Cardiovascular Flashcards
Define Hypertension
Persistently elevated blood pressure (>140/90)
What are the causes of Hypertension?
Essential Hypertension (90%) - cause unknown
Secondary Hypertension
What are the different causes of secondary hypertension?
Renal disorders Cushing's syndrome and pituitary/adrenal tumours Vascular disorders Thyroid disorders PCC Alcoholism Pregnancy
What are the common symptoms of hypertension?
Headaches - particularly at the back of the head Lightheadedness Vertigo Tinnitus Altered vision Syncope
What optic signs might be seen as a result of hypertension?
signs of changes to optic disc caused by hypertensive retinopathy
What is a hypertensive emergency?
> 180/110 - evidence of direct damage to one or more end organs producing symptoms, such as chest pain, breathlessness, confusion and drowsiness
In infants - hypertension my present as failure to thrive, breathlessness, seizures or irritability
In children, it may present as headaches, irritability, nosebleeds, facial paralysis, fatigue, failure to thrive or blurred vision
What are the risk factors of hypertension?
Age FH stress Sleep apnoea Afro-caribbean or South Asian ethnicity Excessive alcohol consumption Obesity Little or no exercise High salt diet Low potassium diet Smoking
What investigations are done for high blood pressure?
Measure blood pressure re-check 2/3 times over next few weeks if <140/90
offer ambulatory blood pressure monitoring to confirm the diagnosis
What is the treatment of high blood pressure?
Arrange same day admission if there are signs of malignant HTN
Lifestyle advice
What are the signs of malignant hypertension?
180/110 with papilloedema and/or retinal haemorrhage
What is the first line treatment if patient is under 55 and non black?
ACEi
or ATII receptor blocker
What is the first line treatment if the patient is over 55 or black?
CCB
What is step 2 in treatment HTN?
ACEi + C or D
C + ACEi or D
What is step 3 in treatment of HTN?
ACEi + CCB + D
What is step 4 in tx of HTN?
ACEi + CCB + D
If potassium <4.5 - spironolactone
If >4.5 - alpha blocker, or beta blocker
What lifestyle factors are advised for HTN?
stop smoking
weight loss
avoid excess salt intake
What is atrial fibrillation?
Abnormal heart rhythm characterised by rapid and irregular heart beating
What are the cardiac causes of AF?
ischaemic heart disease rheumatic heart disease cardiomyopathy WPW syndrome atrial septal defect pericarditis cardiac surgery
What are the pulmonary causes of AF?
pneumonia
carcinoma of the bronchus
pulmonary embolus
What are the thyroid causes of AF?
hyperthyroidism
thyrotoxicosis
What are the signs and symptoms of AF?
irregularly irregular palpitations dyspnoea fatigue dizziness syncope angina
What is the primary change seen in the AF?
progressive fibrosis of the atria - brought about by atrial dilation
What is atrial dilation caused by?
Structural abnormalities in the heart that cause a rise in pressure within the heart.
Once dilation has occurred, RAAS is activated and there is a subsequent increase in matrix metalloproteases and disintegrins. This leads to atrial remodelling and fibrosis with loss of atrial muscle mass
Loss of atrial muscle mass - impulses generated by SAN do not go smoothly through myocardium
Electrical impulses - high rate but do not result in a heart beat.
What investigations are done for AF?
History taking
examination
U+E/TFT - rule out thyroid causes
troponin if acute cardiac causes of AF suspected
ECG - no P wave
Atrial flutter - atrial rate typically 300 beats/min - sawtooth flutter wave
What is the classification fo AF?
First detected
Paroxysmal - recurrent episodes that stop on their own in less than 7 days
Persistent - longer than 7 days
Permanent
What is the management of AF in haemodynamically unstable patients?
immediate heparinisation and attempted cardio version with synchronised DC shock
If cardio version fails - IV amiodarone
What are the two strategies for long term management of AF?
Rate control
Anticoagulation
What is the aim of rate control in AF?
reduce heart rate at rest and during exercise but the patient remains in AF
What drugs are preferred for rate control in AF?
Beta blockers
Calcium channel blockers
If co-existent heart failure - digoxin
Who is rhythm control used in?
Younger patients - <65 years of age
Patients who are highly symptomatic
Patients with congestive heart failure
Individuals with recent onset AF
How is conversion to sinus rhythm achieved?
Electrical DC cardio version and administration of B-blockers to control rate
What agents are used for rhythm control in AF
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine
If patients are unresponsive to rate control, what is the treatment?
catheter ablation techniques
In which patients are anticoagulants used?
Calculate CHA2DS2-Vasc score:
1+ in males
2+ in females –> Anticoagulation
how is risk of embolism causing a stroke assessed?
CHA2Ds2 VASc score
C - CHD H- hypertension A2 - aged 75_ D - DM S2 - prior stroke TIA/ thromboembolism
V - vascular disease
A - 65-74
Sc - sex category
What is the one year risk of major bleeding assessed by?
HASBLED score:
H - hypertension A - abnormal kidney/liver function S- stroke B - bleeding L - unstable/high INR E - elderly - >65 D - drug and alcohol use/medication predisposing to bleeding
What anticoagulants are used in AF?
NOACs: Apixiban, rivaroxaban
Warfarin
What is angina?
Exertional chest pain
Decreased blood flow to the heart due to atherosclerosis
through the coronary arteries
When exercising –> increase for blood goes up and demand Can’t be met: therefore chest pain
What are the risk factors for angina?
Obesity
smoking
alcohol
diet + exercise
What is the management for angina
GTN: sublingual
sit down and spray again
After 2 sprays - 999
Beta blocker or CCB (monotherapy = rate limiting)
Then both together
then long-acting nitrate, ivabradine, nicorandil or ranolazine
Counselling for angina
Warn about nitrate free period
Warn about GTN: if 2 uses and still in pain - might be having a heart attack and need to call 999
Side effects of nitrates
Dizziness
headache (very common)
