CVS Health Flashcards
1st line investigation for confirming a diagnosis of HTN in a patient with clinical blood pressure measurement of 140/90 or greater?
ambulatory BP monitoring
Investigations for all people with HTN?
- urine for ACR and dip for haematuria
- bloods-U+Es, HbA1c, total cholesterol and HDL cholesterol
- ECG
- examine fundi for presence of hypertensive retinopathy
With which patients with persistent Stage 1 HTN should a discussion be had regarding starting antihypertensive drug treatment?
- target organ damage
- established CVD
- DM
- renal disease
- 10 year CVS risk of 10% or more
consider in addition to lifestyle advice in those aged under 60 with 10 year CVS risk less than 10%
consider in those over 80 with clinic BP >150/90
Who should be offered an ACE or ARB as step 1 antihypertensive tx?
- if aged under 55 years and NOT of black african or afro-caribbean origin
- if have T1/T2DM and of any age or ethnic origin (ARB preferred if black african or afro-caribbean
also if CKD and ACR or 30 or more
Who should be offered a CCB as step 1 tx of HTN?
- if aged 55 and over
- if african/afro-caribbean ethnic origin of any age and DO NOT have T2DM
if CCB not tolerated then offer a thiazide like diuretic as 1st line
also if e/o heart failure offer a thiazide like diuretic
What is resistant HTN?
HTN not controlled in adults taking optimal tolerated doses an ACEi/ARB plus CCB plus thiazide like diuretic.
Before starting step 4 treatment clinic BP readings should be confirmed again with ABPM or HBPM, and assessment for postural hypotension, and drug adherence
Who should be offered spironolactone as step 4 treatment of HTN?
those with resistant HTN and serum K 4.5 or less
Which patients with HTN require same day speciailist assessment?
clinic BP 180/120 or higher with:
signs of retinal haemorrhage or papilloedema (accelerated HTN) OR
life threatening features e.g. chest pain/heart failure/new confusion/AKI
also if suspected pheochromocytoma: labile/postural hypotension/headache/palpitations/pallor/abdo pain/diaphoresis
Why are ARBs better for black african/afro-caribbean patients than ACE inhibitors for BP control?
less likely to cause angioedema
When should an ACE inhibitor/ARB be started for a patient with CKD and diabetes and NOT currently hypertensive?
if their ACR is 3 or greater
How often should patients with chronic heart failure be recalled by their GP?
at least every 6 months
What NT-proBNP level should prompt referral to cardiology for urgent assessment and TTE within 2 weeks?
if pt has suspected heart failure and BNP level greater than 2000 ng/litre (236pmol/L)
Which patients with suspected heart failure should be referred to cardiology for assessment and TTE within 6 weeks?
if NT-proBNP level between 400 and 2000 ng/litre (47-236 pmol/L)
When would you not start an ACE-I as initial drug tx of chronic heart failure in relation to heart valve disease?
if suspicious of haemodynamically significant valve disease, until the valve disease has been assessed by a specialist
How often should ACE-I treatment be monitored in management of chronic heart failure once pt achieved target dose or max tolerated dose?
monthly for 3 months then at least every 6 months, and at any time the person becomes acutely unwell
Alternative tx that may be recommended if pt with chronic heart failure with reduced EF (EF<55%) cannot tolerate an ACE-I or ARB?
hydralazine in combination with a nitrate
consider especially if pt of African or Caribbean family origin and NYHA III or IV with reduced EF
When is ivabradine recommended as an option for treating chronic heart failure?
People with NYHA class II-IV stable chronic HF with systolic dysfunction AND
HR 75 or greater and in SR AND
given ivabradine in comb with standard therapy including beta blocker, ACE-I or ARB and aldosterone antagonist, or when beta blocker CI or not tolerated AND
LVEF of 35% or less
When is sacubitril/valsartan recommended for treating symptomatic chronic HF with reduced EF?
NYHA class II-IV AND LVEF 35% or less AND already taking a stable dose of ACE-I or ARB
Advice on stopping driving in heart failure?
must stop driving for at least 1 month (both cars and HGV), restart driving once your doctor tells you it is safe
if still experiencing sx you must stop driving until the DVLA investigates
Definition of LV systolic impairment?
EF of less than 55%
Pain management in people with critical limb ishcaemia?
Offer paracetamol plus weak or strong opioids
Refer to specialist pain management service if any 1 of:
pain not adequately controlled and revascularisation inappropriate/impossible
ongoing high doses of opioids required
persisting pain post revascularisation/amputation
Apart from lifestyle advice, what management should be offered to all patients with intermittent claudication?
supervised exercise programme
When would you stop a beta blocker in a patient who presents in acute heart failure?
- HR <50
- 2nd or 3rd degree heart block
- shock
Which people is the QRISK2 assessment tool not suitable for?
T1DM CKD age 85 or over PH of CVD familial hypercholesterolaemia
Criteria for familial hypercholesterolaemia diagnosis?
TC>7.5 and LDL>4.9 in adult, TC >6.7 and LDL > 4 in child/young person AND
tendinous xanthomas, or e/o these in 1st/2nd degree relative, or DNA based evidence of LDL receptor mutation, familial defective apo B-100 or a PCSK9 mutation.
When can a person be diagnosed with possible familial hypercholesteroaemia (not definitite)?
adult TC>7.5 and LDL>4.9, child TC>6.7 and LDL>4 and at least 1 of:
FH of MI-<50yrs in 2nd degree or <60 in 1st degree relative
FH of raised total cholesterol
DVLA guidance for car drivers with angina?
don’t need to notify DVLA but must STOP driving if sx at rest/with emotion/whilst driving, and can restart once satisfactory control of sx.
group 2-musn’t drive and must notify DVLA when symptoms occur. May be able to drive after 6 weeks symptom free.
DVLA guidance for car drivers post MI which has been treated with PCI?
if successfully treated and no further surgery needed then must not drive for 1 week.
if unsuccessful then must not drive for 4 weeks.
no need to tell DVLA
DVLA guidance for car drivers post MI which hasn’t been treated with angioplasty?
must not drive for 4 weeks
no need to tell DVLA
DVLA guidance for group 2 drivers post MI?
must inform the DVLA and must not drive for 6 weeks
CAA guidance for flying post MI?
if uncomplicated can fly after 7-10 days
if complicated then cannot fly until 4-6 weeks
post CABG should wait 10-14 days before air travel
post PCI-3 days
When can sexual activity resume post MI?
when comfortable to do so, usually at about 4 weeks post MI
Monitoring requirements for amiodarone?
- U+Es, LFTs, TFTs and CXR before starting tx (U+Es as hypokalaemia can increase risk of arrhythmias developing)
- 6 monthly TFTs and LFTs
- annual CXR
also note any visual disturbance, can cause corneal microdeposits and optic neuritis
note long half life-25-100 days
DVLA guidance for group 1 driver post PPM implantation?
1 week off driving, MUST inform the DVLA
if box change cannot drive for 1 week but don’t need to inform DVLA
group 2-6 weeks off driving
DVLA guidance for group 1 driver post CABG?
4 weeks off driving, DVLA need not be notified
group 2- 3 months
DVLA guidance post ICD insertion?
- if prophylactic and group 1 license then cannot drive for 1 month
- if inserted for sustained ventricular arrhythmia and group 1 license then cannot drive for 6 months
- if group 2 then cannot drive.
DVLA guidance post non VT ablation?
group 1-no driving for 48 hrs
group 2-no driving for 2 weeks
VT ablation, group 1-no driving for 4 weeks, group 2-no driving and must notify DVLA, may resume after 3 months if controlled
Management of pt presenting to clinic with BP 180/120 or higher with no signs necessitating emergency admission?
urgent Ix for target organ damage-if identified start BP medication immediately
if no target organ damage, rpt BP measurement within 7 days
If clinic BP 140/90 or higher but ABPM not diagnostic, and no e/o target organ damage, how should pt be managed?
Measure clinic BP at least every 5 years, more frequent monitoring if clinic BP close to 140/90
How long after starting a new antihypertensive drug treatment should be given to determine response?
4 weeks
For patients with HTN who choose to self monitor their BP how should this be done?
HBPM-should use average BP level taken during the patients waking hours
DVLA guidance following heart transplant?
group 1-cannot drive for 6 weeks
group 2-cannot drive for 3 months
Define paroxysmal AF?
episodes lasting longer than 30s but less than 7 days (often less than 48hrs), that are self terminating and recurrent
Define persistent AF?
episodes lasting longer than 7 days, or less than 7 days but requiring pharmacological or electrical cardioversion
Define permanent AF?
AF that fails to terminate using cardioversion, is terminated but relapses within 24hr, or longstanding AF (usually more than 1 year) in which cardioversion has not been attempted or indicated
Risk reduction of stroke offered by anticoagulation for AF?
2/3
Which people with an underlying cause of AF should be referred to a specialist?
- r/f to cardiology if WPW, valvular heart disease assoc. with AF or suspected heart failure.
- r/f to endocrine if suspected thyroid disease
- r/f to pulmonary oncologist if lung cancer suspected
R/f to a cardiologist for consideration of pharmacological or electrical cardioversion should be done for those with a reversible cause of AF e.g. chest infection, or have heart failure thought to be primarily caused or worsened by AF.
When is digoxin an alternative for rate control tx in patients with AF?
if patient has non-paroxysmal AF and is sedentary
When should patients be followed up if started on rate control tx for AF in primary care? (or had any dose alteration)
within 1 week
- consider r/f for cardioversion if sx continue after HR has been controlled or rate-control strategy is not successful
- R/f people to be seen within 4 weeks at any stage if tx fails to control sx and specialist input required. Note if rate control not successful and drug at max tolerated dose can try combination tx before referral with 2 of beta blocker, digoxin or diltiazem (off label)
- Review people with AF at least annually.
DVLA guidance for type 1 drivers with AF?
- must cease driving if AF has caused or is likely to cause incapacity
- driving may be permitted after 4 weeks if underlying cause has been identified and controlled
- DVLA to be notified if causing distracting or disabling sx
DVLA guidance for type 2 drivers with AF?
- disqualified if has caused or is likely to cause incapacity
- permitted to drive if sx controlled for 3 months, LVEF of 40% or greater and no other disqualifying condition
What HR are we aiming for in rate control of AF?
60-80 at rest, 90-115 during moderate exercise
Which beta blockers are licensed for AF?
atenolol metoprolol propranolol acebutolol oxprenolol nadolol
CAA guidance on fitness to fly after uncomplicated PCI?
may be fit to travel after 3 days but individual assessment required
DVLA guidance for driving after elective PCI?
group 1-cannot drive for 1 week, need not notify DVLA
group 2-must notify DVLA, may be able to drive after 6 weeks
CAA guidelines for patients post TIA/stroke?
advised to wait 10 days post event but may be able to travel after 3 days if stable
DVLA guidance for group 2 drivers with HTN?
must not drive if BP 180/100 or higher
Anti-anginal drugs that can be added to a beta blocker and calcium channel blocker?
ISMN
nicorandil (note ulceration risk)
ivabradine (if HR >75)
ranolazine
When should admission to hospital for suspected ACS be done if patient doesn’t have current chest pain?
if had chest pain in last 12 hours and have an abnormal ECG or an ECG is not available
When does a person with hx of chest pain require referral for urgent same day assessment?
- no chest pain at present but chest in pain in last 12 hours with normal ECG and no complications
- no chest pain at present but chest pain in last 12-72 hours and no complications
When is referral to specialist needed for chest pain within 2 weeks?
- hx of chest pain more than 72hrs ago and suspect ACS with no complications
- suspected underlying malignancy
- lung/lobar collapse or pleural effusion not requiring admission
