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Primary Care > CVS > Flashcards

CVS Flashcards

1
Q

Mitral Facies

A

bluish discolouration of the cheeks associated with low cardiac output (form of peripheral cyanosis)

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2
Q

A patient with unexplained clubbing should?

A

be referred for urgnent CXR

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3
Q

Pulsus Paradoxus occurs in?

A

(pulse weakens on inspiration- 10mmHg)
asthma
cardiac tamponade
pericarditis

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4
Q

Pulsus Tardus (slow-rising)

A

shock
pericardial tamponatde
aortic stenosis

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5
Q

ABPI measurement?

A

BP in one arm
Inflate cuff around lower calf
Doppler- record maximum pressure @ which pulse is heard
ankle pressure/ brachial pressure

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6
Q

Interpretation of results?

A

ABPI < 0.8 ischaemia

ABPI < 0.5 Critical Ischaemia

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7
Q

What can cause falsely elevated readings in ABPI?

A

Arterial calcification due to DM

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8
Q

Selection of patients for primary intervention of CVD?

A

Patients> 75yrs
Familial Monogenic Dyslipidaemia
Most patients with DM
CVD 10 yr risk >20%

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9
Q

If patients close to threshold for intervention, consider;

A 
Low socio-economic group
BMI > 40
Aready taking hypertensives and anti-lipid?
Recently stopped smoking?
Antipsychotic medications? 
CKD? RA? SLE? HIV?
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10
Q

A consistent difference of >10mmHg when measuring BP in both arms indicates?

A

Independent Risk Factor for CVD
Treat risk factors
Use higher reading

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11
Q

Why should you check radial/brachial pulse before measuring blood pressure?

A

Not an accurate measurement if irregular pulse present

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12
Q

Prevalence of white coat HTN?

A

10%

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13
Q

When to offer ambulatory BP monitoring?

A

BP > 140/90mmHg on two occassions

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14
Q

If BP > 180/110 mmHg, how should you proceed?

A

Start antihypertensives immediately

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15
Q

When should you refer a patient with severe HTN (>180/110) for urgent same day specialist assessment?

A 
Accelerated HTN (BP>180/110mmHg +/- papilloedema +/- retinal haemorrhage)
Phaeochromocytoma ( postural hypotennsion, tachycardia, headache, pallor, palpitations, diaphoresis)
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16
Q

ABPM is considered abnormal if?

A 
Average Daytime (20mins) >135/85mmHg
Average Night-time > 120/70mmHg
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17
Q

Instructions for HBPM?

A

4-7 consecutive days
2x/d (morning and evening) seated
2 reading >1min apart
Discard day 1 readingaverage of the 6days

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18
Q

Postural Hypotension?

A

Drop in systolic and diatsolic BP >20mmHg on standing

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19
Q

Measuring Postural Hypotension?

A

Measure seated

Measure after 1min standing

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20
Q

Managemet of Postural Hypotension?

A

Review Meds: sedatives, diuretics
Optimize tx: CVD, Parkinsons, DM
Advise: care

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21
Q

Percentage of people >60 yrs with HTN?

A

60%

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22
Q

Risk factors for essential/primary HTN?

A

Alcohol

Obesity

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23
Q

Causes of secondary HTN?

A

Renal disease
Endocrine: Cushings (+ steroid use),Phaeochromocytoma, Acromegaly, Hyperparathyroidism, Conn’s
Pregnancy
Coarctation of the aorta

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24
Q

Non-Dipping on ABPM is associated with?

A

Increases risk of end organ damage (LVH, Renal damage)

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25
Q

> 10% dipping @ night is associated with?

A

Increased risk of CVD events

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26
Q

Further Assessment of patients with HTN includes?

A

Identify target organ damage
Examine: heart, fundi- silver wiring, AV nipping, flame haemorrhages, cotton wool spots

Bloods: U&E, HbA1C, Lipid Profile,
Urine:RBCs, Protein, ACR
CV Risk Estimation
ECG +/- Echo if LVH

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27
Q

Lifestyle advice: Alcohol intake should be reduced to?

A

<21units/week Males

<14units/week Females

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28
Q

each 2mmHg increase in BP is associated with a ___% increased risk of mortality IHD and a _____% risk of mortality stroke

A

7%

10%

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29
Q

Prescribe Statin if;

A

HTN complicated by CVD, irrespective of cholesterol/LDL

Primary prevention in patients >40yrs with HTN and 10yr CVD risk > 20%

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30
Q

General rules for antihypertensive drug treatment:

A

Drug not tolerated: stop, move on

Drug tolerated but BP not dropped: Add next step

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31
Q

Antihypertensive treatment targets in patients without CKD or diabetes?

A 
140/90 
>80yrs 150/90
ABPM/HBPM: 
<135/85
>80yrs 145/85
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32
Q

Antihypertensive Treatment targets in diabetics?

A

Uncomplicated T2DM: <140/80
Uncompplicated T1DM: <135/85
Complicated: <130/80

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33
Q

Antihypertensive Treatment targets in CKD?

A

<130/80

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34
Q

Review Intervals for patinets with hypertension?

A 
Starting treatment: 1mnth
Controlled: 3mnths
Uncontrolled: Repeat BP reading. 
If sustained: alter meds 
Repeat mnthly
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35
Q

Referal hypertensive patients if?

A 
Accelerated HTN
Renal Impairment 
Suspected secondary Htn
Patients <40yrs
Difficult to treat BP
Pregnancy
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36
Q

B blockers are not used as initial tx for HTN except;

A

Women of childbearing potential
Patients w/t increased sympathetic drive
Patient w/t contraindications to ACEi/ARBs

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37
Q

If initial tx is with B-Blocker and second drug needed, what should you prescribe and why?

A

Non rate limiting CCB- amlodipine, felodipine

decrease risk of DM

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38
Q

How should Triglycerides be interpreted?

A

Independent risk factor for CVD

>5 High Risk

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39
Q

Ratio of total cholesterol:HDL >6

A

High Risk

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40
Q

% of patients with increased cholesterol that drops to normal on repeat measurement?

A

25%

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41
Q

Testing for Hyperlipidameia?

A

> /= 2 samples
Fasting: Initiating treatment or screening Familial dyslipidaemia
Non-Fasting: Screening and follow-up

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42
Q

When should you consider treatment of high lipids with a statin?

A

Lipids remain high despite low cholesterol diet and 10yr CVD risk >20%

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43
Q

Screening for familial hyperlipidaemia is indicated if?

A

First degree blood relatives >18yrs every 5yrs if;
FHx- familial hyperlipidaemia
FHx-premature CVD (M<55yrs, W,65yrs)

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44
Q

A patient with hypothyroidism has hyperlipidameia, how should you proceed?

A

Treat Hypothyroidism first (levothyroxine)
May resolve lipid abnormality
Increased risk of myositis with statins

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45
Q

If cholesterol level >5mmol/L, low-cholesterol diets result in decrease cholesterol by ___%

A

8.5% @ 3mnths

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46
Q

In patients with a BMI>30, weight decrease by ___kg causes a 7% decreasein LDL and 13% increase in HDL

A

10kg

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47
Q

Stain treatment?

A

Primary Prevention:
>20% 10yr risk CVD
>75yrs
DM >40yrs or with additional risk factors

Secondary Prevention:
Hx CVD irrespective of lipids

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48
Q

Before starting statin treatment assess?

A 
Fasting lipid profile (Initiating tx)
Fasting blood glucose
Renal Function
Liver Function
TSH if dyslipidaemia
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49
Q

Statins are contraindicated for?

A

Pregnant women
Breastfeeding Women
Active liver disease

(Transaminases that are not increase 3x are not a contraindication)

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50
Q

Statins interact with what types of drugs?

A

Warfarin (increase effect )

Increased risk of myositis wheen taken with?
Other lipid lowering drugs (Fibrates, Anion Exchange resin, Nicotinic Acid, Ezetimibe)
Macrolide antibiotics (Erythromycin)
CCB
Ciclosporin

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51
Q

NNT with statin in primary prevention to prevent 1 adverse event is

A

34.5

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52
Q

NNT with statin in secondary prevention to prevent 1 adverse event is

A

13.8

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53
Q

Prevalence of myositis as an adverse effect of statin use?

A

11/100000

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54
Q

If a patient on statin therapy presents with myositis, how should you proceed?

A

Check CK level
>5x upper limit withdraw therapy
Normal = 22-198

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55
Q

Prevelance of peripheral neuropathy as an adverse side effect of? statin use?

A

12/100000 person years

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56
Q

Patients on simvastatin should be advised to exclude what from their diet?

A

grapefruit juice

57
Q

80mg of simvastatin is only recommended in patients with?

A 
severe hypercholesterolemia (>240)
high risk of CVD
58
Q

Regarding hyperlipidaemia, refer patients who have;

A

Familial Hypercholesterolaemia
High TGs (independent RF)
Hypercholesterolaemia resistant to tx/ difficult to tx

59
Q

Diagnosis of unstable angina?

A 
History:
New onset intermittent chest pains Crushing central pain
radiates to Jaw/neck pain
Pain on exertion
stops with rest/ GTN sprays
60
Q

How would you exclude arteritis in the scenario of central chest pain?

A

ESR blood test

61
Q

Referal of patients with suspected stable angina to a rapid access chest pain clinic?

A

Confirm angina
Perform exercise ecg
Educate-tretament

62
Q

The % of patients with unstable angina that will suffer an MI in <1mnth

A

15%

63
Q

The incidence of unstable angina?

A

6/10000

64
Q

CABG > PCI, for treatment of unstable angina, in which cases?

A

DM
>65yrs
LAD artery disease
Complex 3x vessel disease

65
Q

Side effects of GTN?

A

Flushing
Headches
Light-headedness

66
Q

GTN education on use?

A

1-2 puffs as needed for pain and before exercise
Repeat after 5min if pain persists
Pain persists 5min after 2nd dose- call emergency ambulance

67
Q

When should you consider surgery for management of angina?

A

Not managed with two anti-anginal drugs

68
Q

When should you consider adding a third anti-anginal drug?

A

Symptoms are not well controlled with two anti anginal drugs and patient not suitable for surgery

69
Q

How would you check if a patient is B-Blocked?

A

Resting HR <65bpm

Exercise < 90bpm

70
Q

Which B Blockers should be used in paients with asthma or COPD?

A

Cardio-selective

Atenolol, Bisoprolol, Metoprolol, Nebivolol

71
Q

What should you tell a patient that wants to stop their B Blocker?

A

Do not stop suddenly or run out

Tail off over 4 weeks

72
Q

The use of 75mg aspirin as secondary prevention in patients with angina decreases mortality by?

A

34%

73
Q

Secondary Prevention of CHD mortality involves what types of treatment?

A

Aspirin/clopidogrel
Statins
Ace Inhibitors

74
Q

Following MI, what medications should a patient be on?

A

-Modify Risk Factors:
Statin
B-Blocker/Rate Limiting CCB

  • ACE Inhibitors/ ARB
  • Aspirin/Clopidogrel
75
Q

How many deaths does initiation of a B-Blocker following MI prevent?

A

12/1000/yr

76
Q

ACE Inhibitors prevent death <1mnth following MI in how many patients?

A

5/1000 treated

77
Q

How soon should aspirin be started following MI and why?

A

<24hrs

prevents 80 vascular events over 2y/1000patinets treated

78
Q

When should clopidogrel be prescribed in addition to aspirin?

A

For 12mnths: NSTEMI/unstable angina
For 1mnth: STEMI w/t no stenting
For 3mnths: STEMI w/t bare metal stenting
For 12mnths: STEMI w/t drug/eluting stent

79
Q

Patients following acute MI w/t symptoms and signs of heart failure and EF < 0.4?

A

Start Aldosterone antagonist (spironolactone) within 3-14days of MI, after ACE Inhibitor

80
Q

Return to work guide following (uncomplicated) MI?

A

Sedentary:4-6wk
Light Manual:6-8wk
Haevy Manual:3mnth

81
Q

Physical Activity Guide following MI?

A

2wk: stroll in garden
2-6wk: walk 0.5mile/day upto 2miles @ 6wks
6wks: 2miles <30mins
*sexual Activity after 6wks

82
Q

% of patients that are depressed after MI

A

50%

25% after 1 yr

83
Q

Dressler Syndrome?

A

2-10wks following MI
Recurrent fever, chest pain, pleural/pericardial effussion
Tx: Steroids and NSAIDS

84
Q

Causes of falsely decreased natriuretic peptide?

A 
Obesity
Diuretics
ACE inhibitors/ ARBS
B Blockers
Aldosterone antagonists- spironolactone
85
Q

Causes of falsely Increased natriuretic peptide?

A 
MI
Baseline higher in women and >70yrs
COPD, PE
Renal Impairment 
DM
Liver Failure 
Sepsis
86
Q

Grading of severity of Heart Failure (NYHA Classification)

A

I: No limitation
II:Slight Limitation, Comfortable @ rest
III: Marked Limitation-less than ordinary activity. Comfortable @ rest
IV: Discomfort @ ret

87
Q

A patient suspected of having heart failure should be referred for specialist review and echo < 2wks if?

A

Previous MI

BNP >400

88
Q

If BNP measured is 100-400 how should you proceed?

A

Refer for specialist review and echo <6wks

89
Q

Management of Chronic Heart Failure?

A

Review every 6mnths
Screen for Depression (>40%)
Restrict Fluid Intake
Pneumococcal and Influenza Vaccine

Medications:
ACE Inhibitors (ramipril, perindopril)
B Blockers

90
Q

Other drugs to consider in Chronic Heart Failure?

A
  • Anticoagulation: AF, Hx TE, Left ventricular aneurysm, Intrathoracic Thrombus
  • Aspirin: Atherosclerotic arterial disease
  • Statins Hx CVD, >20% 10yr CVD Risk, DM, >75yr
  • Amlodipine: angina and HTN
91
Q

Which drugs should be avoided in chronic heart failure?

A

Rate Limiting CCB: Verapamil, Diltiazepam

Short Acting Dihydropyridine CCB:

92
Q

Referral of patients with chronic heart failure to cardiology?

A 
Initial Dx
Unable to be managed @ home
Not controlled by 1st Line meds
Severe Heart Failure ( >50% mortality within 1yr)
Angina, AF
Valve Disease or Diastolic dysfunction
Co-morbidity
Planning Pregnancy
93
Q

Second Line agents in treatemtn left ventricular systolic dysfunction (specialist supervision)

A

-Aldosterone antagonists - spironolactone
-Hydralazine and Nitrate
ARB + ACEi + B Blocker

94
Q

Digoxin is used to treat?

A

Worsening or severe heart failure due left ventricular systolic dysfunction

95
Q

If a patient is on amiodarone to treat arrhythmias associated with heart failure, you should monitor?

A

TFTs (hyper/hypo)
LFTs
every 6mnths

96
Q

When should an echo be performed on someone with tachycardia?

A

<50yrs
Murmur detected
Heart Failure detected

97
Q

Red Flag symptoms ass. w/t tachycardia?

A

Pre-existing cardiovascular disease
FH of syncope, arrhythmia or sudden death
Arrhythmia ass. w/t falls/syncope

98
Q

You have just diagnosed a patient with ventricular tachycardia after performing a first line resting ECG. How do you proceed?

A

Bluelight Emergency
Give O2 +/- IV Lidocaine
If no pulse - treat as arrest

99
Q

AF increases the risk of stroke by?

Percentage of patients >80 yrs with AF?

A

5x

8%

100
Q

Anticoagulation (warfarin/ LMWH) decreases stroke risk by how much in patients with AF?

A

60%

101
Q

Routine Investigations for AF?

A

ECG
CXR
Bloods: TFTs, FBC, U&E

102
Q

Pill-in the Pocket approach to paroxysmal AF?

A

B Blocker prn
No Hx of LV dysfunction, valvular ischaemic heart disease
BP >100mm Hg
HR > 70bpm

103
Q

Patients with AF should be referred to cardiology if?

A

Fast rate and compromised by arrythmia (chest pain, hypotension, >mild heart failure
Canditae for cardioversion
Uncertainty about diagnosis or treatment
Symptoms uncontrolled

104
Q

Chronic AF treatment?

A

Rate Control:

  • Monotherapy: B Blcker or rate limiting CCB
  • Combination Therapy: BBlocker, Diltiazem, Digoxin

Rhythm Control:
Cardioversion?
-B Blocker, Amiodarone, Ddronedarone
Anticoagulation: CHADSVASC Score

105
Q

Digoxin only considered as monotherapy for rate control in AF if?

A

Patient very sedentary

106
Q

Candidates for cardioversion include?

A 
Heart Failure ass. w/t AF
New onset (<7d)
Atrial Flutter suitable for ablation
AF secondary to treated/ corrected precipitant 
-Rate control ineffective
107
Q

How long after pacemaker insertion can a patient not drive?

A

1mnth

108
Q

Stokes Adams attacks?

A

Cradiac arrest due to AV Block

Sudden LOC +/- limb twitching- cerebral anoxia

109
Q

Untreated 2nd or 3rd degree heart block has a mortality of approx?

A

approx. 35%

110
Q

New murmur and a fever indicates?

A

Endocarditis until proven otherwise

111
Q

Patients at high risk of developing infective endocarditis?

A 
Acquired valvular heart disease
Valvular Replacement 
Structural Congenital heart disease 
HOCM
Hx Infective Endocarditis
112
Q

Causes of infective endocarditis?

A

Infective: strep viridans, straph aureus
Non-infective: SLE, Malignancy

(M>A>T>P)

113
Q

How would you diagnose intermittent claudicaton?

A 
Good Hx (muscular, cramp-like pain on walking, relieved immediately by rest) 
\+ ABPI <0.95
114
Q

Peripheral Ischaemia in the superficial femoral artery causes intermittent claudication where?

A

The calf muscle

115
Q

Intermittent Claudication in the calf, thigh or buttocks is a result of?

A

Disease of the aorta or iliac artery

Weak or absent femoral pulse/bruit

116
Q

Duplex USS is used for?

A

To determine the site of the ischaemia

117
Q

Nerve Root Compression vs. Peripheral Ischamia

A

Sciatica- bilateral, prolonged standing + exercise, not rapidly relieved by rest

118
Q

Percentage of patients with intermittent claudication that progresses to critical limb ischaemia over 10yrs

A

20%

119
Q

Patients with Intermittent claudication have how much of an increased risk from death of MI/stroke

A

3x

120
Q

Treatment for patients with IC?

A

Exercise
Reduce CVS risk factors
Aspirin (all patients)
Foot Care

121
Q

Referral to vascular surgery?

A

Critical Limb Ischaemia (deteriorating claudication, nocturnal rest pain, ulceration, gangrene)
Severe Symptoms
No better after exercise training
Uncertainty about dx

122
Q

Secondary Causes of Varicose Veins

A

DVT
AV Fistula
Pelvic Tumour
Pregnancy

123
Q

Long Saphenous Vein Distribution is where

A

The thigh and medial calf

124
Q

Before advising compression hosiery what should you assess?

A

ABPI > 0.8 to exclude significant arterial disease

125
Q

Women with varicose veins taking the CHC or HRT are at increased risk of?
How should this be treated?

A

Thrombophlebitis (severe pain, erythema, pigmentation over and hardening of the vein)
NOT DVT

Tx: Crepe Bandaging, NSAID, Ice Packs, Elevation, Low dose aspirin

126
Q

Thrombophlebitis migrans is associated with?

A

Pancreatic carcinoma

Recurrent tender nodules affecting veins throughout the body

127
Q

Refer for urgent duplex scanning if a thrombophlebitis..

A

Extends up the long saphenous vein to the saphenofemoral junction

128
Q

A varicose vein present as a lump in the groin, has a positive cough reflex and disappears on lying down, is likely to be?

A

Saphena Varix

129
Q

Incidence of DVT

A

1 in 1000/yr

130
Q

Causes Increased D-Dimer

A 
DVT
Malignancy
Pregnancy
Wound Healing
Recent Trauma
Inflammation
Sepsis
Liver Transplantation
131
Q

If you suspect a patient has a DVT how should you proceed?

A

Referal to rapid access clinic

Delay: LMWH

132
Q

Dx of DVT?

A

Confirmed with imaging

133
Q

If Wells score <2 how should you proceed?

A

D-Dimer
If, +ive treat as medium/high risk (>2)
USS

134
Q

If a patient has a DVT with unknown cause you should consider?

A

Thrombophilia if <45yrs

Malignancy if >45yrs

135
Q

Managemant of DVT?

A

LMWH (IV) 4days + INR 2.5 >2days
Warfarin (outpatient) 3-6mnths after DVT
Graduated Elastic Compression Stockings 2yrs

136
Q

The risk of PE from untreated DVT is?

A

20%

137
Q

What is post thrombotic syndrome?

A

Chronic venous HTN following DVT, causing limb pain, swelling, ulcers, venous gangrene, lipodermatosclerosis

138
Q

DVT may occur?

A 
Proximally (above the knee)
Calf Veins
Cerebral Sinus
Veins of the arm
Retinal Veins 
Mesenteric Veins

Primary Care (9 decks)

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