Cardiovascular Flashcards
Management of stable angina
Lifestyle advice
- smoking cessation
- cardioprotective diet
- weight loss
- exercise (within limits set by their symptoms)
- limitation of alcohol consumption
Medical management
1st line:
-sublingual glyceryl trinitrate (GTN) for the rapid relief of symptoms and to use before activities known to cause symptoms
-beta-blocker or calcium-channel blocker regularly to reduce symptoms
2nd line:
-long-acting nitrate (e.g. isosorbide mononitrate)or nicorandil or ivabradine or ranolazine
-If 2 drugs not effective/tolerated at highest doses, consider revascularisation
Secondary prevention of cardiovascular disease:
- consider aspirin 75mg daily, taking into account bleeding risk and comorbidities
- consider statins if needed
- treat high blood pressure
Stable angina investigations
Exercise ECG - if stable angina with an intermediate or high pretest probability of CHD
Unstable angina/NSTEMI management
Admit to CCU, get IV access, monitor vital signs, serial ECG
Give oxygen (if hypoxic)
Analgesia (GTN (initially sublingual, IV infusion if persistent chest pain), morphine sulphate/diamorphine, antiemetic (metoclopramide))
Offer a 300mg loading dose of aspirin and continue aspirin (75mg) indefinitely unless contraindicated
Offer fondaparinux unless high bleeding risk or immediate angiography (if contraindicated, consider alternative antithrombin)
Use risk scoring system (e.g. GRACE)
If low risk:
-consider conservative management - offer ticagrelor with aspirin unless high bleeding risk
-consider clopidogrel with aspirin, or aspirin alone, for high bleeding risk
-consider ischaemia testing before discharge; consider angiography if ischaemia develops or is shown on testing
If high risk:
-if clinically unstable, offer immediate angiography
-if clinically stable, consider angiography within 72 hours if not contraindicated
-if no separate indication for oral anticoagulation, offer prasugel or ticagrelor with aspirin
-if patient has a separate indication for oral anticoagulation, offer clopidogrel with aspirin
-offer systemic unfractionated heparin in cath lab if having PCI
-if PCI not done, consider angiography findings, comorbidities and risks and benefits when discussing management with interventional cardiologist, cardiac surgeon, and patient
Assess LV function if NSTEMI (and consider assessing in unstable angina)
Cardiac rehabilitation and secondary prevention
STEMI management
Admit to CCU, get IV access, monitor vital signs, serial ECG
Give oxygen (if hypoxic)
Analgesia (GTN (initially sublingual, IV infusion if persistent chest pain), morphine sulphate/diamorphine, antiemetic (metoclopramide))
Offer a 300mg loading dose of aspirin and continue aspirin (75mg) indefinitely unless contraindicated
Immediately assess eligibility for repercussion therapy
If eligible, offer repercussion therapy (primary PCI or fibrinolysis) ASAP:
-angiography with follow-on primary PCI:
-offer if presenting within 12 hours of symptoms and PCI can be delivered within 2 hours
-consider if presenting more than 12 hours after symptoms and continuing myocardial ischaemia or cardiogenic shock
-offer prasugrel (if not already on OA) or clopidogrel (if taking an OA) and aspirin
-offer unfractionated heparin
-if stenting, offer a drug-eluting stent
-offer complete revascularisation if multivessel coronary artery disease and no cardiogenic shock; consider culprit vessel only during the initial procedure if cardiogenic shock is present
-fibrinolysis:
-offer if presenting in 12 hours of symptoms and PCI not possible in 120mins
-give an antithrombin at the same time
-offer ECG 60-90mins after fibrinolysis
-offer ticagrelor with aspirin unless high bleeding risk
-consider clopidogrel with aspirin, or aspirin alone, for high bleeding risk
-do not repeat fibrinolysis; offer immediate angiography with follow-on PCI if indicated by ECG
-consider angiography during same admission if stable after successful fibrinolysis
If unsuitable for reperfusion therapy, offer medical management:
-offer ticagrelor with aspirin unless high bleeding risk
-consider clopidogrel with aspirin, or aspirin alone, for high bleeding risk
-offer cardiology assessment
Assess left ventricular function
Cardiac rehabilitation and secondary prevention
Acute heart failure investigations
Heart failure can be ruled out by BNP < 100 ng/l or NT-proBNP < 300 ng/l
If natriuretic peptide levels are raised, perform transthoracic Doppler 2D echo to look for cardiac abnormalities, within 48 hours of admission
Acute heart failure management
A-E assessment and resuscitation
Consider inotropes or vasopressin in patients with acute heart failure with potentially reversible cardiogenic shock
If a patient has cardiogenic pulmonary oedema with severe dyspnoea and acidaemia consider starting NIV without delay
Consider invasive ventilation in patients with acute heart failure that, despite treatment, is leading to or is complicated by respiratory failure or reduced consciousness or physical exhaustion
Offer IV diuretic therapy (bolts or infusion strategy); if already taking a diuretic, consider giving a higher dose
If already taking beta-blockers, continue unless HR<50bpm/ 2nd or 3rd degree AV block/ shock
Ensure condition is stable for 48 hours after (re)starting beta blockers and before discharging from hospital
Offer ACEi (or ARB if ACEi not tolerated) and aldosterone antagonist during admission if acute HF and reduced LV ejection fraction
Offer surgical aortic valve replacement to patients with heart failure due to severe aortic stenosis (or transcatheter aortic valve implantation (TAVI) if unsuitable for surgery)
Mechanical assist devices can be considered in patients with potentially reversible severe acute heart failure or patients who are potential candidates for transplantation
Chronic heart failure investigation
Refer patients with suspected heart failure and an NT-proBNP > 2000 ng/l to have a specialist assessment and transthoracic echo within 2 weeks
Refer patients with suspected heart failure and an NT-proBNP between 400 - 2000 ng/l to have a specialist assessment and transthoracic echo within 6 weeks
12-lead ECG +/- other tests to exclude possible exacerbating factors or other conditions
Chronic heart failure management
A loop diuretic may be prescribed for symptom relief while awaiting specialist assessment
For confirmed heart failure with reduced ejection fraction (<50%):
-diuretic for relief of symptoms of fluid overload
-ACEi and beta-blocker (introduce one, then introduce the second once patient is stable on the first) to reduce morbidity and mortality
For confirmed heart failure with preserved ejection fraction (>50%):
-low/medium diuretic if necessary
-specialist referral
In all people with confirmed heart failure:
-prescribing an antiplatelet drug and statin should be considered
-comorbidities and precipitating factors should be managed
-screening for depression and anxiety should be undertaken
-supervised exercise-based rehabilitation programme should be offered
-appropriate vaccinations should be offered
-self-care advice should be given
-nutritional status should be assessed
-follow-up and advanced care planning should be offered, if appropriate
-women of child-bearing age should be given advice about contraception and pregnancy
Atrial fibrillation management
Admit patients who have severe symptoms or a serious complications
Identify and manage underlying causes
Treat the arrhythmia:
-rate control (beta-blocker/ rate-limiting calcium channel blocker/ digoxin) is recommended in most people with AF
-rhythm control (in addition to rate control) may be appropriate if the person has AF with a reversible cause (e.g. chest infection); heart failure thought to be primarily caused (or worsened) by AF; or new-onset AF
Assess stroke risk using CHA2DS2VASc assessment tool
Assess risks and benefits of anticoagulation and start treatment if appropriate (use HAS-BLED assessment tool to assess risk of major bleeding and to identify and manage modifiable risk factors for bleeding)
Refer to cardiologist if:
-rhythm control is appropriate
-rate-control treatment fails to control symptoms (refer within 4 weeks)
-echo shows valvular disease or LV systolic dysfunction
-ECG suggests WPW syndrome or prolonged QT interval
CHA2DS2VASc assessment
Estimating risk of stroke in patients with AF
C - Congestive heart failure (or LV systolic dysfunction) - 1
H - HTN (BP consistently >140/90mmHg or treated HTN) - 1
A2 - age >=75 years - 2
D - Diabetes mellitus - 1
S2 - prior stroke/TIA/thromboembolism - 2
V - vascular disease (e.g. PAD, MI) - 1
A - age 65-74 years
Sc - sex category (female) - 1
If score 2+, warfarin or DOAC therapy is recommended
HAS-BLED assessment
Assess 1-year risk of major bleeding in patients taking anticoagulants with atrial fibrillation
H - HTN (uncontrolled, >160 mmHg systolic) - 1
A - Abnormal renal (dialysis, transplant, Cr>2.26mg/dL or 200umol/L) or liver function (cirrhosis, bilirubin >2x normal, AST/ALT/ALP >3x normal) - 1 for renal function, 1 for liver function
S - Stroke (Hx of) - 1
B - Bleeding (previous major bleeding or predisposition to bleeding) -1
L - Labile INR (unstable/high INR - time in therapeutic range <60%) - 1
E - Elderly (age >65years) - 1
D - Drugs or alcohol (prior alcohol or drug usage Hx (>=8 drinks/week), medication usage predisposing to bleeding (antiplatelet agents, NSAIDs) - 1 for Hx of alcohol/drug use, 1 for predisposing medications)
Hypertension investigation
Clinic blood pressure:
- > 180/110 - refer to specialist
- 140/90 - 180/110, offer ABPM to confirm diagnosis (or HBPM if ABPM is unsuitable)
Confirm HTN if ABPM average or HBPM average is 135/85 or higher
- ABPM should be done between the person’s usual waking hours
- for HBPM, 2 consecutive measures should be done each time, at least 1 minute apart with the person seated; BPs should be recorded morning and evening
Hypertension management - lifestyle interventions
Lifestyle interventions - healthy low-salt diet, regular exercise, reduce alcohol and coffee consumption, stop smoking
Hypertension management - criteria for starting medication
Offer antihypertensive drugs to patients with stage 2 HTN (CBP 160/100 - 180/120, ABPM/HBPM >150/95), or stage 1 HTN in adults under 80 or with target organ damage/established CVD/renal disease/diabetes
Hypertension management - medications
Under 55yrs and not of black African or African-Caribbean family origin; T2DM + HTN:
- ACEi or ARB
- CCB
Age 55yrs or over; black African or African-Caribbean family origin
- CCB
- ACEi or ARB or thiazide-like diuretic
All patients:
- ACEi/ARB + CCB + thiazide-like diuretic
- If still unmanaged = resistant hypertension -> confirm CBP with ABPM/HBPM, assess for postural HTN, discuss adherence ->
- spironolactone if serum potassium <=4.5
- alpha- or beta-blocker if serum potassium >4.5
Review annually
