CV Management Flashcards
Aortic valve replacement.
a) How it’s performed
b) Indications
a) Open (fit patients, preferred), or TAVI (less fit patients; risk of stroke ~ 5%)
b) Syncope; severe stenosis
Post-MI management.
a) What activities should patients refrain from in the first 4 weeks?
b) Drug management - 2o prevention
c) Conservative management - 2o prevention
a) Sex, heavy lifting, driving, strenuous exercise
b) DAPT, BB, statin, ACEI
c) Smoking cessation, alcohol reduction, weight loss, increase physical activity, better diet
ACS management.
a) Immediate assessment and management
b) NSTEMI/unstable angina
c) STEMI
d) Monitoring
e) Long-term
a) - Suspect ACS? (chest/jaw/arm pain + typical features like nausea, sweating or decompensation)
- A-E and escalate (999)
- 12-lead ECG to determine management: STEMI or NSTEMI/unstable angina
b) - DAPT: Aspirin 300mg + clopidogrel/ticagrelor
- Plus anticoagulation: LMWH/ UFH/ fondaparinux
- For pain - GTN (sublingual, buccal or IV)
- If GTN doesn’t control pain - morphine/diamorphine + antiemetic (metoclopramide) - no limit provided BP >90/60
- If NSTEMI but high risk of death, can also give a GpIIb/IIIa inhibitor (e.g. tirofiban, eptifabatide)
- Take high-sensitivity troponins 3-6 hours post-onset of chest pain and then another 3 hours later
- Monitor ECG
- May be suitable for revascularisation
c) 1. Initial management as for NSTEMI (MONA + anticoagulation)
2. Reperfusion therapy:
- Coronary angiography + PCI if presentation is within 12 hours of symptom onset and can be delivered within 120 mins (target ‘door to balloon’ time = 90 mins)
- Thrombolytics/fibrinolytics (e.g. alteplase, streptokinase) are an alternative if patient presents > 12h post-symptom onset or PCI cannot be delivered within 2h of diagnosis
- Also offer anticoagulation (e.g. LMWH/ UFH)
d) - Monitor with ECG
- Troponins at 6h and 12h
e) - Conservative: smoking, weight, exercise, diet, alcohol
- Medical: DAPT (clopidogrel for 1 year), statin, ACEI, BBs
- Surgical: PCI or CABG (consider CABG if multi-vessel disease)
Causes of raised troponins.
a) Cardiac
b) Non-cardiac
a) - Acute MI (STEMI or NSTEMI)
- Other damage to cardiac muscle: stable CHD, arrhythmias, CCF, tachycardia, myo/endo/pericarditis,
HTN, cardiac contusion/trauma including surgery, HCM, ablation, pacing, aortic valve disease or aortic dissection
b) - PE, severe Pulmonary HTN
- Skeletal muscle injury
- Sepsis
- Renal failure
Stable angina: non-drug management
a) Conservative measures
b) Blood tests at diagnosis
c) Monitoring
a) Conservative measures: smoking, weight, exercise, diet, alcohol. Control comorbidities (e.g. cholesterol, HTN, diabetes)
b) FBC (anaemia), lipids and glucose, TFTs, renal function (UEs/creatinine), baseline LFTs
c) HTN, cholesterol, glucose, etc.
Angina: symptomatic control with GTN (advice)
- If chest pain onset, rest and take GTN
- Wait 5 minutes
- If persists, take another GTN and wait another 5 minutes
- If persists for another 5 minutes (i.e. total of 10 mins), or pain is getting worse, or feeling unwell (clammy, nauseous) - call 999
Angina: drug management
a) 1st line
b) 2nd line drugs
c) If medical management fails - ?
a) - Aspirin (plus gastroprotection); if already on clopidogrel (e.g. post-stroke), continue taking this and add aspirin as well
- BB or CCB (check HR and BP)
- GTN spray (check BP)
- Statin (check LFTs)
- ACE inhibitor (if DM, HTN, post-MI, CCF or CKD)
b) - If both BBs and CCBs are contraindicated/ not tolerated, try monotherapy with:
- Long-acting nitrate (e.g. isosorbide mononitrate)
- Ivabradine (antiarrhythmic - acts of funny Na channel)
- Nicorandil (vasodilator)
- Ranolazine
c) If medical/conservative measures fail = PCI or CABG
AF management.
a) Acute (<48h) and haemodynamically unstable
b) Acute (<48h) and haemodynamically stable
c) >48h: treatment ladder
d) Paroxysmal AF - pill in the pocket approach
e) Contraindicated medications in patients with structural heart disease
a) Electrical cardioversion
b) Electrical or chemical cardioversion (IV amiodarone or fleicanide); or rate control
c) 1st line: Rate control: BB, verapamil/diltiazem or digoxin (only in sedentary patients or those with CCF)
- 2nd line: combine BB with CCB or digoxin
- 3rd line: If still symptomatic under rate control, consider rhythm control: oral antiarrhythmics (sotalol, propafenone, fleicanide, amiodarone) or cardioversion once anticoagulated for 4 weeks
- Anticoagulation (CHADSVASc 1 or more)
- Consider pulmonary vein ablation
d) Patients can take an oral antiarrhythmic (fleicanide or propafenone) when attacks occur
e) Fleicanide, propafenone
Hypertension: diagnosis
a) Stage 1
b) Stage 2
c) Severe
a) 140/90 on 2 clinic readings or 135/85 on ABPM:
Treat if < 80 and any of the following:
- signs of end-organ damage (eg. renal disease, CVD)
- QRISK > 10%
- Diabetic
b) 160/100 on 2 clinic readings or 155/95 on ABPM
- Treat regardless of age
c) >180/120
Hypertension: management
a) Conservative
b) Drug management (steps 1 - 5)
c) Severe HTN - define
d) Targets
e) Monitoring frequency
f) All patients with HTN should also undergo what tests?
g) Which patients with stage 1 HTN should you treat? (based on above tests)
a) - Dietary changes - DASH - high fruit and veg, low fat, low salt
- Lower alcohol intake
- Smoking cessation
- Exercise - 30 mins 5 days per week
- Weight loss
- Stress management
b) 1st line: (A or C or D)
- <55/diabetic/CKD - ACE or ARB
- >55/black - CCB or Thiazide-like diuretic
2nd line:
- Combine the above (A + C or D)
3rd line:
- ACE/ARB + CCB + Thiazide-like (A + C + D)
4th line (resistant HTN):
- Spironolactone (if K+ <4.5)
- BB or alpha-blocker (if K+ >4.5)
5th line:
- Specialist referral
c) BP> 180/120.
- If signs of papilloedema/end organ damage - refer for same day assessment.
- If not, consider starting immediate anti-HTN therapy and arrange tests for end organ damage
d) - >80 years: below 150/100
- <80 years: below 140/90
- Diabetes: below 130/80
e) - Every 3 months until BP stabilised
- Once stable BP, annual review
f) - Check cholesterol level (high = statin)
- Check QRISK2 score (>10% = aspirin)
- 12-lead ECG
- Renal function annually: Serum UEs/creatinine, urine dipstick, ACR
- Monitor treatment adherence and management of risk factors
g) Target organ damage, established cardiovascular disease, renal disease, diabetes, QRISK2 of 10% or more.
IE: risk factors
- IVDU (staph)
- Valve replacements/ valvular defects
- Dental surgery
Acute heart failure: management
a) Drug
b) Non-drug
c) If patient is hypotensive/ shocked (HFrEF vs HFpEF)
a) LOON: Loop diuretics, Oxygen, Opiate (eg. morphine) Nitrates (e.g. isosorbide mononitrate)
(Note: - beware nitrates in hypotensive patients)
b) - Sit patient up, raise legs
- Fluid +/- sodium restriction
- CPAP (if T1RF), BiPAP (if T2RF)
c) - Monitor BP and for signs of shock (cool peripheries, prolonged CRT, reduced urine output, confusion)
- Monitor central venous pressure (CVP)
- HFrEF: if CVP adequate (adequate preload) - give an inotrope (eg. dobutamine); if this still doesn’t raise BP, consider a vasopressor (but beware - this will increase afterload)
- HFpEF: use vasopressor (eg. vasopressin, NAd); no inotropes, as systolic function is preserved)
Chronic heart failure: management
a) Conservative strategies
b) HFREF - 1st line
c) HFREF - 2nd line strategies (some under specialist supervision only)
d) HFPEF
e) Other interventions
f) Monitoring
g) Contraindicated drugs in HF
a) - Exercise (cardiac rehab programme)
- Manage risk factors
- Compression stockings, pillows
- Heart failure clinic, community HF nurses
b) - BB licensed in HF (bisoprolol, carvedilol, nebivolol)
- ACE inhibitor (or ARB)
(note: introduce one drug at a time, and only introduce second drug once condition is stable)
- Loop diuretic for symptom control
c) - If BB + ACE doesn’t adequately control symptoms add aldosterone antagonist (spiro/eplerenone) unless contraindicated (hyperkalaemia/ renal failure)
- Add-on therapies (under specialist supervision):
digoxin, ivabradine, sacubitril valsartan, hydralazine + long-acting nitrate
d) - Managed by heart failure specialist
- Loop diuretics for symptom control
- Manage comorbidities
e) - Vaccinations: pneumococcal and annual influenza
- Anticoagulation should be offered to patients with AF or history of VTE, LV aneurysm or intracardiac thrombus.
- Respiratory support: LTOT, CPAP/BiPAP
- Cardiac resynchronisation therapy (CRT), ICDs or revascularisation (CABG)
f) - Monitor symptoms, function, heart rhythm and fluid status
- Monitor renal function and UEs when initiating or increasing dose of ACE/ARB/aldosterone antagonist
- Monitor HR and BP when initiating/increasing BBs
g) CCBs (except amlodipine)
Chronic heart failure: assessment and management
a) Signs of examination
b) Confirming diagnosis
a) - LHF: cardiomegaly, basal crackles, gallop rhythm (S3), hypoxia, hypotension, weak/thready pulse
- RHF: leg swelling, hepatomegaly, raised JVP, ascites
b) BNP blood test, other bloods (e.g. FBC), ECHO, referral to heart failure clinic
NYHA classification of heart failure
I No limitation of physical activity.
II Slight limitation of physical activity: Ordinary physical activity results in fatigue, palpitation or dyspnoea
III Marked limitation of physical activity: Less than ordinary activity causes fatigue, palpitation, or dyspnoea.
IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases
