Cardiovascular Disease Flashcards
What is atherosclerosis
Combination of atheromas and sclerosis. Atherosclerosis affects the medium and large arteries. chronic inflammation and activation of the immune system in the artery wall. This causes deposition of lipids in the artery wall, followed by the development of fibrous atheromatous plaques.
what are atheromas
fatty deposits in the artery walls
What is sclerosis
the process of hardening or stiffening of the blood vessel walls
What is atherosclerosis caused by
Chronic inflammation and activation of the immune system in the artery wall. This causes deposition of lipids in the artery wall, followed by the development of fibrous atheromatous plaques.
What do atherosclerotic plaques cause
- Stiffening of the artery walls leading to hypertension and heart strain
- Stenosis leading to reduced blood flow (e.g. in angina)
- Plaque rupture giving off a thrombus that blocks a distal vessel leading to ischaemia
What are the non-modifiable risk factors of atherosclerosis
Older age
Family history
Male
What are the modifiable risk factors of atherosclerosis
Smoking Alcohol consumption Poor diet (high sugar and trans-fat and reduced fruit and vegetables and omega 3 consumption) Low exercise Obesity Poor sleep Stress
What co-morbidities increase the risk of atherosclerosis
Diabetes Hypertension Chronic Kidney Disease Inflammatory conditions such as rheumatoid arthritis Atypical Antipsychotic Medications
What is the end result of atherosclerosis
Angina Myocardial Infarction TIA/Strokes Peripheral Vascular Disease Chronic Mesenteric Ischaemia
Primary prevention of CVD
- QRISK3 score: >10% risk in 10 years start statin
- All patients with CKD and T1DM should be started on a statin
What do NICE recommend RE monitoring lipids
Check lipids every 3 months and increase dose to achieve 40% decrease in non-HDL cholesterol
ALWAYS check adherence before increasing dose
What is involved in secondary prevention of CVD
A: aspirin 75mg OD
A: Atorvostatin 80mg OD
A: Atenolol/beta blocker
A: ACEi
What are the ky side effects to note when taking a statin
- Myopathy (check creatine kinase in patients with muscle pain or weakness)
- Type 2 Diabetes
- Haemorrhagic Strokes (very rarely)
What is Angina
constricting chest pain with or without radiation to jaw or arms as a result of narrowing of the coronary arteries. This means that during periods of high demand of blood flow, like in exercise, the heart is not receiving enough oxygenated blood to meet demand.
What is considered as stable angina
symptoms are always relieved by rest or glyceryl trinitrate (GTN)
How do you investigate angina?
- gold standard: CT Coronary angiography
What is CT coronary angiography
This involves injecting contrast and taking CT images timed with the heart beat to give a detailed view of the coronary arteries, highlighting any narrowing.
What baseline investigations should be done in someone with suspected angina
- Physical Examination (heart sounds, signs of heart failure, BMI)
- ECG
- FBC (check for anaemia)
- U&Es (prior to ACEi and other meds)
- LFTs (prior to statins)
- Lipid profile
- Thyroid function tests (check for hypo / hyper thyroid)
- HbA1C and fasting glucose (for diabetes)
What is the management of stable angina
R: refer to cardiology if unstable
A: Advice RE. diagnosis, management, when to call 999
M: Medical treatment
P: Procedural or surgical interventions
What provides immediate symptomatic relief in stable angina
- Their GTN spray is used required. It causes vasodilation and helps relieves the symptoms.
- Take GTN, then repeat after 5 minutes. If there is still pain 5 minutes after the repeat dose – call an ambulance.
What provides long term symptomatic relief in stable angina
- Beta blocker (e.g. bisoprolol 5mg once daily) or;
- Calcium channel blocker (e.g. amlodipine 5mg once daily)
- Long acting nitrates (e.g. isosorbide mononitrate)
- Ivabradine, Nicorandil, Ranolazine
What is a coronary artery bypass graft (CABG)
In severe stenosis, the chest is opened along the sternum, a graft vein from the patient’s leg (usually the great saphenous vein) is sewn on to the affected coronary artery to bypass the stenosis. The recovery is slower and the complication rate is higher than PCI.
What is considered normal blood pressure
<120/80
What is essential hypertension
- 95%
- HTN has developed on it’s own accord and there isn’t something else causing it
What causes secondary HTN
R – Renal disease is the most common secondary cause
O – Obesity
P – Pregnancy induced hypertension / pre-eclampsia
E – Endocrine: hyperaldosteronism (“Conns Syndrome”)
If BP is high and it doesn’t respond to Rx what should you consider?
renal artery stenosis
What are the complications of HTN
- Ischaemic Heart Disease
- Cerebrovascular accident (i.e. stroke or haemorrhage)
- Hypertensive retinopathy
- Hypertensive nephropathy
- Heart failure
What is the gold standard investigation for BP
24hr home ambulatory monitoring
Avoids white coat HTN
What readings are considered Stage 1 HTN
Clinic: >140/90
Ambulatory: >135/85
(2011 NICE likely to be lowered)
What readings are considered Stage 2 HTN
Clinic: >160/100
Ambulatory: >150/95
(2011 NICE likely to be lowered)
What is the first step in management of HTN
ACEi: <55 or non- black
Calcium channel blocker: >55 or black
What is the second step in management of HTN
Non black: ACEi + calcium channel blocker
Black: Angiotensin receptor antagonist e.g. candesartan
What is the third step in Management of HTN
ACEi + beta blocker + thiazide like diuretic e.g. indapamide
Which thiazide like diuretic to use
Potassium >4.5: indapamide
Potassium <4.5: spironalactone
How does spironalactone work
potassium-sparing diuretic” that works by blocking the action of aldosterone in the kidneys resulting in sodium excretion and potassium reabsorption
target BP in under 80s
< 140/90
Target BP in over 80s
< 150/90
Target BP in diabetics
<130/80
ACEi really help reduce complications in HTN + diabetes
First line treatment for hypertension in diabetic patients is an ACE inhibitor in everyone except
Women with child bearing potential: calcium channel blocker
Black patients: ACE inhibitor + calcium channel blocker
What are the Indications for CABG
- left main stem disease
- > 2 vessel disease
- Failure of medical management
- Concomitant valvular replacement
Which vessels are used as grafts in CABG
- Internal thoracic (mammary) vein
- Great saphenous
What medications are started post CABG
- Dual anti-platelet for 12 months (aspiring and clopi)
- Lifelong aspiring after 12 months
- Beta blocker e.g. bisoprolol
- ACEi (or ARB)
