CBL_2 HTN, HF and AF Flashcards
What patients with hypertension are at increased risk of?
- heart failure
- coronary heart disease
- haemorrhagic stroke
- renal damage
Patient position for BP reading
- Patient sat, resting
- 2 BP readings in clinic
- Cuff of correct size, ( small cuff rises BP)
What to do (in the clinic) if the patient has a reading of >140/90
If the BP is up (> 140/90):
- recheck
- also in the other arm
- if arms differ use the highest reading.
What further investigations to arrange for a patient with BP greater than 140/90?
If BP > 140/90:
- arrange a home ambulatory BP (ABPM) monitor reading for 12 hours whilst the patient is active
- alternative is home BP monitor (HBPM) e.g. if someone has a job needing arm movement I
How to carry out home BP monitor measurement? (HBPM)
- The patient records the lowest of 2 readings, repeated twice a day and for a week
- Exclude the first day readings. The remaining 12 readings are averaged
- should be < 135/85
What’s a normal target BP?
135/85
What’s target BP for >80 y old?
<150/90 clinic
<145/85 ABPM or HBPM
What to examine for if a patient has HTN?
- atheroma
- secondary HTN changes
- secondary HTN causes
- QRISK (and required investigations)
QRISK score of which would require a therapy?
>20%
What a QRISK inform us about?
A risk of coronary event in 10 years
What should be the initial step in the management of HTN?
Lifestyle advice initially: diet, exercise, alcohol , caffeine, salt, smoking
Stage 1A hypertension and its management
STAGE 1a hypertension:
BP > 135/85 but <150/95 on ABPM and QRISK <20%
Management: LIFESTYLE measures + review
Stage 1 hypertension - when to treat?
What’s stage 1B hypertension and when to treat?
STAGE1b hypertension:
BP>135/85 but < 150/95 and QRISK>20% or secondary prevention and <80 yrs old : TREAT
Values for stage 2 hypertension. Do we treat it?
STAGE 2 hypertension
any age BP>150/95 -> TREAT
What to do in a <40 years old patient with hypertension?
Refer to specialist to exclude secondary causes of HTN
When do we need same day referral in a patient with HTN? (2)
- possible phaeochromocytoma
- BP >180/110 and papilloedema or retinal haemorrhage
What’s defined as severe hypertension?
Clinic systolic BP >= 180 mmHg
OR
clinic diastolic BP >= 110 mmHg
Treatment of hypertension
What is resistant hypertension?
What’s the management?
a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best-tolerated doses
Management: step 4 treatment and expert advice
What’s step 4 treatment for resistant hypertension?
- consider further diuretic treatment
- if potassium < 4.5 mmol/l add spironolactone 25mg od
- if potassium > 4.5 mmol/l add higher-dose thiazide-like diuretictreatment
- if further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker
*if failed = expert advice
What are the complications of an uncontrolled AF?
- symptomatic palpitation
- inefficient cardiac function
- increased risk of stroke (as thrombus may form due to turbulent blood flow)
Classification of AF
- first detected episode (irrespective of whether it is symptomatic or self-terminating)
- paroxysmal AF - if 2 or more episodes and they terminate spontaneously (usually last 24 hours and less than 7 days)
- persistent AF - if AF is not self-limiting (usually more than 7 days)
- permanent AF - continuous AF which cannot be cardioverted (or if attempts are made they are inappropriate)
Treatment goals for permanent AF
permanent AF - continuous AF which cannot be cardioverted (or if attempts are made they are inappropriate)
Treatment goals: anticoagulation, rate control
Symptoms and sign (1) of AF
Symptoms
- palpitations
- dyspnoea
- chest pain
Signs
- an irregularly irregular pulse
What (3) conditions can manifest with irregularly irregular pulse?
- AF
- ventricular ectopics
- sinus arrhythmia
Two aims of management of AF
- stroke prevention
- rate/rhythm control
What are the approaches for rate and rhythm control in AF?
- rate control: accept that the pulse will be irregular, but slow the rate down to avoid negative effects on cardiac function
- rhythm control: try to get the patient back into, and maintain, normal sinus rhythm. This is termed cardioversion.
Which one, rhythm or rate control approach in AF is recommended by NICE?
NICE advocate using a rate control strategy except in a number of specific situations such as coexistent heart failure, first onset AF or where there is an obvious reversible cause.
What drugs are used for ‘rate control’ in AF?
First line: Beta-blocker or a rate-limiting calcium channel blocker (e.g. diltiazem)
If one drug does not control the rate adequately NICE recommend combination therapy with any 2 of the following:
- a betablocker
- diltiazem
- digoxin
What is used for rhythm control in AF?
cardioversion
What are the risks of cardioversion?
In cardioversion, the moment a patient switches from AF to sinus rhythm presents the highest risk for embolism leading to stroke. I
(thrombus formed in the fibrillating atrium suddenly being pushed out when sinus rhythm is restored)
For this reason patients must either have had a short duration of symptoms (less than 48 hours) or be anticoagulated for a period of time prior to attempting cardioversion
What are the conditions that must be met before cardioversion is attempted?
Due to high risk of stroke during cardioversion:
- patients must either have had a short duration of symptoms (less than 48 hours)
OR
- be anticoagulated for a period of time prior to attempting cardioversion
What’s the name of the clinical tool used to determine the most appropriate anti-coagulant strategy?
CHA2DS2-VASc score
Components of CHA2DS2-VASc score
Interpretation of CHA2DS2VASc score
What are (2) modes of cardioversion?
- electrical - ‘DC cardioversion’
- pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease
What’s AF?
- irregular, disorganized electrical activity in atria, leading to irregular ventricular rhythm
- the ventricular rate untreated AF often averages 160–180 bpm ( typically slower in elderly)
Common causes of AF (4)
- CHD
- HTN
- valvular heart disease (usually mitral stenosis)
- hyperthyroidism
ECG changes in AF patient
- irregular pulse
- no relationship of P-waves to QRS
- chaotic baseline
- irregular ventricular rate
When we should refer for cardioversion?
Referral for cardio-version in addition to rate-control treatment may be appropriate if there is a reversible cause e.g. chest infection or new-onset AF
What type of patients with AF require anticoagulation without the need of assessment for it?
Patients with valvular heart disease
When to refer a patient with AF to a cardiologist? (5)
- Rhythm control is appropriate
- Rate-control or anticoagulant treatment is contraindicated.
- Rate-control treatment fails to control the AF (refer within 4 weeks)
- The person has valve disease or left ventricular systolic dysfunction ( LVSD) on echocardiography.
- Wolff–Parkinson–White syndrome or a prolonged QT interval is suspected on ECG.
What assessment tool is used for the risk of bleeding while on anti-coagulation Rx?
HASBLED
Components of HASBLED
HAS-BLED scoring components and interpretation
What side of the heart is the most commonly affected by HF?
Most cases of heart failure are left systolic failure because this chamber has the highest workload and pressures
What about ejection fraction in L ventricular systolic HF?
EF will be reduced
What’s acute heart failure?
- life-threatening emergency
- sudden onset or worsening of the symptoms of heart failure
- it may present with or without a background history of pre-existing heart failure
- AHF without a past history of heart failure is called de-novo AHF
- Decompensated AHF is more common (66-75%) and presents with a background history of HF
What’s HF?
Heart failure describes the clinical syndrome that develops when the heart cannot maintain adequate cardiac output
NYHA classification
Risk factors for HF
- Diabetes
- Anaemia
- Arrhythmias
- Hyperthyroid
- Hypoxia
Symptoms of LHF
- SOB, cough, wheeze -> pulmonary oedema
- Dizzy and confused
- Palpitation
- Depression, anxiety
- Fatigue, weakness and reduced exercise tolerance
- Cyanosis
- Orthopnoea
- Syncope
Symptoms of RHF
- Abdominal pain and ascites
- Liver enlargement and splenomegaly
- Nausea
- weak and anorexia
- Weight gain
- nocturia
BNP levels in HF (2 scenarios: levels and referral)
- BNP should be more than >100 –then it’s likely to be HF, an echo should be performed 6 weeks afterwards
- BNP is 400 or more then the patient should be referred to cardiologists, and they should have an echo done within 2 weeks
Possible ECG changes in HF
ECG -> this would show a left ventricle hypertrophy, or a p pumonale, arrhythmias, T inversion, LBBB, and AF
Ejection fraction <40 (on ECHO in HF). What does it mean?
Left ventricular diastolic dysfunction
What does it mean when ejection fraction (on ECHO in HF) is >45% ?
EF is preserved
Possible clinical/exam signs of HF
- low BP
- low pulse
- low volume pulse
- poor renal function
- Raised JVP
- S3
- gallop
What’s a gallop rhythm?
A gallop rhythm
- heard when the first (S1) and second (S2) heart sounds are followed by a pathological third (S3) and/or fourth (S4) heart sound
- most commonly associated with left ventricular failure
- when this rhythm is associated with tachycardia, the heart sounds cannot be individually distinguished and therefore ‘summate’ into a single sound.
Third sound
- when does it occur
- cause
- meaning / associations with pathological conditions
The third heart sound
- occurs in early diastole
- caused by the rush of blood entering the ventricle as it relaxes
- presence of a third heart sound can be a normal finding in those below 40 years of age
- pathological is associated with cardiac failure, mitral regurgitation and dilated cardiomyopathy
The fourth cardiac sound
- when does it occur in the cardiac cycle
- its cause
- conditions associated with
The fourth heart sound
- occurs just before the first heart sound in the cardiac cycle
- caused by the atria contracting against the abnormally stiff ventricle
- it is always pathological
- can be heard in left ventricular hypertrophy, e.g. caused by aortic stenosis, systemic hypertension, amyloidosis and hypertrophic obstructive cardiomyopathy.
Both third and fourth heart sounds are best auscultated with the bell, with the patient leaning to the left.
CXR in HF. What are the possible signs?
- Pulmonary oedema
- Cardiomegaly
- Kerley B lines
- Prominent vasculature
- Upper lobe diversion
1st line Ix in suspected heart failure
all patients should have an N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test first-line.
What’s BNP?
B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain
*high levels associated with poor prognosis
BNP levels
- high
- raised
- normal
NT-pro-BNP levels
- high
- raised
- normal
Factors that will increase BNP levels
Factors that will decrease BNP levels
Possible complications of HF (just name the conditions)
- renal failure
- hyperkalemia
- hypokalaemia
- impaired liver function
- thromboembolism
- atrial and ventricular arrhythmias
Renal failure as a complication of HF. Why?
Renal failure:
- caused by poor renal perfusion, due to the low cardiac output -> there will be very low perfusion going to the kidneys
- this could be made worse if the patient is given either ACE-inhibitors, or angiotensin II receptor blockers (LOSARTAN) or diuretics
Hypokalaemia as a complication of HF. Why?
Hypokalaemia:
- result of treatment with potassium-losing diuretics, and hyperaldosteronism caused by the activation of RAAS and impaired aldosterone metabolism due to hepatic congestion
Hyperkalaemia as a complication of HF. Why?
Hyperkalaemia: this may be due to the effects of drug treatment, especially ACE-Inhibitors and spironolactone, and renal dysfunction.
Impaired liver function as a result of HF. Why?
Impaired liver function:
- caused by the hepatic venous congestion and poor atrial perfusion -> will frequently cause mild jaundice and abnormal LFTs
- this will also reduce the synthesis of the clotting factors, and make the anticoagulant control more difficult
Thromboembolism as a complication of HF. Why?
Thromboembolism:
- DVT and PE are more likely to occur in this case as a result of low cardiac perfection, and enforced immobility
Arrhythmias as a complication of HF. Why?
Atrial and ventricle arrhythmias:
these are very common and may be related to the electrolyte changes
Management of Acute HF
- Sit patient up and that is so you can lower congestion
- Give oxygen - high flow and high concentration
- non-invasive positive pressure ventilation
- nitrates
- loop diuretics -*furosemide* - to lower pulmonary oedema (urgent)
- The patient should be kept on a strictly bed rest, with continuous bed rest monitoring
- mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices
Consideration should be given to discontinuing beta-blockers in the short-term.
Management of chronic HF
- first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
- second-line treatment is now either an aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate
- sacubitril-valsartan is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
- if symptoms persist cardiac resynchronisation therapy or digoxin should be considered. Alternative: ivabradine
- diuretics should be given for fluid overload
- offer annual influenza vaccine
- offer one-off pneumococcal vaccine
*
Criteria for use of Ivabradine (3) in HF
- the patient is already on suitable therapy (ACE-inhibitor, beta-blocker + aldosterone antagonist),
- a heart rate > 75/min
- left ventricular fraction < 35%
(3) beta-blockers licensed for use in HF in the UK
bisoprolol, carvedilol, and nebivolol
Pneumococcal vaccine booster every 5 years in which patients?
adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years
What CCB would you prescribe as a first line for HTN?
Amlodipine 5mg once a day
