Cardiovascular and vascular Flashcards
What is the treatment pathway for stable Angina?
1st: PRN symptom relief = GTN spray/sublingual tab
With advice on when to call 999
2nd: First line treatment
- Beta-blocker or CCB
- Reassess in 2-4 weeks to see response
3rd: Secondary CVD prevention
(prevent more deadly events)
-Stop smoking, dietary advice and exercise
-Consider antiplatelet medication (Aspirin 75mg pday)
-Offer statin (Atorvastatin 20mg if primary, 80mg if secondary)
4th: Offer ACE-I if they have DM (Protective for DM nephthropathy)
Give ACE-I if they have;
HTN, HF, Asymptomatic LV dysfunction, CKD, Previous MI
5th: Revascularisation
-PCI with stent and dual antiplatelet therapy for 12M
Or - CABG (last resort)
What are the non-medical interventions for Stable Angina and ACS?
Smoking cessation (All who have expressed a desire to quit should be offered support and advice, and referral to an intensive support service: NHS Stop Smoking Services)
Healthy diet (Mediterranean-style diet: more bread, fruit, vegetables and fish)
Exercise (20-30 min per day)
Safe alcohol consumption (less than 14 units, divided over 3-4 days)
What is the initial treatment pathway for CV protection NSTEMI/Unstable angina?
(NOT the symptom treatment)
- 300mg Aspirin (CI: bleed risk or allergy)
- Antithrombin therapy:
- no angiography in next 24 hrs = Fondaparinux
- angiography in next 24 hrs = Unfractionated Heparin
- angiography in next 24 hrs and GRACE score is >3% 6month mortality = Bivalirudin
- if in a high risk group (60+, Previous MI/Stroke/TIA/CABG) = Ticagrelor - Assess risk of future CV events in next 6 months:
GRACE 6 month mortality score
- low = 1.5-3% mortality
- Intermediate = 3-6% mortality - If risk is low or more:
300mg Clopidogrel - If risk is intermediate or more, or if low risk but Ischemia comes back:
offer coronary angiography with PCI
What is the initial treatment pathway for symptomatic relief in diagnosed NSTEMI/Unstable angina?
(NOT the CV protection pathway)
- Low flow oxygen if:
- SpO2 <90%
Or - Dyspnoea - Analgesia: IV Morphine 5-10mg
- Antiemetic: IV Metoclopramide
- Nitrates: GTN spray/sublingual tablet
What is the acute treatment pathway for STEMI?
MONACH: (Morphine, O2, nitrates, aspirin, clopidogrel, LMWH)
1. Aspirin 300mg, GTN and high flow oxygen
2. Consider ticagrelor 180mg or prasogrel 60mg
3. Morphine 5-10mg IV
4. Antiemetic metoclopramide 10mg IV (Adjunct to opioid)
5. Fondaparinux
6 Surgery/Fibrinolysis:
- Only if within 12 hours of episode
- First choice = Angiography/PCI with Bivalirudin
- If PCI isn’t available within 2 hrs of presentation = Fibrinolysis
What is the long term treatment of ACS?
- Aspirin 75mg OD per day - for >1 year
- Second antiplatelet (clopidogrel) - for >1 year
- Consider PPI
- Beta blocker (unless CI)
- ACE-I if underlying condition requires
(DM, LV dysfunction, HTN) - High dose statin (Atorvastatin)
Also: echocardiogram to check LV function
What is cardiac rehabilitation?
Offered to all people who have had an MI
Assessment of: motivation to change lifestyle; body mass index; dietary habits; exercise habits and fitness; psychological status; physical symptoms such as chest pain or breathlessness; cardiovascular risk factors.
Education: On the condition and treatment
Referrals (quit smoking, dietary advice)
Exercise programmes
Advice on relaxation
In the aftermath of an MI, what kind of psychological support is offered?
Stress management should be offered
CBT is not offered
After medical treatment and rehabilitation , what advice do we give the patient about their day to day living post-MI?
e.g. driving, sex, air travel, erectile dysfunction,
Driving: check with DVLA, depends on treatment., and if you drive a truck/bus/coach (time off)
Back to work: depends on physicality of job
Sex: usually begin again 4 weeks post-MI
Erectile dysfunction: offer phosphodiesterase inhibitor (sildenafil, tadalafil or vardenafil)
Air travel: Check with civil aviation authority
In the treatment of essential hypertension:
what is the BP target when measured in clinic, for those under the age of 80 who are not pregnant and have no comorbidities?
<140/90 mmhg
If measured at home: 135/85 mmhg
In the treatment of essential hypertension:
what is the BP target when measured in clinic, for those over the age of 80 with no comorbidities?
(Remember that comorbidities often change the target BP)
<150/90 mmhg
If measured at home: <145/85
In the treatment of essential hypertension:
what is the BP target for those under the age of 80 who are pregnant but have no comorbidities?
<150/100 mmhg
Diastolic must be above 80 mmhg
In the treatment of essential hypertension:
what is the BP target for those under the age of 80 who are pregnant and have evidence of target organ damage?
<140/90 mmhg
Which antihypertensive drugs must we stop during pregnancy?
ACE-I’s
ARB’s
What is the treatment pathway for essential hypertension?
A (or B) or C (or straight to D)
then A+C
then A+C+D
then A+C+D+S/D(inc)
A = ACE-I If <55
(If not tolerated use ARB)
C = CCB if >55 or Afrocarribean
(Use thiazide diuretic instead if: oedematous, not tolerated, high risk of HF or evidence of HF)
D = Thiazide diuretic
(Indapamide or chlortalidone)
S = Low dose spironolactone
(If HTN still not controlled and Potassium is low: <4.5 mmol/L)
D(inc) = Increased dose of thiazide diuretic
(If HTN still not controlled and Potassium is >4.5 mmol/L)
B = beta blocker
(If intolerant of A, woman of childbearing potential, pregnant or evidence of increased sympathetic drive)
What is the treatment pathway for hypertension?
- Grade 1 HTN = lifestyle advice
2. Grade 1 HTN + X = antihypertensive medications Where X is; - Target organ damage - CVD - Renal disease - Diabetes mellitus type 1/2 - QRISK2 10 year risk of >20%
- Grade 2 or grade 3 HTN = antihypertensive medications
What is the lifestyle advice for hypertension?
Diet:
Total fat should be <30% of normal intake
Saturated fat should be <7% of normal intake
Substitute saturated fats for monounsaturated fats
5 or more vegetable and fruit portions every day
Decrease intake of: salt, coffee and alcohol
Stop smoking
Exercise:
150 minutes of moderate Intensity exercise per week
Under what circumstances is cardiac resynchronisation therapy (CRT) indicated for in the treatment of chronic heart failure?
Patient has significant electrical and mechanical desynchrony (often this is the cause of the HF)
15% of HF patients are indicated for.
CRT:
Placement of a pacemaker under the thoracic cage with a lead to the atria, and to each ventricle. Acts to take over the rhythm generation and propagation of impulses throughout the heart.
Can be caused by valve issues, dilatation, wall thinning or thickening or arrythymias.
May be used with/without an implantable cardiac defibrillator - used for VENTRICULAR arrhythmias or those at risk of ventricular arrhythmias.
What is the long term treatment pathway for Chronic Heart Failure with reduced ejection fraction?
- Loop diuretic - titrations according to Symptoms
- Prescribe an ACE-I and a beta-blocker
-Must be licences for HF
-Start one at a time; ACE-I if fluid overload or DM
or beta-blocker if angina - If still symptomatic (NYHA grades 2-4): Refer to cardiology
- Consider antiplatelet if CAD
- Consider statin
- Manage causes/comorbidities
- Screen for depression/anxiety
- If stable: refer to cardiac rehabilitation programme
- Offer annual influenza and one-off pneumococcal vaccinations
- Assess BMI and offer advice
What is the treatment pathway for Acute Heart Failure (AKA decompensated heart failure)?
- IV Diuretic
- Monitor renal function, urine output and weight - If Myocardial ischemia, severe HTN or mitral/aortic regurgitation: IV nitrates
- If cardiogenic pulmonary oedema with severe dyspnoea and acidosis: Non-Invasive ventilation
- If severe symptoms or at risk of respiratory failure or their GCS is worsening: Invasive ventilation
If ejection fraction is below 45%:
- Beta blocker
CI - HR<50, secondary/tertiary AV heart block, shock - ACE-I or ARB
If ejection fraction is below 35%:
4. Spironolactone
If patient has significant arrythmia:
- Cardiac resynchronisation therapy (CRT)
If they are also at risk of or have ventricular arrhythmia:
- Add implantable cardiac defibrillator
If the cause of HF is valvular:
7. Valvular surgery
- Aortic valve replacement or mitral valve replacement/repair
(If unsuitable then transcatheter aortic valve implantation - TAVI)
If they are in AF:
8. Anticoagulate with dual antiplatelet therapy
What is the long term treatment pathway for Chronic Heart Failure with preserved ejection fraction?
- Prescribe loop diuretic - up to 80mg furosemide
- Refer to specialist for management advice
- Consider antiplatelet drug - CAD
- Consider statin - hyperlipidaemia
- Manage causes/comorbidities
- Screen for depression/anxiety
- If stable: refer to cardiac rehabilitation programme
- Offer annual influenza and one-off pneumococcal vaccinations
- Assess BMI and offer advice
(Major differences are cap on diuretic dose and no ACE-I/beta blockers)
What is the treatment pathway for infective endocarditis?
- Supportive care: control airway, breathing and circulation
- Broad-spectrum antibiotics:
Amoxicillin +/- Gentamicin/Vancomycin - Surgery: Only if antibiotics won’t take them out of the danger zone
(e. g. risk of severe HF, perivalvular abscess, valve perforation)
- often if cause is prosthetic valve
Treatment depends on presentation of IE:
- Emboli; stroke, DVT,
- Decompensated heart failure; pulmonary oedema
What is the treatment pathway for new-onset atrial fibrillation?
Basically: Sort emergencies, identify causes, rate control, rhythm control (If appropriate), assess stroke risk, assess anticoagulation benefits/risks, arrange follow up.
- Admission if:
- HR >150bpm (Fast AF or Atrial flutter)
- Or BP <90 mmhg systolic - Assess for, (and if indicated test):
- Cardio causes; HTN, Valvular disease, IHD
- Resp causes; Chest infections, PE, lung cancer
- Systemic causes; alcohol intake, thyrotoxicosis, electrolyte depletion, DM
- CXR, TFTs etc - Review ECG for causes
- FIRST LINE TREATMENT: Beta-blocker or rate-limiting CCB
- Atenolol, acebutalol, metoprolol, nadolol, oxprenolol, propanolol
- Verapamil
If AF began in last 48 hours and:
- New onset AF
- AF has reversible cause
- HF caused/worsened by AF
- Atrial flutter
- ADD TO RATE CONTROL: Cardioversion (rhythm control) is offered;
- Pharmacological cardioversion (amiodarone or sotalol)
- If AF persists >48 hours = electrical cardioversion
Cardioversion is CI if onset was >48 hours ago until patient has had 3 weeks of anticoagulation.
- Assess stroke risk: CHA2DS2-VASc assessment tool
- Assess bleed risk from anticoagulation:
HAS-BLED assessment tool - If CHA2DS2-VASc score >1 offer anticoagulation: Warfarin or NOAC (Rivaroxaban, apixaban, dabigatran)
- Follow up within one week - check drug tolerance, and INR if in warfarin
When clamping the abdominal aorta during endovascular surgery for an AAA:
Where do we want to clamp in order to have the minimal stress on the heart?
Infra-renally
This will allow the kidneys to receive their 25% of the CO from the heart and puts the least stress on it.
Will still cause ischemia and reperfusion issues to all organs below the kidneys (bowel)
Other options are:
Supra-renal, high stress on heart and ischemia below the superior mesenteric
Supra-coeliac, highest stress on heart and ischemia below the coeliac artery
