Cardiovascular Flashcards
BP Goals: ABMP 24h monitor
<130/80
BP Goals: ambulatory mean wake
<135/85
BP Goals: HBPM
<135/85
BP Goals: AOBP
<135/85
BP Goals: Non-AOBP / OBPM
<140/90
HTN emergency
HTN encephalopathy
Acute aortic dissection
Acute LVF
ACS
AKI
ICH
CVS
Pre-eclampsia
Secondary cause BP risks: Fibromuscular dysplasia
Resistant >/ 3 meds
>1.5cm renal asymmetry
Abdo bruits w/o artherosclerosis
FMD other vascular area
Fam hx
Secondary cause BP risks: Renovascular
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
Secondary cause BP risks: Hyperaldosteronism
K+ </3.5 or <3 if not diuretic
Resistant to >/ 3 meds
Incidental adrenal adenoma
Secondary cause BP risks: Pheochromocytoma
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
Fibromuscular dysplasia- ix
MRA and CTA - if + screen cervicocephalic intracranial aneurysm
Renovascular - ix/tx
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
Hyperaldosteronism - ix
Plasma aldosterone and plasma renin
Pheochromocytoma - ix
MRI
24h urine total metanephrine
+urinary metanephrine:Cr ratio
BP goal for diabetes or renal transplant
<130/80
How often to screen for HTN
If >40 or risk factors yearly
If 18-39 every 3-5 years
ACEi / ARB contraindications and interactions
bilateral renal artery stenosis
angiodema
pregnancy
K sparing diuretic
Lithium
BB contraindications and interactions
asthma
2nd/3rd degree HB
uncompensated HF
severe PAD
CCB
Antidiabetic
CCB contraindications and interactions
recent mi with pul ede
sick sinus syndrome
2nd/3rd degree HB
BB
Grape fruit juice
Thiazide contraindications
Gout
ACEi / ARB side effects
cough
angioedema
acute renal failure
BB side effects
ed
bronchospasm
insomnia
decreased exercise tolerance
CCB side effects
edema
flushing
dyspnea/pul edem in LVD
Thiazide side effects
renal failure
hypokalaemia
1st choice anti-HTN in CAD
acei/arb
1st choice anti-HTN in stable angina no chf/mi
beta blocker
1st choice anti-HTN in recent mi
betablocker + acei (Arb)
1st choice anti-HTN in hfref
betablocker + acei (Arb)
1st choice anti-HTN in LVD
acei
1st choice anti-HTN in afib
acei (arb)
1st choice anti-HTN in cerebrovascular disease
acei + thiazide
1st choice anti-HTN in CKD
acei
1st choice anti-HTN in renal transplant
d-ccb or arb
1st choice anti-HTN in diabetes
acei
Number to decrease BP if over - in embolic stroke
> 220/120
Number to decrease BP if over - in hemorrhagic stroke
> 180/100
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
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
Initial HTN investigations
Urinalysis
Lytes
Cr
FBG/A1C
Choestrol
ECG
Urinary albumin - if diabetic
Echo - if suspected CAD or LVD
bHCG if indicated
When to bring MAP down 20-25% in HTN emergency and tx
encephalopathy - iv labetolol
pul ede - iv enalapril or nitro infusion
Goal bp and tx in aortic dissection if no hypo perfusion
Systolic BP < 110
Tx:
Nitropresside
Esmolol infusion
Labetolol infusion
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
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.
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
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
Asystole/PEA meds
Epinephrine 1mg q3-5 mins
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.
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.
Reversal causes cardiac arrest
Hydrogen ion excess
Hyper/hypokalaemia
Hypovolemia
Hypothermia
Tension pneumothorax
Tamponade
Thrombsis
Toxins
Things that mean unstable in tacky/bradycardia
Hypotension
Altered mental status
Signs of shock
Chest discomfort
Acute HF
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
What is the CHADS2 score
Anticoag in AF score:
Congestive heart failure - 1
Hypertension - 1
Age >75 - 1
Diabetes - 1
Stroke or TIA - 2
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
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
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
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
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)
When to start DOAC after CVA
TIA - day 1
NIHSS <8 - day 3
NIHSS 8-15 - day 8
NIHSS >15 - day 12 to 14
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
Heart failure meds: BB
Double q2-4 week
Best started dry
Specialist initiates NYHA >/ III
Heart failure meds: ACEi
Double q1-2 week
Best started wet
Continue if Cr increased less than 30%
Heart failure meds: Digoxin
Monitor Cr, K
Typical regime for HFrEF
BB+MRA+SGLT2i+ARNI (or ACEi/ARB)
Additional HFrEF if HR >70 and sinus
consider ivabradine
Additional HFrEF if recent hospitalisation for HF
consider vericiguat
Additional HFrEF if black on optimal therapy or intolerant ARNI/ACEi/AR
B
consider hydralazine/nitrates
Additional HFrEF if suboptimal AF control or persistent symptoms
consider digoxin
Typical regime for HFpEF
Control HTN
ACEi/ARB +/- BB
MRA is K <5 + eGFR >30
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
Classification of ACS - STEMI
Elevation of ST >/ 1mm in 2 consectutive leads of >/ 2mm in V2+V3, can also have Q waves
Classification of ACS - NSTEMI
no ST elevation
no Q waves
+ trop
Classification of ACS - unstable angina
myocardial damage, no ECG or blood work changes
Murmur that may be heard in ACS
S3 gallop
mitral regurgitation
ACS complications
Cardiac Rupture
Arrhythmia
Shock
Hypertension / heart failure
Pericarditis / pulmonary rales
Aneurysm
DVT
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
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:
</2 = 3%
4 = 7%
5 = 12%
>/6 = 19%
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
</ 3: low - 1.5%
4-6: intermediate - 16%
>7: high - 50%
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)
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
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
Other causes of increased trop
HF
malignancy
pericarditis
PE
renal failure
sepsis
stroke
SAH
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
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
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 </1, gracw < 109, low tn-neg female
Early invasive <24h: none of above, presumed new ST depression
Delayed invasive 25-72h: none of above but has DM/CRI, EF <40%, early post-infarct angina, PCI within 6m, propr CABG, TIMI >/2
STEMI management
If symptoms <12h - 24H consider PCI or fibrinolytic
- PCI - goal for contact <120min
- ASA, P2Y12 inhibitor, anticoag - 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 - 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
- Conservative - ASA, PsY12, anticoag, BB, statin, consider ACEi
Causes of pericarditis
Idiopathic
Infectious
Inflammatory
Metabolic
Cardiovascular
Drugs
Trauma
Malignancy
Signs of cardiac tamponade
Hypotension
Pulsus paradoxical
Tachycardia
Elevated JVP
Pericarditis treatment
- Anti-inflammatory 7-14d, then taper 1-2 weeks
- Aspirin 650 q4h
- Ibuprofen 400mg q6h - Corticosteroids for refractory
- Colchicine 0.5mg BID with NSAID for recurrent
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
