Cardiovascular Flashcards
Angina questions
Pain characteristics
Relationship to exertion
Associated symptoms (SOB)
Exercise tolerance
Some patients (especially those with diabetes) may not describe pain but may have reproducible exercise-induced symptoms (nausea/SOB)
CVD risk factors
CVD hx (MI, CABG, CCF, TIA, PVD)
ejection systolic murmur suggesting aortic stenosis.
Hypertrophic cardiomyopathy, e.g. family history, examination, or ECG changes.
Age
Male
Smoker or ex-smoker
FHx IHD<60
Ethnic background, South Asian and Afro-Caribbean
Lifestyle, sedentary, unhealthy diet, alcohol
CKD
Diabetes
Hyperlipidaemia
Hypertension
Obesity or overweight
RA, PCOS
Serious mental health problems
Non cardiac causes of chest pain
Gastrointestinal cause, GORD, biliary colic- Check relation to food
MSK
Pericarditis
Anxiety or panic disorder
Respiratory cause
Breast pain
Shingles
Viral cause
Initial management angina
Atorvastatin 20mg
Aspirin 75mg
GTN
Bisoprolol 2.5mg
Urgent referral rapid access chest pain clinic
Symptoms of unstable angina
Pain at rest, which may occur at night
Pain on minimal exertion
Angina that seems to be rapidly progressing despite increasing medical treatment
Advice to reduce CVD risk factors
Smoking cessation
Diabetes control
Weight management
Appropriate exercise
ECG changes suggesting STEMI
S–T elevation 1 mm or greater in 2 or more I, II, III, AVR, AVL, AVF
S–T elevation 2 mm or greater in 2 or more V1 to V6
New LBBB
widespread ST depression.
T‑wave inversion esp V2, V3, and V4
STEMI management
999, 300mg aspirin, GTN, pain relief
Pericarditis signs
Chest pain, sharp, pleuritic, improved by sitting up + leaning forward
Pericardial friction rub
ECG widespread concave S–T segment elevation or PR depression
Pericardial effusion
Fever, flu-like symptoms, raised CRP
Pericarditis can cause raised troponin.
Underlying causes of AF
Infection
Dehydration
Surgery
Cardiac- MI, HTN or valvular heart disease, ischaemic or non-ischaemic cardiomyopathy
Respiratory- exacerbation COPD, sleep apnoea, PE, pneumonia
Excessive alcohol intake
Thyrotoxicosis
Obesity
CHA2DSVASc
Congestive heart failure
Hypertension hx
Age>75
Diabetes
Stroke
Vascular disease (CVD, PVD)
Age 65-74
Female
ORBIT
Hb under 120 F, 130 M
Age >74 years +1
Bleeding history +2
Any history of GI bleeding, intracranial bleeding, or hemorrhagic stroke
GFR <60 mL/min/1.73 m2 +1
Treatment with antiplatelet agents +1
Admit AF if
Pulse>150
SBP<90 mmHg
Myocardial ischaemia
Severe dizziness or SOB
Haemodynamic instability
Pulmonary oedema
Chest pain
Syncope or presyncope
Rate control medication
Bisoprolol
Diltiazem
Verapamil (NOT WITH B-BLOCKER)
Digoxin
pAF management
Routine cardiology referral for holter to diagnose
Anticoagulate as in AF
Routine cardiology ref re ablation/pill in pocket flecainide
Symptoms CCF
Dyspnoea
Peripheral oedema
Fatigue
Weakness
Decreased exercise tolerance
Ix CCF
FBC, electrolytes and renal function, LFT, TFT, lipids, HBa1c, ferritin, urinalysis
BNP
ECG
CXR
Urgent cardio ref if BNP>400
Lifestyle modification for CCF
Reduce salt intake (2g/day)
Stop alcohol + smoking
Cardiac rehab for breathlessness
Annual influenza + one off pneumococcal
CCF exacerbation causes
MI
Arrhythmia
Poor adherence to treatment
New medication
Diet/exercise
Anaemia
Infection
Murmur hx
Chest pain
Syncope
Palpitations
SOB
Fatigue
Congenital heart disease
Rheumatic fever
Heart failure
Positions of murmurs
The apex in the left lateral position in expiration (mitral murmurs)
The left sternal border sitting forward in expiration (aortic regurgitation)
The neck for radiation (aortic stenosis).
MRS ASS
When do you need fasting lipids?
For LDL, needs 12 hrs fast overnight
Secondary causes of hyperlipidaemia
T2DM (TGs)
Hypothyroidism (cholesterol + TGs)
Nephrotic syndrome (cholesterol)
Cholestatic liver disease (cholesterol)
Alcohol excess (TGs)
Obesity (TGs)
Anorexia nervosa (cholesterol)
Drug causes:
Olanzapine, clozapine
Sertraline, venlafaxine, quetiapine, mirtazapine
Cyclosporin
New high lipid Ix
HbA1c, TFTs, U+E, urine dip, LFT
How do you diagnose familial hypercholesterolaemia?
Definite if:
Cholesterol>7.5 + tendon xanthomas
(or in 1st or second degree relative)
OR LDL-receptor mutation, familial defective apo B100, or a PCSK9 mutation
Possible if MI<50 2nd degree or 60 1st degree
Cholesterol>7.5 adult or 6.7 child
LDL-C>4.9 adult 4.0 child
When do you offer statin regardless of QRISK?
T1DM if
-older than 40 years.
-diabetes diagnosed>10 yrs
-established nephropathy.
-other CVD risk factors.
Any CKD
Which medications cause long QT?
Antiarrhythmics, e.g. flecainide, amiodarone, sotalol
Lithium
TCAs
SSRIs- citalopram, escitalopram
Antipsychotics, e.g. haloperidol, phenothiazines such as chlorpromazine
Domperidone
Methadone
Erythromycin, clarithromycin, quinolones such as ciprofloxacin
Fluconazole
Quinine
High risk Vs med risk Vs low risk CCF
And referral
High risk – any of:
BNP greater than 2000 nanogram/L
Previous MI
Major ECG changes, ischaemia or LBBB or QRS>120
Medium risk – BNP> 400
Low risk – BNP less than 400 no cardiac history, no cvd risk factors
High + medium both urgent referral cardiology
CCF treatment
ACEi/ARB Ramipril 2.5mg
Bisoprolol 2.5mg OD
Spironolactone 12.5-25mg OD
Consider dapagliflozin
Consider aspirin 75mg if CVD, consider atorvastatin 20mg
Dapagliflozin details
10mg once daily
Risk fourniers gangrene, normoglycaemic ketoacidosis
Sick day rules
UTIs and genital infections
Red flags palpitations
breathlessness, chest pain, syncope, or pre-syncope
Sudden onset and offset, very rapid, and can be described as too fast to count + haemodynamic instability (?SVT/VT)
Triggered by exercise
Hx sudden death
Common triggers palpitations
Caffeine
Alcohol
Ilicit drugs
Salbutamol
Theophylline
Decongestants
Citalopram
TCAs
Underlying cause palpitations
Cardiac structural disease- cardiomyopathy, valvular disease
Psychiatric- anxiety, PTSD
High output state-infection, anaemia, pregnancy
Endocrine- hyperthyroid, phaeochromocytoma
Electrolyte imbalances
Stages of hypertension
Stage 1
Clinic BP 140/90-159/99 mmHg HBPM average BP 135/85-149/94
Stage 2
Clinic BP 160/100-180/120
HBPM average BP 150/95+
Stage 3
Clinic BP 180 /120+
Treatment HTN
1st line
If age<55 or T2DM =A
If age>55 or black African = C
If CCF = D
2nd line
A + C or A + D or C+D
3rd line
A + C + D
4th line- refer + B or alpha blocker
A = ACEi or ARB (ARB if black African)
B= bisoprolol
C= CCB
D= indapamide/thiazide
Ix HTN
Assess for end organ damage
-ECG for LVH
-Retinopathy
-U+E and urine ACR, HbA1c, lipids
