Cardiovascular Flashcards
What is the most appropriate treatment of hypertension during pregnancy?
1st Line: Labetolol - if starting treatment or if changing (pt already on ACE/ARB etc for prev htn )
- Nifedipine (CC) if labetolol not suitable ie patient is asthmatic (unlicensed use)
- Consider methyldopa 3rd line
ACE/ARBs/thiazide like diuretics not recommended during pregnancy
Clinical features of mitral stenosis
SOB, fatigue, malar flush
Mid-late diastolic murmur
ECG changes: bifid P waves (P mitrale) - sign of atrial enlargement
Side Effects of statins
- myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase
- Liver impairment- check LFTs at baseline, 3 months and 12 months. Stop if 3x upper limit normal
- some evidence that statins may increase the risk of intracerebral haemorrhage in patients who’ve previously had a haemorrhagic stroke- avoid in these pts
Statin Dosing primary vs secondary?
atorvastatin 20mg for primary prevention
- (increase the dose if non-HDL has not reduced for >= 40)
atorvastatin 80mg for secondary prevention
Contraidications for statins
- macrolides (erythromycin/clarithromycin)
- pregnancy
What drugs should be given on discharge post PCI?
a statin, an ACE inhibitor, a beta-blocker and dual antiplatelet therapy after PCI to reduce the likelihood of future coronary events
What is the acceptable rise in creatinine and potassium from baseline after starting ACEi?
30% rise in creatinine, K+ up to 5.5mmol/l
- check U&E 2 weeks after starting and 2 weeks after each dose change. Once maintenance dose established check U&E at 1, 3 and 6 months
What are the features of aortic regurgitation?
- early diastolic murmur
- collapsing pulse
- wide pulse pressure
- Quincke’s sign (nailbed pulsation)
- De Musset’s sign (head bobbing)
- mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams
What are the causes of AR: acute vs chronic
Chronic:
- rheumatic fever
- bicuspid aortic valve
- connective tissue disorders (SLE, RA)
- calcified valve disease
- Marfans/EDS
- HTN
- Syphilis
Acute:
- infective endocarditis
- Aortic root dissection
Management of chronic refduced or mildly reduced EF heart failure
ABAL
- A- ACEi
- B- Beta blockers
- A- Aldosterone antagonist (MRA) ie spiro
- L- Loop diuretics ie furosemide when overload present
What % ejection fraction = reduced, mildly reduce or preserved EF
<40% = HFrEF
41-49% =HFmrEF
>50%= HF-PEF
Drugs that worsens HF?
NSAIDs, CCBs, BBs
When to refer HF pts based on BNP
- If NT-pro-BNP >2000 ng/L (236 pmol/L), refer urgently for specialist assessment and echo to be seen within 2 weeks.
- If NT-pro-BNP between 400–2000 ng/L (47–236 pmol/L), refer for specialist assessment and echoto be seen within 6 weeks.
- If NT-pro-BNP <400 ng/L (47 pmol/L), be aware that a diagnosis of heart failure is less likely. Consider discussion with a physician with subspecialty training in heart failure if a clinical suspicion of heart failure persists.
What are the clinical features of pericarditis?
chest pain: may be pleuritic. Is often relieved by sitting forwards
other symptoms include a non-productive cough, dyspnoea and flu-like symptoms pericardial rub
What ECG changes are seen in pericarditis?
- Global changes
- PR depression
- Saddle/concave ST elevation
Medical Management of angina
- Symptoms relief= GTN spray, rpt dose after 5 min, rpt dose after further 5 min, if after further 5 min symptoms remain call 999
2.Prevent symptoms= beta blocker (bisoprolol) + CCB (amlodipine). Other options (initiated by specialist) = nicorandil, ivabradine, nitrates - Secondary prevention = 4As
- Aspirin - 75mg
- Atovastatin - 80mg
- ACEi - ramipril
- Atenolol (will likely already be on BB)
Causes of pericarditis
- Idiopathic
- Infection- mainly viral ie TB, HIV, EBV
- Autoimmune- SLE, RA
- Injury to heart- MI, heart surgery, trauma
- Uraemia- renal impairment
- Cancer
- Medications- methotrexate
What are the 4 As of angina secondary prevention
Aspirin - 75mg
Atovastatin - 80mg
ACEi - ramipril
Atenolol (will likely already be on BB)
Features of pericarditis
- pleuritic chest pain- worse on lying down, relieved by sitting forward
- low grade fever
what drug would you give to cardiovert a patient in AF WITH structural heart disease
Amiodarone (or can use flecinide if there is NO structural disease)
What are the risk factors of AF?
SMITH
Sepsis
Mitral valve disease
Ischaemic heart disease
Thyrotoxicosis
HTN
Others: caffeine, alcohol, cardiomyopathy
What are the risk factors for coronary heart disease?
Non-modifiable risk factors:
- Older age
- Family history
- Male
Modifiable risk factors:
- Raised cholesterol
- Smoking
- Alcohol consumption
- Poor diet
- Lack of exercise
- Obesity
- Poor sleep
- Stress
Medical Co-Morbidities
- Diabetes
- Hypertension
- Chronic kidney disease (CKD)
- Inflammatory conditions, such as rheumatoid arthritis
- Atypical antipsychotic medications
What can cause falsely low BNP levels?
obesity, aldosterone antagonists, ACE inhibitors, angiotensin-II receptor antagonists, beta-blockers and diuretics can all falsely lower BNP levels,
Symptoms of aortic stenosis
SAD
Syncope
Angina
Dyspnoea or exertion
Features of AS
crescendo-decrescendo, high-pitched ejection systolic murmur
narrow pulse pressure
slow rising pulse
a thrill palpable over the cardiac apex
What is the most common cause of death in patinets post MI?
VF
