LIFELONG anticoagulation.
Balloon valvuloplasty - reserved for patient too high risk for surgical intervention now replaced by transcatheter methods.
Watch & wait - Annual ECHO, intervention when gradient > 75 mmHg. In ASYMPTOMATIC patients or unfit for surgery
Two most common valves needing replacement?
Outline adv/ disadvantages of two main options for valve replacement
1) mitral and aortic valves
Outline the stages of hypertension
Stage 1 HTN CLINIC 140/90 , ABPM 135/85
Stage 2 CLINIC >=160/100, ABPM >= 150/95
Stage 3. (SEVERE) CLINIC systolic > =180 OR diastolic >= 120
Thresholds for treatment of hypertension
Stage 1 HTN ( > 140/90/ 135/85) treated if:
- Evidence of target organ damage
-Established CV disease
-Renal disease
-Diabetes
- QRISK score > 10%
Stage 2 HTN ( > 160/11, 150/95) - Treat ALL patients, regardless of age
Lifestyle advice for HTN mx
1) low salt diet aiming less than 6g/ day ( ideally 3g/day)
2) Reduce caffeine intake
3) Smoking cessation
4) Reduce EtoH
5) Increase exercise & Weight loss
6) Healthy balanced diet
Patients diagnosed with essential HTN under 40 what should occur?
Referral to specialist to exclude secondary causes of HTN
Outline the stages of treatment for HTN
Step 1: Under 55 yrs OR T2DM 1st line ACEi/ ARB ( ARB if ACE i not tolerated e.g cough). Over 55 yrs OR black african/ african carribean patients 1st line CCB ( ACEi reduced efficacy in african origin).
Step 2: If already taking ACEi/ ARB then add CCB or thiazide like diuretic. If already on CCB then add ACEi/ARB or thiazide like diuretic.
*Note for black african patients taking a CCB consider an ARB as second line agent over ACEi. *
Step 3: Add 3rd drug e.g. ACEi + CCB then add Thiazide etc
Step 4: Resistant HTN - add 4th drug. 1st check for 1) confirm elevated BP in clinic or with ABPM 2) Assess for postural hypotension 3) Discuss drug adherence. Then add 4th based of K levels:
If K < 4.5 add low dose spironolactone
If K > 4.5 add alpha or beta blocker
If BP remains uncontrolled on 4 drugs then referral to specialist.
What are the BP targets in treating HTN
Under 80 yrs - aiming for clinic under 140/ 90and ABPM under 135 /85
Over 80 yrs - aiming under 150/90 and ABPM under 145 /85
ECG features of hypokalaemia
In hypokalaemia U have not Pot and no T but a long PR and long QT
U waves
Absent or small T waves
Long PR
Long QT
ST depression
Aortic dissection: 2 Classifications / Percentages of presentation
Stanford:
Type A - ascending aorta 2/3rds cases
Type B - descending aorta 1/3rd cases
DeBakey classification
Type 1 - originates in ascending aorta, involves at least the arch if not the whole aorta
Type 2 - isolated to ascending aorta
Type 3 a- originates descending aorta involving only section above diaphragm
Type 3b - originates in descending aorta involving section below diaphragm
Define aortic dissection
Tear forms in the inner layer of the aorta, blood enters between the intima and media layers of the aorta creating a false lumen. Most commonly affects ascending aorta and aortic arch. Right lateral ascending aorta most common as highest site of stress as blood exits the heart.
Risk factors for aortic dissection
Same RF as Peripheral arterial disease:
Age
Male
HTN
Smoking
Poor diet
Hypercholesterolaemia
Connective tissue diseases - Ehlers Danlos/ Marfans
Cocaine use / heavy weight lifting
Cardiac surgery - Aortic valve replacement, CABG
Cardiac malformation - Bicuspid aortic valve, coarctation of aorta
Presentation of aortic dissection
Sudden onset severe “ ripping/ tearing” chest pain
Radiates to back
May be in anterior chest when ascending is affected, or in back if descending is affected. Pain may migrate.
Other features:
HTN
Difference in BP between the arms ( more than 20 mmHg is significant)
Radial pulse deficit ( radial pulse in one arm decreased/absent/ does not match apex beat)
Diastolic murmur
Focal neurological deficit - Limb weakness or paraesthesia
Chest AND abdominal pain
Collapse
Hypotension as dissection progresses
Diagnosis/ investigations of aortic dissection
ECG and CXR - common initial investigations to rule out MI ( although acute MI can occur in conjunction with aortic dissection, treatment of which can lead to progression of aortic dissection).
CXR - widened mediastinum
CT angiography of the chest abdomen and pelvis is IX of choice. Suitable for STABLE patients, false lumen key finding.
TOE - Suitable for unstable patients too risky to take to CT scanner.
Management of aortic dissection
Type A - surgical management but BP should be controlled to target systolic 100-120 whilst awaiting intervention. Midline sternotomy to remove defect in aortic wall and replace with synthetic graft.
Type B - conservative management, bed rest, reduced BP with IV labetalol to prevent progression. Endovascular has more of a role to play now - TEVAR. (Thoracic endovascular repair).
Complications of aortic dissection
1) MI ( normally inferior)
2) Aortic valve incompetence/regurgitation & risk of tamponade
3) Stroke
4) Paraplegia - motor or sensory impairment in legs
5) Renal failure
6) Death
Diagnosis of HTN: Steps as a GP to take
Offer ABPM / HBPM to any patient with BP > 140/90. NICE recommend taking second reading and using lowest of second reading to determine management. Measure BP in both arms, recording should be made from arm with higher reading.
If BP > 180 / 120 –> admit for specialist ax if signs of retinal haemorrhage/ papilloedema, new onset confusion, chest pain, signs of HF, AKI.
Referral if any evidence of phaeochromocytoma - labile or postural hypotension, headache, palpitations, pallor, sweating.
If none of the above arrange for urgent investigations for end organ damage - ECG, Bloods, Urine ACR. If target organ damage identified then consider starting antihypertensive treatment immediately without waiting for ABPM.
Management of Angina pectoris (Stable angina)
1) all patients should receive aspirin and statin ( in abscence of contraindications)
2) Sublingual GTN to abort angina attacks
3) Beta blocker or CCV 1st line
4 )If CCB 1st line then rate limiting e.g. verapamil or diltiazem should be used
5) If used in combo with BB then longer acting such as amlodipine or MR nifedipine should be used
6 ) remember NO verapamil with BB - risk of heart block and HF
7) If poor response to first medication then increase to max tolerated dose
8) If patient still symptomatic after monotherapy then add other drug
9) if patient on monotherapy but cannot tolerate CCB/BB then consider one of:
- long acting nitrate
- ivabradine
- nicorandil
-Ranolazine
Anticoagulant treatment post ischaemic stroke
Aspirin 300 mg daily for 2 weeks immediately following by Clopidogrel 75 mg lifelong ( if tolerated and not contraindicated)
clinical features of symptomatic aortic stenosis
SAD
Syncope, angina, dyspnoea on exertion
Murmur - Ejection systolic murmur, classically radiates to the carotids, decreased after valsalva manouvre, loudest R 2nd IC space, crescendo - decrescendo
Other features of severe aortic stenosis:
Narrow pulse pressure
Slow rising pulse
Delayed ESM
Soft/ absent S2
S4
Thrill
LV hypertrophy/ L sided HF
Causes of aortic stenosis
Degenerative - calcification most common cause in older patients
Bicuspid aortic valve - commonest cause in younger patients
Post rheumatic disease
Subvalvular HOCM
Management of aortic stenosis
If asymptomatic generally observation as general rule.
Symptomatic then valve replacement. If asymptomatic but valvular gradient > 40 mmHg / LVSF then consider surgery. Surgical options:
AVR choice for young , low-medium risk operative patients. CV disease can coexist therefore angiogram often done prior to surgery so procedures can be combined.
Transcatheter AVR ( TAVR) is used for patients with high operative risk
Balloon valvuloplasty - may be used in children with no aortic valve calcification or in adults with critical aortic stenosis but not fit enough for valve replacement.
SE of ACEi
Cough - due to increased bradykinin levels
Angioedema - can occur up to a year after starting tx
Hyperkalaemia
1st dose hypotension ( more common if taking diuretics)
Cautions of ACEi / Contraindications
Pregnancy and breastfeeding - avoid
renovascular disease - may result in renal impairment
aortic stenosis - can result in hypotension
specialist advice if K > 5.5
