Cardiovascular Conditions Flashcards
Abdominal aortic aneurysm (risk factors, history, differentials, surveillance, indications of repair)
Key points
● 65% of patients with a ruptured AAA die
● There is no routine screening in asymptomatic patients even with there is a strong family history
● If a patient is symptomatic then they should be investigated and referred to a vascular surgeon
Risk factor: > 65 years with history of peripheral vascular disease, advancing age, male, smoking, family history, atherosclerosis, HTN, hypercholesterolaemia, aneurysm.
History: smoking, chronic obstructive pulmonary disease, hypertension, genetic (Marfan and Ehlers-Danlos)
Differentials: renal calculus, diverticulitis, incarcerated hernia, lumbar spine disease.
Surveillance: 3-3.9 24 months, 4-4.5 12 months, 4.6-5 6 months, >5 3 months.
Indications for repair: >5.5 male, >5 female, change of >1 cm in 1 year, symptomatic
Acute pulmonary oedema
radiological findings, initial treatment pre-hospital vs. ED setting
Radiological findings - cardiomegaly, Kerley lines, azygos, pleural fluid.
Initial treatment (Pre-hospital)
1. Sit patient upright
2. Frusemide 20-80mg IV STAT and reassess in 20 mins
3. High-flow oxygen if SatO2 <94%
4. Consider GTN 400 mcg sublingual repeat every 5 min up to 1200 mcg IF SBP >100 mmHg
Initial treatment (ED setting)
1. Frusemide 20-80mg IV STAT and reassess in 20 mins
2. IF SBP >100 mmHGm GTN 10mcg/min IV infusion
3. CPAP (start 10cm of water pressure)
4. Morphine 1-2.5mg IV once only
Aortic dissection (classification, mechanism, risk factors, presentation, investigations)
Classification: refer to page 53 of GP Study Notes
Mechanism: tear in the aortic intima.
Risk factors: age, male, hypertension, preexisting aortic aneurysm, connective tissue disorder, Turner syndrome,
trauma, cocaine use.
Presentation: anterior chest pain ‘tearing’ posterior chest or back pain.
Investigations: If stable = CT angiogram.
Atrial fibrillation - classification
First diagnosed - First episode, has not previously been diagnosed
Paroxysmal - Self-terminating within 48 hours (up to 7 days)
Includes episode that have been cardioverted back
Persistent - Last longer than 7 days
Includes those cardioverted after 7 days
Long-standing persistent - Lasts > 1 year with rhythm control
Permanent - Rhythm control not used because remaining in AF acceptable by patient
Atrial fibrillation (approach to management, rate control, anti-coagulation)
Approach to management
Goals: reduction of VTE/stroke risk, symptom relief, treatment of comorbidities.
Rate-control: appropriate in asymptomatic patients with normal LVEF.
Rhythm-control: appropriate in patients who are highly symptomatic or have LV dysfunction.
Treatment choice:
● Immediate cardioversion: haemodynamically unstable atrial fibrillation.
● Delayed cardioversion: haemodynamically stable, left atrial thrombus excluded.
● Rate or rhythm control: haemodynamically stable atrial fibrillation lasting less than 48 hours (low risk of VTE)
Rate control Aim: HR < 110 bpm First-line: beta blocker ● Atenolol 25 mg PO daily ● Use carvedilol, bisoprolol or metoprolol succinate in HF patients Second-line: calcium channel blocker ● Diltiazem MR 180 mg PO daily Left ventricular dysfunction: ● Amiodarone 200mg PO daily
Anti-coagulation
CHADSVASc
Benefit of treatment:
● Men with score >2
● Women with score >3
Valvular vs. non-valvular atrial fibrillation
Valvular
● Criteria: Moderate or severe mitral stenosis and/or mechanical heart valve
● Significance: increased risk of VTE or stroke
● Anticoagulation choice: warfarin
Non-valvular
● Have benefit from anti-coagulation
● Can use other oral agents aside from warfarin
Cardiac tamponade (triad, causes)
Triad: elevated JVP, pulsus paradoxus, muffled heart sounds.
Cause: any process that causes pericarditis.
● Viral
● Drugs (hydralazine, procainamide, isoniazid, minoxidil)
● Connective tissue disease - systemic lupus erythematosus, rheumatoid arthritis
● Uraemia
Stable angina (definition, management)
Definition: precipitated by exertion, typical radiation to shoulder/jaw/inner arm, relieved by rest or GTN in 10 mins.
Management of acute episode in stable:
● GTN spray 400 microgram sublingual, every 5 mins in pain persists, up to total of 3 doses if tolerated
● If pain persists after 10 minutes despite two doses, take a third dose of GTN and call an ambulance.
Ongoing management:
● Atenolol or metoprolol 25mg daily OR,
○ Consider carvedilol or bisoprolol in there is an element of heart failure
● Diltiazem 180mg PO daily
○ Do not use in combination with beta-blocker due to risk of severe bradycardia and heart failure
Acute chest pain - key points, initial therapy
Key points
● Consider AMI in all cases where a clear alternative diagnosis is not evident
● A normal ECG does not rule out AMI
● If a troponin is indicated then refer to ED
Initial therapy
- Aspirin 300mg PO (chewed or dissolved)
- If stable, GTN 400-800 microg sublingually every 5 mins (up to 3 doses)
- For pain, morphine 2.5mg IV
- Oxygen if SatO2 <94%
Cardiac investigations (stress ECG, stress ECHO, myocardial perfusion imaging, coronary CTA, calcium scoring)
Key points
● CT angiogram is gold standard
Stress ECG
● ST-segment depression on stress
● 70% sensitive and specific for CAD in men (60% in women)
Stress echocardiography
● 80% sensitive and specific in men and women
● Predictive value is optimised in patients with intermediate pretest probability of having CAD.
Myocardial perfusion imaging
● Thallium or sestamibi used
● Indicates regions of reversible and irreversible MI
● Useful in patient with abnormal resting ECG (e.g. LBBB)
Coronary CT angiography
● Indications:
○ Undifferentiated chest pain, normal ECG and normal troponin
○ Continuing, stable chest symptoms and normal stress test
Calcium scoring
● Indication: asymptomatic patients with intermediate Framingham risk (i.e. CVD risk of 10-15% in next 5
years)
● Not MBS rebated
Familial hypercholesterolaemia (presentation, ddx, calculator tools, treatment)
Presentation: severely elevated LDL with xanthoma and strong family history of premature cardiovascular levels (men
<55, female <60)
Need to exclude: nephrotic syndrome, severe cholestasis, hypothyroidism
Calculator tools: Dutch Lipid Clinic Network Score
Treatment: Commence treatment at time of diagnosis. Generally started at 10 yrs in children.
Familial hypercholesterolaemia (medication options)
Ezetimibe
(10mg PO daily)
- Can lower LDL by 20-25% in combination with statin
- Modest reduction in cardiovascular events but no effect on mortality.
- ADR: muscle pain, mild elevation of ALT.
Statin - High potency: ● Atorvastatin 40mg PO daily ● Rosuvastatin 5mg PO daily - LFTs: not indicated to monitor. Consider ceasing if ALT 3x upper limit on the second measurement.
Bile acid binding resin
- Example: cholestyramine 4g PO daily
- Often used in combination with statin.
- Avoid in patients with high triglycerides.
Fibrates
- Example: fenofibrate 145 mg PO daily (eGFR >60).
- Lowers triglycerides, modest reduction in LDL.
- Consider checking CK regularly if it is used in combination with statin.
Hypercholesterolaemia (non-pharmacological management)
Non-pharmacological options:
● Reduce intake of saturated and trans fats
● Replacing saturated fats with monounsaturated and polyunsaturated fats
● Increasing intake of soluble fibre
● Introducing plant sterol-enriched milk, margarine or cheese products
● Exercise and weight loss most effective and increased HDL levels
Heart failure - key points
● HFrEF = LVEF <50%, HFpEF = LVEF >=50%
● ECHO (gold standard), BNP can be used if ECHO not available (repeat 3-6 months post-commencement of
therapy)
● ACEI/ARB, beta blockers and spironolactone have mortality benefits for HFrEF (up tp 50-60% reduction)
● Entresto should be commenced if LVEF <40%
● Ivabradine should be commenced for LVEF <35% (if HR > 70 bpm)
● Metoprolol succinate (sustained release)
Heart failure - classifications
NYHA grading I = no limitations II = slight limitations III = marked limitations IV = unable to perform without discomfort
Heart failure - diagnostic criteria
HFrEF
- Symptoms +/- signs of heart failure
- LVEF <50%
HFpEF
- Symptoms +/- signs of heart failure
- LVEF >50%
- Objective evidence of relevant structural heart disease and/or diastolic dysfunction
Heart failure - diagnostic workup
** Refer to page 177 of GP Study Notes
Heart failure - management
Algorithm
** Refer to page 178 of GP Study Notes
Medications
- Heart failure specific beta blockers: carvedilol (3.125mg BD), metoprolol succinate (12.5mg daily), bisoprolol (1.25mg
daily).
● Start low and double dose every 2 weeks until maximum tolerated dose reached
- Angiotensin receptor neprilysin inhibitor: entresto (LVEF <40%)
- Other: ivabradine (restricted to symptomatic systolic CHF w/ HR >=77bpm, LVEF <35% and NYHA class II/III).
- Diabetes: SGLT2 (i.e. empagliflozin) inhibitor if concurrent HF.
Hypertension - principles of therapy, medications
Principles of therapy
1. Start with low-moderate dose of first line drug
Review every 4-6 weeks for tolerance, efficacy, adverse effects and adherence
2. If target not reached after 3 month then add a second agent from a different class at low-moderate dose
3. If target reached then review ever 3-6 months
Medications
● First-line (uncomplicated and non-pregnant): ACEI, ARB, CCB, thiazide and thiazide-like diuretics.
● Second-line: beta-blockers (unless history of HFrEF and/or CVD).
Hypertension - medication profiles
ACEI (Perindopril 5mg PO daily)
- Monitor for hypotension kidney impairment and hyperkalaemia.
- Avoid combining diuretics and NSAID.
- No need to cease if there is an increase in Cr (up to 25%) or potassium (normal range).
- ADRs: cough, angioedema.
- Indications: HFrEF, CKD, diabetes
- Contraindication: pregnancy.
CCB (amlodipine 10mg PO daily)
- ADRs: peripheral oedema
- Indications: stable angine
Thiazide or thiazide-like diuretics (Hydrochlorothiazide
12.5mg PO daily or Indapamide 1.25mg PO
daily)
- Avoid in gout
- Associated with risk of new-onset diabetes in younger patients
- Indications: patients > 65 yrs
Hypertension - pregnancy, combinations to avoid, factor for poor response
Pregnancy:
● Centrally acting antiadrenergic: Methyldopa (125mg PO BD) or clonidine (50 microg PO BD)
○ DO NOT stop clonidine suddenly due to risk of severe rebound hypertension
● Beta-blocker: Labetalol
Combinations to avoid:
● Diltiazem with beta-blocker (heart block)
● ACEI/ARB with K+ sparing diuretic (hyperkalaemia)
● ACEI with ARB (renal dysfunction)
● Verapamil with beta-blocker (heart block)
Factors for poor response:
● Non-adherence
● Undiagnosed secondary causes for hypertension
● Treatment resistance due to sleep apnoea
● Undisclosed use of alcohol or recreational drugs
● Unrecognised high salt intake
● NSAID use
Hypertrophic cardiomyopathy (key points, clinical features, findings, ECG)
Key points
● Most commonly inherited cardiac disorders
● Number one cause of sudden cardiac death in young adults
Clinical features:
● Exertional syncope or presyncope
● Pulmonary congestion (exertional dyspnoea, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea)
● Chest pain
● Palpitations (supraventricular or ventricular arrhythmias)
Physical findings: systolic ejection crescendo-decrescendo murmur, holosystolic murmur at apex and axilla, other
(apical precordial impulse displaced laterally).
ECG finding: asymmetrical septal hypertrophy
● Voltage criteria for LVH, deep narrow Q waves <40ms wide in the lateral leads, aVL and V5-6
Immune thrombocytopenic purpura (triad, features, types, diagnostic criteria)
Triad: bruising + oral bleeding + epistaxis
Clinical features: ● Acute onset ● No systemic illness ● Isolated thrombocytopenia ● Easy bruising, epistaxis, bleeding gums ● Examination otherwise normal
Types
● Acute - usually in children, usually post-viral
● Chronic - autoimmune disorder, usually in adult women, all cases need referral
Diagnostic criteria:
● One of exclusion
● Only isolated thrombocytopenia without another apparent cause
Metabolic syndrome (criteria)
Criteria: Any three of below criteria.
- Elevated waist circumference (>94 men, >80 women)
- Elevated triglyceride (>1.7)
- Reduced HDL (<1 men, <1.3 women)
- Elevated BP (SBP >130, DBP >85)
- Elevated fasting glucose (>5.5)
Myocarditis (cause, significant)
Causes:
● Viral - HIV, influenza A, adenovirus
● Bacterial - mycoplasma
● Immune mediated - sarcoidosis, SLE, Kawasaki’s disease
● Drugs/toxin - clozapine, amphetamines
Significance: Increased risk of arrhythmias, cardiac failure, cardiogenic shock and death in the acute setting. May
cause dilated cardiomyopathy.
Pericardial effusion (imaging findings, examination, investigations)
Radiological finding: old-fashioned ‘water bottle sign’
Examination: in the absence of cardiac tamponade, physical signs are not sensitive or specific for pericardial effusion
Investigation: ECG and CXR (initial), ECHO (definitive).
Absolute cardiovascular risk calculator
Good to assess risk in patients >45 years without known history of CVD.
Criteria already known to be linked with high risk:
● Diabetes and age > 60 years
● Diabetes with microalbuminuria
● Moderate or severe chronic kidney disease
● Previous diagnosis of familial hypercholesterolaemia
● Systolic BP >=180 or diastolic >=110
● Serum total cholesterol >7.5
● ATSI >74 years
CVD and BP target
General: <140/90 (or lower if tolerated)
CVD: <140/90 (peripheral vascular disease), <130/80 (coronary heart disease and prevention in diabetes)
Diabetes: <130/80
CKD: <140/90 (or lower if tolerated)
CVD and lipid targets
***Same for everyone*** Total cholesterol: <4 HDL: > 1 LDL: < 2 (1.8) Non-HDL-C: <2.5 Triglyceride: <2
Raynaud phenomenon (key point, mechanism, trigger, presentation, management)
Key point
● Can be primary or secondary (suspect connective tissue disorder or malignancy if there are other signs)
Mechanism: vasospasm of the digits.
Triggers: cold.
Presentation: episodic blanching, cyanosis and then erythema. Can be painful.
Management:
● Treat the underlying cause (if there is one)
● Gloves, warm clothing, cessation of smoking, avoid beta blockers.
● Severe cases:
○ Amlodipine 5 mg PO daily
○ Nifedipine MR 30 mg PO daily
Thoracic aortic aneurysm (findings, complications)
Radiological findings: widened mediastinum, convex tracheal displacement, right sided bulge = ascending aorta, left
sided bulge = descending aorta.
Complications:
● Aortic dissection
● Atherosclerotic thoracic aortic aneurysm
Pulmonary embolism (tip, when to order D-dimer
Tip
● Superficial femoral vein is a DEEP vein
When to order D-dimer
- PERC rule positive
Imaging: CTPA (gold standard), VQ perfusion (pregnancy/severe renal failure)
Anticoagulation:
● Before - FBE, UEC, LFT, APTT, INR, bHCG (child-bearing age)
● Oral therapy (not first-line in pregnancy or cancer-related, no NOAC if eGFR <25-30)
○ Apixaban (CrCl>25) - 10 mg PO BD for 7 days, then 5 mg PO BD
○ Rivaroxaban (CrCl >30) - 15 mg PO BD for 21 days, then 20mg PO daily
*** If using dabigatran there is a need for bridging enoxaparin for 5 days prior to commencement
Post-thrombotic syndrome (significance, presentation, prevention, treatment)
Significance: commonly associated complication following DVT and can result in venous ulcer.
Presentation: chronic dependent swelling and pain, discomfort on walking, skin discolouration.
Prevention: graduated compression stockings.
Treatment: supportive (pain relief, stockings).
VTE - duration of treatment
Proximal DVT/PE with provoking factor removed
● 3 months and review
Isolated distal DVT
● 6 weeks and review
Unprovoked distal DVT and or proximal DVT/PE
● 3 months and review for ? cessation vs. ? indefinite continuation
VTE - prevention
Aspirin 100 mg PO daily can decrease the rate of recurrence for unprovoked proximal DVT or PE.
PICC-related venous thrombosis (RF, timeframe, presentation, management)
Risk factors: previous DVT, obesity, recent surgery, malignancy, critical illness, presence of comorbidities
Timeframe: develops 7-14 days from time of placement
Presentation: arm or forearm swelling, chest/upper arm vein dilation (obstruction bypass)
Management:
● Symptomatic - elevation and NSAIDs
● Anticoagulation - for at least 3 months
** Removal of functional PICC is not recommended because reinsertion is associated with higher risk of VTE.
IVC-related thrombosis (imaging, management)
Imaging: ultrasound.
Management:
● Superficial phlebitis → cease infusion, remove IVC, symptom management (elevation, warm/cold
compresses, NSAIDs)
** Consider suppurative phlebitis, chemical phlebitis or extravasation injury if pain is not well controlled with NSAIDs.
