Cardiovascular Flashcards
Hypertension
Stages 3
Rx 4
Normal targets 2
Lifestyle advice
Def…
Stage 1: ≥140/90, then ABPM/HBPM of ≥135/85
Stage 2: ≥160/100, then ABPM/HBPM of ≥150/95
SEVERE: sys≥180, dias≥110
Rx…
1. A or C
2. A + C
3. A + C + D
4. Add spiro if K ≤4.5, or (stronger thiazide diuretic if greater)
If further diuretic contraindicated/ineffective then + B (alpha or beta blocker)
If no response then - RESISTANT HYPERTENSION therefore refer
Normal…
Less than 80 yo: <140/90 (clinic), <135/85 (ambulatory/home)
Over 80 yo: <150/90, <145/85
Lifestyle…
- Reduce salt (<6mg/d, ideally 3mg/d) and caffeine
- Lower weight and regular exercise
- Stop smoking and lower alcohol intake
- Balanced diet (rich in fruit and veg)
Risk factors for CVD
Non-mod 4; Mod 7
Non-mod:
- Age
- FH
- Male
- Ethnicity
Mod:
- BP
- Lipids
- Smoking
- Alcohol
- Exercise
- Weight
- Diet
QRISK every 5 years, except with…
5
- Hx of CVD
- Familial hypercholesterolaemia
- Age ≥85
- T1DM (sometimes QRISK3 helpful)
- CKD (sometimes QRISK3 helpful)
If 10% 10-year CVD risk…
3
- Discuss pros and cons of statin (atorvastatin 20mg)
- Lifestyle discussion
- Treat co-morbidities, e.g. BP
Offer statins in over 10% QRISK2 score and…
2
- T1DM if >40, DM for 10 years, nephropathy
- Over 85 - consider(!) offering statin
[T2DM - carry out QRISK2 as normal]
Chest pain causes
Causes by system - 6
- Cardiac
- Resp
- GI
- Msk
- Psych
- Non-specific
Chest pain causes
Features - subcategories - 4
- Tight, pressure, central, radiation to shoulder/jaw/arm/neck —> ISCHAEMIC
- Pleuritic —> think PE
- Tearing, between shoulder blades —> think DISSECTING AORTIC ANEURYSM
- Relieved by sitting forward —> think PERICARDITIS
?ACS
Referral (3)
999
Pain right now
ECG new changes
Rx: GTN (&/or opioid, e.g. IV diamorphine), O2 if sats <94%, Aspirin 300mg (unless CI)
- SAME-DAY ASSESSMENT* - currently pain-free
- Pain in last 12h, normal ECG, no complications
- Pain 12-72h, no complications
WITHIN 2 WKS - currently pain free
- Pain >72h, no complications
(Can consider assessment for ACS in 1º care - ECG, trop - & consider aspirin 75mg, GTN stat —> 5 mins —> 999)
ACS Severity Heirarchy
3
Unstable angina —> NSTEMI —> STEMI
Unstable angina & NSTEMI Mx
Initial; High risk; If insufficient; Long-term
INITIAL
- Oxygen
- Nitrates
- Morphine
- Aspirin + Clopidogrel / Prasrugrel (if undergoing PCI)
- also: LMWH, B-blockers indefinitely (if CI, then diltiazem or verapamil)
Secondary prevention (+ statins)
Offer ____ (1)
If history of ____ (5 eg)
Offer ATORVASTATIN 80mg (seek specialist advice if contraindicated)
If history of CVD
- eg MI, angina, stroke, TIA, PVD
Statin side-effects
3
Headache
GI disturbance
Myalgia
(N.B. Remember link with grapefruit juice - may increase statin concentration)
Monitoring of statins
3
- Lipids - at 3/12, aim for 40% drop in non-HDL cholesterol
- LFTs - at 3/12 and 12/12
- CK - if unexplained muscle symptoms
Angina…
…caused by myocardial ischaemia (5)
- CAD (atheroma)
- Aortic stenosis
- HOCM
- Htn
- Coronary artery spasm (Prinzmetal’s)
Angina…
…Ix (3)
- Resting ECG may be normal
- Exercise ECG may show ST depression
- Exercise myocardial perfusion scans may be useful
Angina…
…symptom control
3
- Acute —> GTN
- Prevention 1 —> B blocker OR Ca channel blocker
- Prevention 2 —> monotherapy: Long-acting nitrate (ISMN) / Nicorandil / Ivabradine / Ranolazine
Angina…
…Interventions (2)
- PTCA
= percutaneous transluminal coronary angioplasty - inflating a balloon to correct atheromatous obstructions - CABG
= coronary artery bypass grafting - multivessel disease, failed PTCA, etc (a vessel, e.g. internal mammary artery, is used to bypass the blocked areas)
Angina…
…2º prevention
3
- Consider antiplatelet - usually aspirin 75mg OD (may already be on clopidogrel)
- Consider ACEi if diabetes (other conditions as per NICE guidance)
- Statin/Hypertension treatment as per NICE guidance
MI definition
= myocardial infarction
= death of heart muscles due to ischaemia, usually due to ruptured plaque
MI diagnosis
3
Overall: symptoms + ECG + troponin
- Features: pale, sweaty, cardiac pain, unwell
- ECG: STE, T wave inversion, tall T waves, STD, Q waves
- Troponin, CK, AST, LDH
MI types
2
STEMI (usually full blockage)
NSTEMI (usually partial blockage)
MI treatment
2
Reperfusion by PCI (PTCA) preferred
OR
Fibrinolysis (if PCI not possible within 120 minutes)
E.g. with streptokinase/alteplase
Post-MI Mx
3
- Lifestyle (eg smoking, diet)
- Cardiac rehab programme & exercise
- Medication (4A’s)
ACEi or ARB (A) - indefinite
Beta-blocker (A - atenolol) - at least 12/12
Statin (A - atorvastatin) - indefinite
Antiplatelets (A)
Post-MI Antiplatelets
2
- If medially managed (NSTEMI or STEMI):
Aspirin 75mg OD + Ticagrelor 90mg BD - 12/12
(If high risk of bleeding, continue for at least one month)
(If high ischaemic risk can consider continuing for up to 36/12 - w ticagrelor dose of 60mg BD)
- ACS + PCI:
Aspirin 75-100mg BD + one of following for UP TO 12/12
- Prasrugrel 10mg OD (5mg if <60kg / >75yo)
- Ticagrelor 90mg BD
- Clopidogrel 75mg OD (if above two are not suitable)
Then aspirin alone
Lifestyle modification (Lipids modification)
4
- Stop smoking
- Alcohol (14 units male/female)
- 150 mins per week of moderate intensity exercise
- Diet
Diet modification (lipids modification)
7
- Fat intake <30% total energy intake (saturated <7%)
- Olive oil/rapeseed oil instead of butter
- 5 portions fruit/veg per day
- 2 portions fish per week (1 oily)
- 4-5 portions unsalted mixed nuts/seeds per week (1 portion approx 30g)
- Whole grain cereals/breads, etc
- Salt low (<6g/day), sugar low
BONOFFS
Heart failure definition
Cardiac output / BP inadequate for body’s needs
Poor prognosis - 50% 5y mortality
Types of heart failure
2
- LEFT - ischaemia, hypertension, valve disease, etc
2. RIGHT - 2º to left, cor pulmonale (lung disease)
Heart failure signs/symptoms
Sx 5; signs 6; CXR 4
Sx
- Orthopnoea
- PND
- SOBOE
- Fatigue
- Pink frothy sputum
Signs
- Bibasal creps
- Raised JVP
- Tachycardia
- Displaced apex
- 3rd HS
- Oedema
CXR
- CARDIOMEGALY!
- Kerly B lines
- Upper lobe diversion
- Pleural effusions
Heart failure:
Acute Mx
- FBC, U&E, BNP, CXR, ECG, echo
- IV diuretic
(No routine use of opioids, nitrates, inotropes, vasopressors)
If suspected heart failure, how to act with BNP levels…
> 2000: special assessment & echo within 2 weeks
400 - 2000: specialist assessment & echo within 6 weeks
<400: consider alternatives
Heart failure:
Long term Mx
(3)
- Reduced EF:
ACEi and licensed B-blocker (start one at a time) - Preserved EF:
Specialist advice
3. Consider: Antiplatelet Statin Treat medical causes Review drug causes Annual flu jab
Hypertension:
Causes
(2)
- 90-95% essential
2. 5-10% other (renal, endocrine, vascular)
HTN:
Sx
(Sx 4; signs 3)
Sx
- Headache
- Vision change
- Fits
- Epistaxis
Signs
- Retinopathy
- Proteinuria
- LVH on ECG
HTN:
Dx (2) & stages(4)
(Suspect if clinic BP 140/90)
CONFIRM with
- ABPM: 2 measures per hour, average of at least 14 measurements
- HBPM: 2x daily for at least 4 days - ideally 7 - and then average
STAGES:
- Clinic 140/90 and ABPM/HBPM 135/85
- Clinic 160/100 and ABPM/HBPM 150/95
- Severe - clinic sys 180 or dias 120
- Accelerated - clinic >180/120 with papilloedema/retinal haemorrhage (—> same day admit!)
HTN Rx:
When to treat
(4)
- Offer treatment to all at stage 2
- D/w those aged <80 with stage 1…
…w end organ damage, CVD, renal disease, diabetes, >10% 10yr CVD risk - Consider Rx for those <60yo with stage 1 and <10% 10yr CVD risk
- Consider specialist advice if <40yo with HTN
HTN Rx:
Steps
(4)
A = ACE (ARB) B = beta blocker C = CCB D = diuretic
1. A If T2DM (any age or family origin) Under 55 (and not African/Afro-Caribbean origin)
Or
- C
If >55 (and no diabetes)
African/Afro-Caribbean origin (and no diabetes) - A+C
A+D
C+D - All 3
A + C + D - 4th drug (A blocker, B clocker, spironolactone)
Refer…
Bradycardias:
Sx
(4)
(Defn <60bpm)
- Chest pain
- Collapse
- Dizziness
- SOB
Bradycardia:
Causes
(2)
- Sinus - usually asymptomatic
May be normal in athletes/elderly
Hypothyroid, hypothermia, drugs (eg B-blockers) - Sick sinus syndrome, SA block, AV block
Bradycardia:
Rx
(2)
Generally think…
- Atropine
Or
- Pacing
Pacemakers
4
- Electrical stimuli cause heart contraction when electrical activity is slow or absent
- Indications include symptomatic bradycardia, heart block
- Consist of pulse generator (can be internal or external) and pacing leads
- Can be temporary or permanent
Tachycardias:
Narrow complex
(4)
NARROW COMPLEX:
- QRS complex shorter than 120ms
- Can be asymptomatic
- Can have CP, palpitations, dizziness, syncope
- Sinus tachycardia, AF, re-entrant tachycardias
Tachycardias:
Broad complex
(5)
- QRS longer than 120ms
- Ventricular or supraventricular
- Present: collapse, palpitations, pain, failure
- ECG: usually regular, wide QRS, tachy (up to 130), classic ‘capture beats’, ‘fusion beats’
- ABC, life support, may need DC shocks, amiodarone
AF:
Types
(3)
- Paroxysmal (recurrent, 30 seconds-7 days)
- Persistent (>7 days)
- Permanent/long-standing (despite cardioversion)
AF:
Presentation
(4)
- Causes: usually cardiac + hyperthyroid
- Presentation: palpitations, chest pain, SOB, stroke/TIA
- Irregularly irregular pulse
- Absent P-waves on ECG, check TFTs
AF:
Mx
(3)
Rate-control generally preferred to rhythm control, except…
…new onset (48hr) / reversible cause / heart failure
- Initial rate-control Mx: MONOTHERAPY
B-blocker / rate-limiting CCB (diltiazem, verapamil)
Digoxin if non-paroxysmal AF and sedentary lifestyle - If rate not controlled: DUAL THERAPY
B-blocker / diltiazem / digoxin (cardiology advice with b-b/d combo) - If rate still not controlled: CARDIOLOGY within 4 weeks
AF:
Rhythm control
(2)
- Electrical cardioversion
2. Pharmacological, e.g. flecainide/amiodarone
AF:
CHA2DS2-VASc
(2)
- For stroke risk
2. Offer anticoagulation if score of 2 or men with score of 1
AF:
HAS-BLED
For bleeding risk (look for score of 3)
If on balance need to anticoagulation, either warfarin or NOAC
Atrial flutter
5
- Less common than AF
- Many causes including non-cardiac (eg obesity/alcohol)
- Saw-tooth flutter waves on ECG
- Main aim usually cardioversion/medications (eg amiodarone/sotalol) but may need ablation if persistent/recurrent
- Antithrombotic therapy as with AF
PVD:
Key details
(7)
- = reduced blood supply to legs
- Key lifestyle: smoking++; other CVD risk factors
- Key Sx: Cramping in calf/thigh/buttock, relieved by rest (=IC)
- Red flags (signs of critical ischaemia): Night/rest pain
- Key exam: pale, cold, skin shiny, hair loss, weak/absent pulses
- Key Ix: CVD exam, FBC, lipids, glucose, ECG, consider thrombophilia screen, ABPI, angiography (CT/MRI)
- Key DDx: spinan stenosis (relieved by leaning forwards), neuropathy, MSK problems
PVD:
ABPI
(2)
<0.9 = PVD
<0.5 = critical ischaemia - needs urgent vascular referral!
Intermittent Claudication:
Mx
(3)
- Supervised exercise programme if available (2 hours per week for 3/12)
- Refer for ?angioplasty, ?bypass if no improvement
- Consider NAFTIDROFURYL OXALATE if pt doesn’t want referral/surgery
(If PVD and bus/coach/lorry driver then —> DVLA)
Varicose veins
Def (1)
RFs (4)
Sx (6)
Exam (2)
Ix (1)
Mx (2)
Defn= Tortuous/dilated veins in leg - usually due to back flow of blood through valves in veins
RFs
- Pregnancy
- Obesity
- Age
- Prolonged standing
Sx
- Cosmetic concern
- Itching
- Burning
- Cramps
- Oedema
- Discomfort
Exam
- Fluid thrill over incompetent vein?
- Chronic insufficiency changes including venous eczema, ulcers, pigementation, lipodermatitis
Ix
- usually Duplex USS
Mx
- Medical: compression stockings (exclude arterial disease)
- Surgical: eg foam sclerotherapy, endothermal ablation, stripping
DVT:
Sx
(4)
(= clot in deep veins, usually in leg)
Sx:
- Swelling
- Redness
- Tenderness
- Pain behind calf (or thigh)
DVT:
RFs
(8)
- Previous Hx
- COCP
- Long flights
- Cancer
- Immobility
- Smoking
- Age
- Obesity
DVT:
Well’s score
(2)
DVT likely if score ≥2
If LIKELY —> USS within 4 hours
(If not possible then D-dimer, anticoagulant, USS in 24 hours)
If UNLIKELY —> check D-dimer
(If D-dimer raised, USS within 4 hours - if not possible then as above)
DVT:
Rx
(3)
- Initially LMWH or fondaparinux
- Will need ongoing anticoagulation for AT LEAST 3/12 (warfarin/NOAC)
- No travel for at least 2 weeks
(Unprovoked DVT —> screen for cancers, thrombophilia screen)
Murmurs
4
- Ejection systolic
(AS, HOCM, ASD) - Pansystolic
(MR, TR, VSD) - Early diastolic
(AR, PR) - Mid diastolic
(MS, TS)
Early diastolic murmurs
4
- Aortic stenosis
- Aortic sclerosis
- HOCM
- ASD
Pansystolic murmurs
3
- Mitral regurgitation
- Tricuspid regurgitation
- VSD
Early diastolic murmurs
2
- Aortic regurgitation
2. Pulmonary regurgitation
Mid-diastolic murmurs
2
- Mitral stenosis
2. Tricuspid stenosis
Murmurs in children
3
- Often innocent systolic flow murmurs
- Can change with posture
- Should have no symptoms/rest exam normal
Asymptomatic cardiomyopathy (diseases of heart muscle)
3
- Heart failure
- Arrhythmia
- Sudden death
Dilated cardiomyopathy
Def; Causes 3; Rx
= weakened walls lead to dilation and poor contraction
Due to:
- Ischaemia
- Alcohol
- Thyrotoxicosis
Rx: usually medical (eg of HF symptoms)
Hypertrophic cardiomyopathy
Def, cause, consequence
= hypertrophy of an undilated LV
Autosomal dominant (most common genetic CV disease) or sporadic mutation (rare)
—> sudden death in younger people - Rx surgery
Restrictive cardiomyopathy
Def; causes; consequence; Rx
= rigid ventricular walls
Multiple causes eg amyloidosis, sarcoidosis
—> reduced filling
Symptomatic Rx usually medically
Rheumatic fever
Cause; Sx 6; Dx; Ix 4; Rx 4; consequences 2
Much less common now
CAUSE:
Group A beta haemolytic streptococci
Sx:
- Sore throat
- Fever
- Can affect heart (e.g. pancarditis)
- Joints (e.g. arthritis)
- Skin (e.g. erythema marginatum)
- Nervous system (e.g. chorea)
Dx:
Jones criteria used to diagnose (using major and minor criteria)
Ix:
- Throat swab
- Antistreptococcal antibodies
- Echo
- ESR/CRP
Rx:
- Bed rest
- Treat infection (penicillin)
- Treat inflammation (e.g. aspirin/steroids/NSAIDs)
- Treat heart failure
Can —> mitral stenosis, CCF
Pericarditis
Def; Cause 3; Sx 2; Rx 2
= inflammation of the pericardium
Most common cause:
- Viral (e.g. Coxsackie)
- MI (Dressler’s syndrome)
- Renal failure
Sx:
- Sharp pain - relieved by leaning forward
- Pericardial rub
Rx:
- Treat any underlying disorder
- Analgesia (NSAIDs)
Myocarditis
Def; Cause 3; Sx; Rx
= inflammation of myocardium
Cause:
- Usually viral (e.g. Coxsackie)
- Metabolic
- Connective tissue disease
Sx:
Similar to MI
Rx:
Depends on underlying disease
Endocarditis
Think; RFs; Cause; Sx 4; Exam 7; Ix 2; Dx; Rx 2
New murmur + Fever —> must think endocarditis!
RFs:
Other heart conditions, e.g. valve conditions, valve surgery
Cause:
Staphylococcus aureus most common organism - can be others (e.g. strep)
Sx: Wide range of presentation...e.g. 1. Fever 2. Fatigue 3. Back pain 4. Abdo pain
Exam:
- Fever
- Murmur
- Splinter haemorrhages
- Petechia (e.g. hands/mouth)
- Clubbing
- Osler’s nodes
- Janeway lesions
Ix:
Include
1. Blood cultures
2. Echo
Dx:
Modified Duke Criteria (major/minor criteria)
Rx:
- Usually IV Abx
- May need surgery
AAA
RFs 5; Sx 4
Can be abdominal (AAA) or thoracic
Cause usually unknown but RFs include:
- Atherosclerosis
- Male
- FH
- Smoking
- Age
Can present without symptoms, e..g screening in UK
- males, once, 65 years, USS used to measure diameter
Sx:
- Back pain
- Pulsatile mass
- Distal ischaemia
- Rupture (shock, hypotension, pale, acute, abdomen, collapse)
AAA:
Un-ruptured vs Ruptured
UN-RUPTURED:
- CVD assessment, USS/CT/MRI
- If <5.5cm generally medical management (USS monitoring, RFs), consider surgery >5.5cm (open vs endovascular)
RUPTURED:
- Surgical emergency with high mortality
- Repair may be possible, e.g prosthetic graft
CVD
5
- Angina
- MI
- Stroke
- TIA
- PVD
Offering statins
3
- T1DM pt - offer statin if >40, DM for 10 years, nephropathy
- T2DM: carry out QRISK2 as normal
- > 85yo - consider offering statin
ACS umbrella term
3
- Unstable angina
- Non-STEMI
(Above 2 are caused by narrowing/partial blockage or coronary artery)
- STEMI
(Caused by complete occlusion)
