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
