Cardiovascular Flashcards

1
Q

BP Goals: ABMP 24h monitor

A

<130/80

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2
Q

BP Goals: ambulatory mean wake

A

<135/85

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3
Q

BP Goals: HBPM

A

<135/85

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4
Q

BP Goals: AOBP

A

<135/85

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5
Q

BP Goals: Non-AOBP / OBPM

A

<140/90

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6
Q

HTN emergency

A

HTN encephalopathy
Acute aortic dissection
Acute LVF
ACS
AKI
ICH
CVS
Pre-eclampsia

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7
Q

Secondary cause BP risks: Fibromuscular dysplasia

A

Resistant >/ 3 meds
>1.5cm renal asymmetry
Abdo bruits w/o artherosclerosis
FMD other vascular area
Fam hx

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8
Q

Secondary cause BP risks: Renovascular

A

Sudden onset / worsening <30 or >55 y/o
Abdo bruit
Resistant >/ 3 meds
Increased Cr >/ 30% on ACEi/ARB
Arterosclerosis
Pul edema with increased BP

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9
Q

Secondary cause BP risks: Hyperaldosteronism

A

K+ </3.5 or <3 if not diuretic
Resistant to >/ 3 meds
Incidental adrenal adenoma

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10
Q

Secondary cause BP risks: Pheochromocytoma

A

Paroxysmal/ severe BP >/ 180/110
Refractory to meds
Catecholamine excess - H/A, sweating, palpitations, panic attacks, pallor, HTN triggered by b-blocker and MAOI
Incidental adrenal mass

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11
Q

Fibromuscular dysplasia- ix

A

MRA and CTA - if + screen cervicocephalic intracranial aneurysm

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12
Q

Renovascular - ix/tx

A

Ix:
Captopril-enhanced radioisotope renal scan -egfr >60
Doppler
CT-angio
MRA - egfr >30
Tx:
Stent/angioplasty if uncontrolled hen, acute pul edema, decreased cr

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13
Q

Hyperaldosteronism - ix

A

Plasma aldosterone and plasma renin

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14
Q

Pheochromocytoma - ix

A

MRI
24h urine total metanephrine
+urinary metanephrine:Cr ratio

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15
Q

BP goal for diabetes or renal transplant

A

<130/80

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16
Q

How often to screen for HTN

A

If >40 or risk factors yearly
If 18-39 every 3-5 years

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17
Q

ACEi / ARB contraindications and interactions

A

bilateral renal artery stenosis
angiodema
pregnancy

K sparing diuretic
Lithium

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18
Q

BB contraindications and interactions

A

asthma
2nd/3rd degree HB
uncompensated HF
severe PAD

CCB
Antidiabetic

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19
Q

CCB contraindications and interactions

A

recent mi with pul ede
sick sinus syndrome
2nd/3rd degree HB

BB
Grape fruit juice

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20
Q

Thiazide contraindications

A

Gout

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21
Q

ACEi / ARB side effects

A

cough
angioedema
acute renal failure

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22
Q

BB side effects

A

ed
bronchospasm
insomnia
decreased exercise tolerance

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23
Q

CCB side effects

A

edema
flushing
dyspnea/pul edem in LVD

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24
Q

Thiazide side effects

A

renal failure
hypokalaemia

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25
1st choice anti-HTN in CAD
acei/arb
26
1st choice anti-HTN in stable angina no chf/mi
beta blocker
27
1st choice anti-HTN in recent mi
betablocker + acei (Arb)
28
1st choice anti-HTN in hfref
betablocker + acei (Arb)
29
1st choice anti-HTN in LVD
acei
30
1st choice anti-HTN in afib
acei (arb)
31
1st choice anti-HTN in cerebrovascular disease
acei + thiazide
32
1st choice anti-HTN in CKD
acei
33
1st choice anti-HTN in renal transplant
d-ccb or arb
34
1st choice anti-HTN in diabetes
acei
35
Number to decrease BP if over - in embolic stroke
>220/120
36
Number to decrease BP if over - in hemorrhagic stroke
>180/100
37
Causes of induced hypertension
P - pheochromocytoma, polycythemia, pre and ecamplsia R - renovascular E - endocrine: hypertsh, cushing, aldosteronism S - substance: estrogen, caffeine, decongestants, cocacine, sympathemometics, etoh S - structural - coarctation, arteriosclerosis U - upper motor neuron problem - elevated icp R - renoparenchymal - glomerulonephritis, dm nephropathy E - essential, error in cuff size
38
HTN physical exam and what you're looking for
Vitals - bmi, bp, hr Fundoscopy - arteriolar changes Neck exam - carotid bruits, thyroid Cardiopulmonary - chf/lvf, intrascapular murmur Abdo - palpable kidneys, renal bruit Neuro - stroke Pulse/legs - PVD, edema
39
Initial HTN investigations
Urinalysis Lytes Cr FBG/A1C Choestrol ECG Urinary albumin - if diabetic Echo - if suspected CAD or LVD bHCG if indicated
40
When to bring MAP down 20-25% in HTN emergency and tx
encephalopathy - iv labetolol pul ede - iv enalapril or nitro infusion
41
Goal bp and tx in aortic dissection if no hypo perfusion
Systolic BP < 110 Tx: Nitropresside Esmolol infusion Labetolol infusion
42
Who to screen for dyslipidemia
Men and women >/ 40 or postmenopausal Any age if: Fam hx Arterosclerosis AAA DM HTN Smoking Clinical signs: corneal arcus, xanthelasma, xanthoma Fam hx premature CVD CKD Diabetes Inflammatory diseases HIV ED COPD Hx of HTN in pregnancy
43
Statin indicated conditions
Diabetes >40 y/o, >30 y/o for 15 years, microvascular disease. CKD age >50 and eGFR <60 or ACR>3. Atheroscelrotic cardiovascular disease. AAA.
44
Cholestrol levels and risk to start statin with treatment target
Low Risk (FRS <10%) Treatment advised if LDL-C >=5.00 mmol/L Treatment target: >50% reduction LDL-C Intermediate Risk (FRS 10-19%) Treatment advised if LDL-C >=3.50 mmol/L OR Non-HDL-C >=4.30 mmol/L OR ApoB >=1.20 g/L. Consider treatment for men >=50 and women >=60 yrs with one additional CV risk factor. Treatment targets: LDL-C <2.00 mmol/L OR decrease by >50% OR Non-HDL-C <2.60 mmol/L OR ApoB <0.8 g/L High Risk (FRS >=20% or presence of high risk features) Treatment advised in all patients Treatment targets: LDL-C <2.00 mmol/L OR decrease by >50% OR Non-HDL-C <2.60 mmol/L OR ApoB <0.8 g/L
45
VF / pulseness VT meds
After 1st shock - Epinephrine 1mg q3-5mins - increased myocardial and cerebral flow After 2nd shock - Amiodarone 300mg x 1 then 150mg x1 OR lidocaine 1-1.5mg/kg x 1 then 0.5-0.75mg/kg x 1 afterwards
46
Asystole/PEA meds
Epinephrine 1mg q3-5 mins
47
Bradycardia meds
If symptomatic then atropine 0.5mg IV q3-5 min (max 3mg) but should not delay pacing. Can also consider dopamine, epinephrine or transcutaneous pacing.
48
Tachycardia meds
Symptomatic - cardiovert with sedation if you can Narrow complex - vasovagal, adenosine 6mg IV push wait 2 min then repeat 12mg, consider CCB or b-blocker. Wide complex - consider precordial thump, amidarone.
49
Reversal causes cardiac arrest
Hydrogen ion excess Hyper/hypokalaemia Hypovolemia Hypothermia Tension pneumothorax Tamponade Thrombsis Toxins
50
Things that mean unstable in tacky/bradycardia
Hypotension Altered mental status Signs of shock Chest discomfort Acute HF
51
When do to elective cardioversion in AF and what to do prior
Valvular AF or NVAF <12h and CVA <6 months or NVAF 12-48h and CHADS >/2 oe NVAF >48h OAC >/ 3 weeks TEE to exclude thrombus Following you give oca for 4 weeks then based on CHADS-65
52
What is the CHADS2 score
Anticoag in AF score: Congestive heart failure - 1 Hypertension - 1 Age >75 - 1 Diabetes - 1 Stroke or TIA - 2
53
When to do urgent cardio version and treatment after
Hemodynamically unstable acute AF or NVAF <12h and no recent CVA or NVAF 12-48h and CHADS2 0-1 Give OAC ASAP Following you give oca for 4 weeks then based on CHADS-65
54
Rhythm control AF
Amiodarone - cannot use if AV condition, liver dx or QT prolongation Sotalol - cannot use HF, risk QTp Dronedarone - cannot use HF, permanent AF Flecanide/Propafenone - cannot use 2rd/3rd AV block, HF, LVH, CAD, severe hepatic or renal failure
55
Rate control AF
Betablocker - avoid in asthma, COPD, bradycardia, 2/3rd degree HB ND-CCB - avoid LVEF <40% Add Digoxin If difficult then consider rhythm control or pacemaker / ablation
56
What is CHADS-65 score
Score for paroxysmal or persistent af/flutter: Age >/65 - YES - OAC CHADS2 >/1 - YES - OAC CAD or PAD - YES - ASA +/- clopidogrel or rivaroxaban If no to all then no antithrombotic
57
What is the HASBLED score
1 point for each HTN (SBP >160) Abnormal LFTS/CR >200 Stoke Bleeding/anaemia Labile INR Elderly >65 Druhs or alcohol (aspirin/plavix)
58
When to start DOAC after CVA
TIA - day 1 NIHSS <8 - day 3 NIHSS 8-15 - day 8 NIHSS >15 - day 12 to 14
59
Precipitating factors of heart failure
Forgetting meds / meds that worsen - BB, CBC, NAID, TZD, chemo toxins Arrhythmia/anemia - afib and anaemia Ischemia/infection - CAD, pneumonia, myocarditis, influenza Lifestyle - increased salt, alcohol, fluid intake Upregulation - pregnancy, hyperTSH, steroids Renal failure - increased preload, CKD Embolism - increased right sided afterload, PE Stenosis - worsening AS, RAS
60
Heart failure meds: BB
Double q2-4 week Best started dry Specialist initiates NYHA >/ III
61
Heart failure meds: ACEi
Double q1-2 week Best started wet Continue if Cr increased less than 30%
62
Heart failure meds: Digoxin
Monitor Cr, K
63
Typical regime for HFrEF
BB+MRA+SGLT2i+ARNI (or ACEi/ARB)
64
Additional HFrEF if HR >70 and sinus
consider ivabradine
65
Additional HFrEF if recent hospitalisation for HF
consider vericiguat
66
Additional HFrEF if black on optimal therapy or intolerant ARNI/ACEi/AR B
consider hydralazine/nitrates
67
Additional HFrEF if suboptimal AF control or persistent symptoms
consider digoxin
68
Typical regime for HFpEF
Control HTN ACEi/ARB +/- BB MRA is K <5 + eGFR >30
69
Follow up times for HF
Acute change - 1 to 2 days Med change and unstable - 7 days Med change and stable - 2 weeks Stable and optimised - 3 to 6 months
70
Classification of ACS - STEMI
Elevation of ST >/ 1mm in 2 consectutive leads of >/ 2mm in V2+V3, can also have Q waves
71
Classification of ACS - NSTEMI
no ST elevation no Q waves + trop
72
Classification of ACS - unstable angina
myocardial damage, no ECG or blood work changes
73
Murmur that may be heard in ACS
S3 gallop mitral regurgitation
74
ACS complications
Cardiac Rupture Arrhythmia Shock Hypertension / heart failure Pericarditis / pulmonary rales Aneurysm DVT
75
Work up for stable chest pain and what to look for
- ECG - Look for ST, new LBBB, new Q wave - Labs - CBC (anemia), INR, lipids, FBG/A1C, LFTs, Cr, lytes - CXR - CHF, cardiomegaly, pneumonia, pneumothorax - Stress test - Echo - Angio - if high risk, diagnosis unclear and positive stress test
76
What is the TIMI score for NSTE-ACS score (thombolysis in mi)
Age >/65 Markers elevated ECG - st depression Risk factors >/3 - increased lipids, htn, t2dm, smoker, fam hx, obesity Ischemic chest pain >/2 episodes in past 24h Coronary stenosis - hx >/ 50% Aspirin - usage in last 7 days 1 point each risk of cardiac event in 14 days: /6 = 19%
77
What is the HEART score
Risk cardiac event in 4-6 weeks: 0 - 1 - 2 History: slightly suspicious - moderate - highly ECG: normal - nonspecific repoloarization - st dep Age: <45 - 46-64 - >65 Risk factors: none - 1 to 2 - >3 Troponin: normal - 1 to 3 x normal limit - >/3 7: high - 50%
78
First line (and alt) medications for ischemic heart disease
- Nitro PRN - BB - target HR<70 (long acting ccb if bb CI - PR >0.24, 2nd/3rd HB, asthma, reactive airway) - Statin - ASA (Clopidogrel is ASA CI)
79
Other medications to consider in ischemic heart disease and when
- ACEi - LVEF <40, HTN, DM, CKD, ant STEMI (ARB if CI) - Ticagrelor (Clopidogrel) if any: - NSTE-ACS - Fibrinolysis - Stent - Elective PCI - Afib and elecrive PCI
80
Acute management ACS chest pain
Morphine 3-5mg after maxing anti-ischemia meds Oxygen if sat <90 ASA 160-325mg or clopidogrel 300mg if CI Nitro 1-2 speay q5minx3
81
Other causes of increased trop
HF malignancy pericarditis PE renal failure sepsis stroke SAH
82
Which leads of ECG represent which part of the heart
Septal: V1, V2 Anterior: V3, V4 Lateral: V5, V6 Inferior: II, III, aVF High lateral: I, aVL Posterior: tall R wave and ST depression V1, V2
83
Acute meds for ACS
- ASA 162-325mg chewed x1 then continue 81-325mg indefinitely - Ticagrelor 180mg x1 then 90mg BID usually for 1 year - Anticoagulant continue for atleast 48h or until PCI performed - Betablocker initiate within 24h if no HF/ low output, risk of cardiogenic shock or CI. - ACEi initiate in 24h if LVEF <40%, HTN, DM, CKD, ant stemi
84
Conservative vs invavsive management in NSTE-ACS
Immediate invasive <2h: refractory angina, s+s HF, hemodynamic instability, recurrent angina/ischaemic at rest, sustained VT/VF Conservative/ischemia guided: TIMI /2
85
STEMI management
If symptoms <12h - 24H consider PCI or fibrinolytic 1. PCI - goal for contact <120min - ASA, P2Y12 inhibitor, anticoag 2. Fibrinolytic: Give ASA, clopidogrel anticoagulant - Absolute CI: ICH, cerebral lesion, malig, head/facial trauma <3m, ishcemic stroke <3m, active bleed, aortic dissection, intracranial/intraspinal surg <2m, severe uncontrolled HTN - Relative CI: hx poorly controlled HTN, current BP >180/110, current OAC, ischemic stroke >3m, recent internal bleed <4wk, major sx <3wk, pregnancy, active peptic ulcer, dementia 3. CABG (urgent): if ongoing ischemia, cardiogenic shock, severe HF and not candidate for PCI or fibrinolytic. Rx ASA, discontinue P2Y12 atleast 24h, prefer 5 days 3. Conservative - ASA, PsY12, anticoag, BB, statin, consider ACEi
86
Causes of pericarditis
Idiopathic Infectious Inflammatory Metabolic Cardiovascular Drugs Trauma Malignancy
87
Signs of cardiac tamponade
Hypotension Pulsus paradoxical Tachycardia Elevated JVP
88
Pericarditis treatment
1. Anti-inflammatory 7-14d, then taper 1-2 weeks - Aspirin 650 q4h - Ibuprofen 400mg q6h 2. Corticosteroids for refractory 3. Colchicine 0.5mg BID with NSAID for recurrent
89
When is rhythm control preferred in AF
New diagnosis <1 year Highly symptomatic, significant QOL impairment Multiple reoccurrences Difficult to achieve rate control Arrhythmia induced cardiomyopathy