Cardiovascular Flashcards
Angina pectoris: drug management
1. Aspirin + Statin
2. GTN spray
3. BB or CCB first line
–> If CCB monotherapy: use rate limiting one; *verampril or diltiazem *
–> If w/ BB then use longer acting; amlodipine or modified release nifedipine
4. BB and CCB
–> If pt on monotherapy AND cannot tolerate addition of CCB or BB then consider
* long-acting nitrate
* ivabradine
* nicorandil
* ranolazine
5. If on CCB + BB only add third drug if awaiting assessment for PCI or CABG
NOTE
–> don’t give BB and VERAMPIL risk of COMPLETE HEART BLOCK
Pulmonary embolism: management
1. Outpatient tx in low risk PE patients
–> PESI score
2. Anticoagulant therapy
–> 1st line: DOAC (apixaban or rivaroxaban)
–> renal impairment: unfractionated heparin or LMWH then VKA
–> antiphospholipid syndrome: LMWH then VKA
3. Length of coagulation
–> unprovoked = 6 months
–> provoked = 3 months
Haemodynamic instability
–> THROMBOLYSIS
Repeated PE
–> IVC filter?
Score used to assess risk of bleeding in patients with PE:
ORBIT SCORE
Loop diuretics: side effects (furosemide)
OH DANG
O - ototoxicity
H - hypokalaemia
D- dehydration
A- allergy
N- nephritis
G- gout
Systolic vs Diastolic murmurs
Systolic: ASMR
–> aortic stenosis
–> mitral regurg
–> tricuscpid regurg
Diastolic: ARMS
–> Aortic regurg
–> mitral stenosis
Stenosis murmurs
- mid-diastole / systole
- increased pressure from ventricle needed to pump blood past the stenosis
Early diastolic/ systolic
- regurgitation, leaky valve after ventricular contraction
RILE
- right, inspiration
- left, expiration
Hypertension: management guidelines
Infarction of what vessel is associated with complete heart block
Right coronary artery
–> supplies the atrioventricular node
Types of heart block
- FIRST DEGREE: PR interval > 0.2 seconds
-
SECOND DEGREE
a) MOBITZ 1 –> progressive prolongation of PR interval until dropped beat
b) MOBITZ 2 –> PR interval constant, P wave not followed by QRS -
THIRD DEGREE
–> no association between P-wave and QRS complezes
Atrial Fibrillation: anticoagulation
1. CHADVASC score
–> 0 = no treatment
–> 1 = males: consider AC, females: no tx
–> 2 = AC
2. TOE
–> exclude valvular heart disease
- DOAC is 1st line
–> apixaban
–> dabigatran
–> edoxaban
–> rivaroxaban - WARFARIN is 2nd line
Atrial fibrillation: management
Pulmonary embolism: investigation and management
- PERC
–> if ALL absent, PE < 2% - calculate 2-LEVEL PE WELLS SCORE
–> PE LIKELY >4 points
–> PE UNlikely < 4 points
3. PE likely
a) CTPA w/ interim AC –> DOAC (apixaban or rivaroxaban)
–> CTPA + –> PE CONFIRMED
–> CTPA - –> proximal leg vein USS
4. PE unlikely
a) D-DIMER
–> if + –> CTPA (w/ interim AC, DOAC if delay)
–> - –> PE unlikely, stop AC, consider alternate diagnosis
If renal impairment: V/Q scanning
ECG shows findings characteristic of what condition
- Sinus tachycardia
- S1, T3 and T wave inversion
PULMONARY EMBOLISM
- large S wave in lead I
- large Q wave in lead III
- T wave inverted l
Investigating palpitations
1st Line
–> 12 lead ECG
–> TFTs (thyrotoxicosis?)
–> U&Es (low K+)
–> FBC
Capturing episodic arrhytmias
–> HOLTER monitoring
If no abnormality and symptoms continue
–> external loop recorder
–> implantable loop recorder
Signs of Right heart failure
- raised JVP
- ankle oedema
- hepatomegaly
ECG shows
LBBB
–> MI (Sgarbossa criteria)
–> htn
–> AS
–> cardiomyopathy
Rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
Always pathological
WILLIAM MARROW
in LBBB there is a ‘W’ in V1 and a ‘M’ in V6
in RBBB there is a ‘M’ in V1 and a ‘W’ in V6
3 day old newborn: now breathless, lethargic, struggling to feed.
OE: tachypnoeic, tachycardic, increased work of breathing
Systolic murmur under left clavicle and over back under left scapula.
PMH: had murmur at birth
Characteristic of:
COARCTATION OF AORTA
- duct is suppling BF to descending aorta
- when duct closes at 2 days of age , BF cut off
- BP in lower limbs drops
- murmur then heart in LHS, under clavicle and over scapula
Non shockable rhythms
ASYSTOLE
PULSELESS ELECTRICAL ACTIVITY
- IV access or IO
- Adrenaline 1mg asap
Mx
Warfarin: management of high INR
What is takaysau arteritis:
- Large vessel vasculitis
- causes occlusion of aorta
- absent limb pulse
Mx: steroids
Chronic heart failure: drug management
1st Line
–> ACEi AND BB (one at a time)
—–> *BB: bisoprolo, carvedilol, nebivolol *
2nd Line
–> aldosterone antagonist: spironolactone, eplerenone
SGLT-2i
–> canaglifozen, dapagliflozin etc
3rd Line
–> Specialist
* Ivabradine: > 75bpm, LVF < 35%
* sacubitril-valsartan: LVF <35%, HR w/ rEF + symptomatic on ACEi / ARB
* digoxin: coexistent AF?
* hydralazine w/ nitrate: afro-caribbean
* cardiac resynchronisation therapy: widened QRS, LBBB?
Others
- annual influenza
- one of pneumococcal (every 5 years IF asplenia, splenic dysfunction or CKD)
Management of STEMI
1. PCI w/i 120 minutes
–> if after 12 hours and still ongoing ishcaemia then PCI considered
–> radial acess»> femoral
–> if not on AC –> PRASUGREL
–> if on AC –> clopidogrel
2. OR Fibrinolysis
–> if ECG taken after 90 mins shows fibrinolysis has failed to resolve ST elevation –> TRANSFER FOR PCI
Management of NSTEMI / unstable angina
- PCI if
–> unstable
–> w/i 72hrs if GRACE > 3% - Unfractionated heparin +
–> not on AC: PRASUGREL or ticagrelor
–> on AC: clopidogrel
Conservative
–> not high risk of bleeding: ticagrelor
–> high risk of bleeding: clopidogrel
NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
ECG shows
Ventricular fibrillation
–> shockable
Aneurysm: investigation + mx
SCREENING > 65 abdominal USS men
Low rupture risk
–> asymptomatic, < 5.5cm
–> surveillance, optimise risk factors
High rupture risk
–> SYMPTOMATIC >5.5cm OR rapidly enlarging >1cm/ year
–> 2 ww VASCULAR for intervention
a) EVAR: if open repair unsuitable
Myocarditis: causes , Ix, Mx
Viral: coxsackie B, HIV
Bacteria: diphtheria, clostridia
Spirochaetes: Lyme disease
Protozoa: Chaga’s disease, toxoplasmosis
Autoimmune
Drugs: doxorubicin
Key investigations:
Bloods: Raised (inflammatory markers, cardiac enzyme
Lower leg ulcer: types and management
- Venous
–> Mx: 4 layer compression banding, no healing after 12 weeks –> skin graft? - Arterial
–> deep, punched out, painful, cold, low ABPI - Neuropathic
–> aar pressure
–> Mx: cushioned shows to reduce callous formation
For arterial ulcers - the management is to treat the cause; most commonly PAD:
If ABPI is less than 0.9 routine referral to vascular (+ clopidogrel and statins)
If ABPI is less than 0.5 urgent referral to vascular (endovascular revascularisation or endartectomy)
