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AKT - Lizzie Bain > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

According to NICE, which patients should be assumed ‘high risk’ of CV disease, and do NOT require risk assessment with a scoring system?

A

Patients with type 1 diabetes who:
* are aged more than 40 years
* have had diabetes for more than 10 years
* have established nephropathy
* have other CVD risk factors.

Patients with chronic kidney disease stage 3 or beyond.

Patients with familial hypercholesterolaemia.

these groups will be offered a statin (20mg atorvastatin) anyway

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2
Q

What ABPI value would indicate peripheral arterial disease?

A

less than 0.9

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3
Q

Which antianginal medication should be avoided in cardiomyopathy with left ventricular outflow tract obstruction?

A

nitrites (leads to significant hypotension by peripheral vasodilation and decreasing afterload). e.g ISMN

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4
Q

What are the ECG features of WPW?

A
  • delta wave - a slur to the upstroke of the QRS complex. Causes a shorter PR interval. (signs of ventricular pre-excitation)
  • Leads to episodes of tachycardia - fast AF
ventricular pre-excitation results from abnormal atrio-ventricular conduction along a pathway - the bundle of Kent. The rapidity of the aberrant conduction pathway causes the PR interval to be shorter than normal. It is important to identify and refer patients with WPW syndrome as there is a risk of life-threatening dysrhythmias.
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5
Q

If a patients angina symptoms are not controlled on a CCB or Beta Blocker alone, what is the next step in management?

A
  • switch to the other option or combine the two e.g bisoprolol and amlodipine (or felodipine - a dihydropyridine)
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6
Q

What is the most appropriate lipid lowering medication for patients with established CVD?

A

atorvastatin 80mg

(lowers LDL, cheaper and less risk of myopathy than simvastatin)

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7
Q

Following an MI, which medications should a patient be taking?

A

ACE inhibitor,a statin, dual antiplatelet therapy and a betablocker.

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8
Q

What are the ECG features of Brugada syndrome?

A

ECG demonstrates ‘Brugada sign’: coved ST segment elevation of at least 2mm in V1 and/or V2, followed by a negative T wave

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9
Q

How is Brugada syndrome diagnosed?

A

Diagnosis depends on ECG changes (which may be transient) associated with one or more of the following clinical criteria:

  • Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT)
  • Family history of sudden cardiac death at under 45 years of age
  • Coved-type ECGs in family members
  • Inducibility of VT with programmed electrical stimulation
  • Syncope
  • Nocturnal agonal respiration
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10
Q

What can trigger arrhythmias in brugada syndrome?

A
  • ECG changes and ventricular arrhythmias can be triggered by large meals, alcohol, drugs or fever, and are most common at night.

Undiagnosed, patients with a characteristic ECG and history of syncope have a 3.2% mortality per year. Treatment is with an implantable cardioverter-defibrillator (ICD). should be referred for same-day expert cardiology assessment

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11
Q

Which medications should be avoided in HF?

A
  • NSAIDS
  • pioglitazone
  • doxazosin
  • rate-limiting calcium channel blockers (diltiazem, verapamil)
  • dipeptidyl-peptidase 4 inhibitors (gliptins e.g sitagliptin)
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12
Q

What are the ECG changes in complete heart block?

A
  • In third-degree (or complete) heart block there is complete failure of conduction through the atrio-ventricular node (AVN).
  • the regular atrial contractions (p-waves) can be seen continuing completely independently from the ventricular contractions (QRS complexes).

Definitive treatment, once reversible causes such as drugs or electrolyte imbalance have been excluded, is with a permanent pacemaker.

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13
Q

When should renal function be checked when starting an ACEI?

A

U&E and BP should be measured before starting an ACEI and again within one or two weeks of starting treatment.

Monitor as appropriate as dose titrated upwards, until target dose is reached, and then at least annually.

More frequent monitoring may be needed in patients who are at increased risk of deterioration in renal function.

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14
Q

Which medication can be added for intermittent claudication when supervised exercise has not led to satisfactory improvement and patient does not want angioplasty/bypass?

A

Naftidrofuryl oxalate
Progress should be reviewed after three to six months and discontinue if there has been no symptomatic benefit.

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15
Q

What are the side effects of amiodarone? What monitoring is required?

A
  • hypo/hyper thyroidism (contains iodine)
  • phototoxicity (rash),slate grey appearance
  • pulmonary fibrosis/pneumonitis
  • liver fibrosis/hepatitis
  • periperal neuropathy
  • prolongs QT interval, bradycardia.
  • corneal deposits.

Baseline: TFT, LFT, U&E (check potassium - arrhythmias), CXR.
6 monthly: LFTs and TFTs

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16
Q

What are the Simon Broome Criteria for definite familial hypercholesterolaemia?

A
  • used to make a clinical diagnosis of familial hypercholesterolaemia in primary care
  • Child age <16 TC > 6.7 mmol/l and LDL-C > 4.0 mmol/l
  • Adult TC > 7.5 mmol/l and LDL-C > 4.9 mmol/l
    and tendinous xanthomas, or evidence of them in first or second degree relative

or,

DNA-based evidence of LDL-receptor mutation, familial defective apo B-100, or a PCSK9 mutation

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17
Q

What are the Simon Broome Criteria for possible familial hypercholesterolaemia?

A
  • Child/young person TC > 6.7 mmol/l and LDL-C > 4.0 mmol/l
  • Adult TC > 7.5 mmol/l and LDL-C > 4.9 mmol/l and at least one of:
  • FHx MI aged <50 (second degree relative) or <60 1st degree relative
  • FHx (1st or 2nd degree) TC >7.5, or >6.7 in child
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18
Q

What age range gets an NHS Health Check for CVD prevention? How often do they get it?

A
  • age 40-74
  • every 5 years
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19
Q

What age range is QRISK3 for? For primary prevention

A
  • Age 25-84
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20
Q

What is the threshold QRISK3 score that considers a patient at high risk of CVD?

A
  • 10% or higher over the next 10 years
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21
Q

What are the risk factors for CVD in QRISK3?

A
  • Age, sex, ethnicity, postcode
  • smoking
  • diabetes
  • angina or MI in 1st degree relative <60
  • AF
  • HTN on medication
  • eGFR <60 (CKD 3, 4, and 5)
  • migraine
  • corticosteroid use
  • SLE
  • RA
  • atypical antipsychotic use
  • severe mental illness (independent of antipsychotic use)
  • ED
  • BP variability
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22
Q

What is QRISK3 used for?

A

primary prevention of CVD (coronary heart disease - angina/MI and Stroke/TIA)

Not used in people who already have CVD - this is secondary prevention of atherosclerosis.

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23
Q

Which patient populations does NICE ask GPs to recognise may have their CVD risk under-estimated?

A
  • HIV
  • Those on risk lowering medications already
  • Those who have recently stopped smoking
  • on medications causing dyslipidaemia
  • severe mental illness
  • autoimmune and systemic inflammatory disorders
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24
Q

What are the modifiable lifestyle risk factors for CVD?

A
  • diet
  • exercise
  • weight loss
  • alcohol
  • smoking
  • social deprivation (included in QRISK3)
25
Q

IF QRISK3 is >=10%, what should be done?

10% or more risk of CVD over the next 10 years

A
  1. Lifestyle modification first
  2. Review, and if that is not successful - Qrisk remains >10%, offer 20mg atorvastatin after risk/benefit discussion.
26
Q

Which medical conditions can raise cholesterol levels? (secondary causes of dyslipidaemia)

A
  • excess alcohol
  • poor diabetic control
  • hypothyroidism
  • liver disease
  • nephrotic syndrome
  • family history- familial hypercholesterolaemia.
26
Q

QRISK measures the total cholesterol/HDL ratio. What is an adverse ratio?

A

> 6

26
Q

What lipid blood results require referral to secondary care lipid specialist?

A
  • cholesterol >9
  • non-HDL >7.5
  • triglycerides > 20
  • TG 10-20 - repeat fasting after 5-14 days and refer if still >10
27
Q

What baseline blood tests should be done before starting a statin?

A
  • lipids, U&E, LFTs.
  • If already have muscle pain -check baseline CK
  • HbA1c
  • TSH - hypothyroidism causes hyperlipidaemia. Untreated hypothyroidism increases risk of statin-induced myopathy.

if LFTS <3x ULN - can still give statin

28
Q

What should be done if eGFR <30, and planning to start a statin?

A
  • if this is stable CKD, can start atorvastatin 10 or 20mg. If target reduction of 40% non-HDL cholesterol is not reached - get specialist advice.
  • LFTs - transaminases raised. Statin can be started with LFTs up to 3x ULN
  • CK raised with muscle pain- if >5x ULN - repeat in 1-2 weeks. Do not start statin if persistent. If <=5x ULN - start 10mg atorvastatin OD &monitor/
29
Q

What drugs can interact with statins to increase their concentration and therefore increase risk of myopathy & rhabdomyolysis?

A
  • inhibitors of cytochrome P450 enzyme
  • e.g clarithromycin, erythromycin, oral anti-fungals, diltiazem, verapamil, ciclosporin. Grapefruit juice.
30
Q

What is the target reduction in lipids recommended by NICE for primary prevention? When should bloods be checked after starting statin?

A
  • 40% reduction in non-HDL cholesterol
  • review at 3 months with repeat bloods: lipid profile & LFTs, and at 12 months. LFTs then not needed again.
  • If transaminases are <3x ULN, continue
  • IF >3x ULN stop statin.
31
Q

What is the risk of statin induced muscle pain (myalgia)?

A

2%

32
Q

If patients develop unexplained muscle pain, tenderness or weakness, what should be done?

A
  • stop statin
  • check bloods; CK and U&E (checking for rhabdomyolysis and AKI)

If worsening or new myasthenia gravis - stop statin & refer new cases to neuro.

33
Q

How should CK be interpreted?

A
  • CK <5x ULN unlikely to be due to the statin
  • CK >5x ULN should stop statin, check for AKI, may need urgent referral.
34
Q

What is the second line statin if atorvastatin is not tolerated?

A
  • rosuvastatin
  • third line: simvastatin
35
Q

When is a statin contraindicated?

A
  • do not take statins for 3 months prior to conception - can affect foetal development
  • Breastfeeding
  • If conceived on a statin - stop immediately.
  • active liver disease
  • ALT or AST >3xULN
  • rosuvastatin contraindicated in hereditary muscular disorders and CKD 4 or 5.
  • rosuvastatin 40mg contraindicated in people with predisposing factors to rhabdo.: Asian, CKD3, FH hereditary muscular disorders, alcohol misuse.
  • caution: specialist advice needed if Hx haemorrhagic stroke
36
Q

If someone is high risk of diabetes, when should they have HBa1c monitored when starting a statin’?
How common is the side effect of developing T2DM?

A
  • baseline, then 3 months.
  • risk of 1% over 4-5 years
37
Q

What dose of atorvastatin is recommended for those with diagnosed CVD (secondary prevention)?

A

80mg

38
Q

What are the common adverse effects of statins?

A
  • asthenia (weakness/lethargy)
  • constipation
  • diarrhoea, flatulence, GI discomfort, nausea
  • headache
  • myalgia
  • sleep disorders
  • thrombocytopenia
39
Q

What are the less common side effects of statins?

A
  • alopecia
  • hepatic disorders
  • pancreatitis
  • tendinopathy
  • myopathy and rhabdomyolysis
  • diabetes - in those already at risk
  • myasthenia gravis (new or aggravate)
40
Q

What Dutch Lipid Clinic Network (DLCN) score would allow a clinical diagnosis of familial hypercholesterolaemia?

A

Score >5

41
Q

Once a clinical diagnosis of FH has been made in primary care, what is the next step?

A

Refer all to specialist for confirmation of diagnosis, and cascade (DNA) testing of relatives.

42
Q

How should patients with confirmed homozygous familial hypercholesterolaemia be managed?

A

Should be managed in secondary care

43
Q

How should children with confirmed familial hyopercholesterolaemia be managed?

A

In secondary care

44
Q

When should patients with confirmed heterozygous FH be referred to be managed in secondary care?

A
  • when they are very high risk of CHD:
  • established CHD
  • FH premature CHD
  • two other CVD risk factirs e.g. male , smoking, HTN, DM
45
Q

For adults with confirmed heterozygous FH being managed in primary care, what investigations should be done?

A
  • baseline ECG
  • baseline bloods:
    -CK if muscle pain, LFTs, U&E, HbA1c, TFTs
46
Q

For adults with confirmed heterozygous FH being managed in primary care, what advice is indicated?

A
  • address CVD risk fx: smoking, BP, obesity, AF, RA, SLE, mental health disorders
  • dietician advice
  • identify other cases of hyperlipidaemia and manage them: excess alcohol, diabetes, hypothyroidism, liver disease, nephrotic syndrome, CKD
47
Q

For adults with confirmed heterozygous FH being managed in primary care, what medication is indicated?

A
  • atorvastatin 20mg or rosuvastatin 10mg
  • use ezetimibe 10mg OD if statins contraindicated. And refer specialist.
48
Q

What is the target reduction in LDL cholesterol for those with FH at 3 months? What should be done if target not reached?

A

> 50% reduction in baseline LDL levels.

Increase up to max tolerated dose of statin. If still not reached target, add in ezetimibe 10mg OD or start simvastatin 80mg.

Refer specialist if not worked after this.

49
Q

What is the pattern of inheritance of FH?

A
  • autosomal dominant.
  • an affected person has one copy of a mutant gene and one normal gene, or two mutant genes on a pair of autosomal (non-sex) chromosomes.
  • Siblings and children of a person with FH have a 50% risk of inheriting the condition.
50
Q

Which drugs should be offered following an MI, for secondary prevention?

A
  • ACEI or ARB - indefinitely
  • dual antiplatelet - aspirin indefinitely, clopidogrel/ticagrelor for as long as recommended by specialist.
  • beta blocker - for at least 1 year post MI. Indefinitely if LVSD
  • statin - indefinitely

Annual Flu jab

51
Q

What is a cardioprotective diet?

A
  • reducing refined sugards incl fructose
  • salt intake <6g a day
  • wholegrain
  • 4 portions a week of unsalted nuts and seeds
  • 2 portions of fish a week
  • 5 fruit and veg a day
  • olive oil/rapeseed oil spreads (rather than butter)
  • reduce saturated fats
52
Q

What exercise is recommended for secondary prevention of MI?

A
  • cardiac rehab programme
  • aiming >150mins moderate intensity aerobic exercise per week
  • muscle strengthening on 2 days a week
53
Q

Which routine post-MI assessments should be organised by 2ry care?

A
  • ECHO ax of LV function
  • Ax of bleeding risk (at first FU appt)
  • cardio review whether coronary revascularization is appropriate
54
Q

What are the group 1 DVLA rules post MI?

A
  • do not need to inform DVLA
  • should stop driving for 1 week post succesful PCI
  • stop driving for 4 weeks if PCI unsuccesful
  • stop driving for 4 weeks if not had PCI
55
Q

What are the group 2 DVLA rules post MI?

A
  • Must inform DVLA
  • Stop driving for 6 weeks
  • assessment with doctor after 6 weeks, DVLA may organise specific tests.
56
Q

When can you have sex after an MI?

A

usually 4-6 weeks post-MI

AKT - Lizzie Bain (55 decks)

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