Cardiovascular Flashcards
NSTEMI
Acute coronary syndrome
non-ST elevation myocardial infarction
- Aspirin 300mg
- Nitrates or morphine to relieve chest pain if required
- Antithrombin treatment. Fondaparinux /Heparin
- Ticagrelor and prasugrel are now the preferred second antiplatelet instead o
- Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban)
- Coronary angiography
Angina
drug management
Aspirin and \
Statin in the absence of any contraindication
GTN to abort angina attacks
Beta-blocker or
Calicum channel blocker
channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used
If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine).
Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)
if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)
if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa
a long-acting nitrate, ivabradine, nicorandil or ranolazine
if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG
Anti-platelets
Percutaneous coronary intervention
ACS (MI)
CVA & TIA
PVD
ACS (MI) & PCS
Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)
If aspirin contraindicated, clopidogrel (lifelong)
CVA & TIA
Clopidogrel (lifelong)
Aspirin (lifelong) & dipyridamole (lifelong
PVD
Clopidogrel (lifelong)
Asprin (lifelong)
CHA2DS2-VASc
Anticoagulation
Atrial fibrillation
Congestive heart failure 1
Hypertension (or treated hypertension) 1
Age >= 75 years 2 : Age 65-74 years 1
Diabetes 1
Stroke or TIA 2
Vascular disease (IHD PVD) 1
Sex (female) 1
0 No treatment
1 Males: Consider anticoagulation
Females: No treatment (this is because their score of 1 is only reached due to their gender)
2 or more Offer anticoagulation
HASBLED
Score
Hypertension, uncontrolled, systolic BP > 160 mmHg 1
Abnormal renal function (dialysis or creatinine > 200) Abnormal liver function (cirrhosis, bilirubin > 2 times normal, ALT/AST/ALP > 3 times normal
1 for any renal abnormalities
1 for any liver abnormalities
Stroke 1
Bleeding history 1
Labile INRs (unstable/high INRs, time in therapeutic range < 60%) 1
Elderly (> 65 years) 1
Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs) or Alcohol Use (>8 drinks/week)
1 for drugs 1 for alcohol
There are no formal rules on how we act on the HAS-BLED score although a score of >= 3
Atrial fibrillation
rate control and
maintenance of sinus rhythm
Agents used to control rate in patients with atrial fibrillation
beta-blockers
calcium channel blockers
digoxin (not considered first-line anymore as they are less effective at controlling the heart rate during exercise. However, they are the preferred choice if the patient has coexistent heart failure)
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine
BNP
High levels > 400 pg/ml (116 pmol/litre)
NTproBNP > 2000 pg/ml (236 pmol/litre)
Raised levels
100-400 pg/ml (29-116 pmol/litre)
400-2000 pg/ml (47-236 pmol/litre)
Normal levels
< 100 pg/ml (29 pmol/litre)
< 400 pg/ml (47 pmol/litre)
Increase BNP levels
Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (including pulmonary embolism)
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis
Decrease BNP levels
Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists
Interpreting the test
if levels are ‘high’ arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
if levels are ‘raised’ arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks
DVLA
Specific rules
Hypertension - can drive unless treatment causes unacceptable side effects, no need to notify DVLA. If Group 2 Entitlement the disqualifies from driving if resting BP consistently 180 mmHg systolic or more and/or 100 mm Hg diastolic or more
angioplasty (elective) - 1 week off driving
CABG - 4 weeks off driving
acute coronary syndrome- 4 weeks off driving, 1 week if successfully treated by angioplasty
angina - driving must cease if symptoms occur at rest/at the wheel
pacemaker insertion - 1 week off driving
implantable cardioverter-defibrillator (ICD): if implanted for sustained ventricular arrhythmia: cease driving for 6 months. If implanted prophylatically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers
successful catheter ablation for an arrhythmia- 2 days off driving
aortic aneurysm of 6cm or more - notify DVLA. Licensing will be permitted subject to annual review. An aortic diameter of 6.5 cm or more disqualifies patients from driving
heart transplant: DVLA do not need to be notified
LBBB
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
Causes of LBBB
ischaemic heart disease
hypertension
aortic stenosis
cardiomyopathy
rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
MI
ECG changes
Coronary artery
Anteroseptal V1-V4 Left anterior descending
Inferior II, III, aVF Right coronary
Anterolateral V4-6, I, aVL Left anterior descending or left circumflex
Lateral I, aVL +/- V5-6 Left circumflex
Posterior Tall R waves V1-2 Usually left circumflex, also right coronary
ECG features of hypokalaemia
In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
ECG:
Normal variants
- Sinus arrhythmia
- Right axis deviation (tall and thin individuals)
- Left axis deviation (short, obese individuals)
- Partial right bundle branch block
Athletes often have a high vagal tone:
- Sinus bradycardia
- 1st degree atrioventricular block
- Wenckebach phenomenon (2nd degree atrioventricular block Mobitz type 1)
- Junctional escape rhythm
CCF
Heart failure drug management
- ACE inhibitors (SAVE, SOLVD, CONSENSUS)
- beta-blockers (CIBIS)
- spironolactone (RALES)
- hydralazine with nitrates (VHEFT-1)
first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker*. Generally, one drug should be started at a time
second-line treatment is now either an aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate
if symptoms persist cardiac resynchronisation therapy or digoxin** should be considered. An alternative supported by NICE in 2012 is ivabradine. The criteria for ivabradine include that the patient is already on suitable therapy (ACE-inhibitor, beta-blocker + aldosterone antagonist), has a heart rate > 75/min and a left ventricular fraction < 35%
diuretics should be given for fluid overload
offer annual influenza vaccine
offer one-off*** pneumococcal vaccine
NYHA
The New York Heart Association (NYHA) classification is widely used to classify the severity of heart failure:
Heart failure NYHA classification
NYHA Class I
no symptoms
no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
NYHA Class II
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
NYHA Class III
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
NYHA Class IV
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
Hypertension
Stage 1 hypertension
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
Stage 2 hypertension
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
Severe hypertension
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg
Step 1; Age <55 - ACE inhibitor. Age >55 or of black African or Caribbean origin - calcium channel blocker
Step 2; ACE inhibitor + calcium channel blocker
Step 3; ACE inhibitor + calcium channel blocker + thiazide-like diuretic
Step 4; consider further diuretic or beta-blockade or alpha blocker and seeking expert advice
Hypertension
Secondary Causes
Renal disease accounts for a large percentage of the other cases of secondary hypertension. Conditions which may increase the blood pressure include:
glomerulonephritis
pyelonephritis
adult polycystic kidney disease
renal artery stenosis
Endocrine disorders (other than primary hyperaldosteronism) may also result in increased blood pressure:
phaeochromocytoma
Cushing’s syndrome
Liddle’s syndrome
congenital adrenal hyperplasia (11-beta hydroxylase deficiency)
acromegaly
Drug causes:
steroids
monoamine oxidase inhibitors
the combined oral contraceptive pill
NSAIDs
leflunomide
Bacterial endocarditis
The vast majority of cases of are caused by gram positive cocci.
Common causes:
Streptococcus viridans
Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)
Staphylococcus epidermidis (in prosthetic valves)
Rarer causes:
Enterococcus
Streptococcus bovis
Candida
HACEK group
Coxiella burnetii
QT interval
Prolonged
drugs block of potassium channels.
Causes of long QT syndrome:
1. Genetic:
LQT1 / LQT2 (potassium channel mutation); LQT3 (sodium channel mutation)
Jervell and Lange-Nielsen syndrome (associated with deafness)
Romano-Ward syndrome
- Electrolytes:
Hypocalcaemia
Hypomagnesaemia
Hypokalaemia
- Drugs:
Antiarrhythmics (e.g. amiodarone, sotalol)
Antibiotics (e.g. erythromycin, clarithromycin, ciprofloxacin)
Psychotropic drugs (e.g. serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic agents)
amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram)
methadone
chloroquine
terfenadine**
erythromycin
haloperidol
ondanestron
electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
acute myocardial infarction
myocarditis
hypothermia
subarachnoid haemorrhage
Diuretics
Furosemide and bumetanide are loop diuretics that act by inhibiting the Na-K-Cl cotransporter
hypokalaemia, hypomagnesaemia
hypochloraemic alkalosis
ototoxicity
hypocalcaemia
renal impairment (from dehydration + direct toxic effect)
hyperglycaemia (less common than with thiazides)
gout
Nicorandil
vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP.
Adverse effects
headache
flushing
anal ulceration
Contraindications
left ventricular failure
So which features make pulmonary embolism more likely?
The PIOPED study1 in 2007 looked at the frequency of different symptoms and signs in patients who were diagnosed with pulmonary embolism.
The relative frequency of common clinical signs is shown below:
Tachypnea (respiratory rate >20/min) - 96%
Crackles - 58%
Tachycardia (heart rate >100/min) - 44%
Fever (temperature >37.8°C) - 43%
Clinical feature
Points
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins)
3
An alternative diagnosis is less likely than PE
3
Heart rate > 100 beats per minute
1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks
1.5
Previous DVT/PE
1.5
Haemoptysis
1
Malignancy (on treatment, treated in the last 6 months, or palliative)
1
Clinical probability simplified scores
PE likely - more than 4 points
PE unlikely - 4 points or less
PE
Treatment
a vitamin K antagonist (i.e. warfarin) should be given within 24 hours of the diagnosis
the LMWH or fondaparinux should be continued for at least 5 days or until the international normalised ratio (INR) is 2.0 or above for at least 24 hours, whichever is longer, i.e. LMWH or fondaparinux is given at the same time as warfarin until the INR is in the therapeutic range
warfarin should be continued for at least 3 months. At 3 months, NICE advise that clinicians should ‘assess the risks and benefits of extending treatment’
NICE advise extending warfarin beyond 3 months for patients with unprovoked PE. This essentially means that if there was no obvious cause or provoking factor (surgery, trauma, significant immobility) it may imply the patient has a tendency to thrombosis and should be given treatment longer than the norm of 3 months
for patients with active cancer NICE recommend using LMWH for 6 months
Scoring systems
CHA2DS2-VASc
Used to determine the need to anticoagulate a patient in atrial fibrillation
ABCD2
Prognostic score for risk stratifying patients who’ve had a suspected TIA
NYHA
Heart failure severity scale
DAS28
Measure of disease activity in rheumatoid arthritis
Child-Pugh classification
A scoring system used to assess the severity of liver cirrhosis
Wells score
Helps estimate the risk of a patient having a deep vein thrombosis
MMSE
Mini-mental state examination - used to assess cognitive impairment
HAD
Hospital Anxiety and Depression (HAD) scale - assesses severity of anxiety and depression symptoms
PHQ-9
Patient Health Questionnaire - assesses severity of depression symptoms
GAD-7
Used as a screening tool and severity measure for generalised anxiety disorder
Statins
Statins inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis
Cardiovascular disease: atorvastatin 20mg for primary prevention,
80mg for secondary prevention
Important for meLess important
Individuals with type 1 diabetes who do not have established cardiovascular disease (CVD) risk factors should be offered atorvastatin 20 mg for primary prevention of CVD if they are:
Older than 40 years of age
Have had diabetes for more than 10 years
Have established nephropathy
Have other CVD risk factors (such as obesity and hypertension)
Supraventricular tachycardia
Whilst strictly speaking the term supraventricular tachycardia (SVT) refers to any tachycardia that is not ventricular in origin the term is generally used in the context of paroxysmal SVT. Episodes are characterised by the sudden onset of a narrow complex tachycardia, typically an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.
Acute management
vagal manoeuvres: e.g. Valsalva manoeuvre, carotid sinus massage
intravenous adenosine 6mg → 12mg → 12mg: contraindicated in asthmatics - verapamil is a preferable option
electrical cardioversion
Prevention of episodes
beta-blockers
radio-frequency ablation
Thiazide diuretics
Thiazide diuretics work by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl− symporter. Potassium is lost as a result of more sodium reaching the collecting ducts. Thiazide diuretics have a role in the treatment of mild heart failure although loop diuretics are better for reducing overload. The main use of bendroflumethiazide was in the management of hypertension but recent NICE guidelines now recommend other thiazide-like diuretics such as indapamide and chlortalidone.
Common adverse effects
dehydration
postural hypotension
hyponatraemia, hypokalaemia, hypercalcaemia*
gout
impaired glucose tolerance
impotence
Rare adverse effects
thrombocytopaenia
agranulocytosis
photosensitivity rash
pancreatitis
