GP ILA 1: Broken Heart Flashcards
HTN, MI, CCF, CKD
Heart failure is a clinical syndrome that requires what 3 things?
Typical symptoms, typical signs and objective evidence of structural/functional abnormality
HF
a) Typical symptoms: (i) LFH x4, (ii) RHF x2, (iii) General x3
b) What is liver cirrhosis caused by RHF called?
c) HF caused by lung disease is called…? Give a drug used to treat pulmonary hypertension.
(i) LHF - SOBOE, PND, orthopnoea, pink frothy sputum; (ii) RHF - ankle swelling, abdominal distention;
(iii) General - fatigue, weight loss, nausea
b) Cardiac cirrhosis
c) Cor pulmonale. Sildenafil
HF
b) Typical signs: (i) LHF x3, (ii) RHF x2, (iii) General x3
Think observation, palpation, percussion, auscultation
(i) LHF - pulmonary oedema (bilateral basal end-insp crackles +/- wheeze), pleural effusion (dullness to percussion, decreased vocal resonance/tactile fremitus, pleural rub), cardiomegaly;
(ii) RHF - raised JVP, hepatomegaly, ascites
(iii) General - low BP, tachycardia, reduced pulse pressure, gallop rhythm (S3)
HF
c) Objective evidence: (i) O/E x2, (ii) Bloods x2, (iii) Imaging x2
(i) Cardiomegaly, S3
(ii) BNP, NT-proBNP
(iii) CXR (ABCDE), Echo (EF < 40%)
Systolic (LVSD) vs Diastolic (HFPEF):
a) EF cutoff for LVSD
b) Cause of HFPEF
a) <40%
b) Mitral stenosis (impaired filling); ASD/VSD
High-output cardiac failure:
a) 2 features
b) 4 causes
a) Primary abnormality not cardiac
b) Anaemia, pregnancy, hyperthyroid, Paget’s, AVMs
Aetiology (low-output HF):
a) 2 most common
b) 3 valvular (preload/afterload)
c) 2 other cardiac disease types
d) Drug-induced: (i) 2 prescription, (ii) 2 recreational
e) 5 endocrine
f) 2 nutritional
g) 2 infective
h) 2 infiltrative
a) HTN, MI
b) AS (afterload), AR/MR (preload)
c) Arrhythmias (e.g. AF), cardiomyopathies (DCM, HCM)
d) (i) ABCDE: Beta-blockers, Ca2+, (ii) Cocaine, alcohol
e) Hypo/hyperthyroid, Cushing, Phaeo, Acromegaly, DM
f) Thiamine
g) HIV, Chagas’
h) Sarcoid, amyloid, haemochromatosis
HF Investigations:
a) If previous MI
b) If no previous MI - 2 main
c) Other bloods
d) CXR - 5 signs
a) 2/52 echo - if normal, measure BNP. If echo and BNP normal unlikely to be HF. If normal echo and raised BNP - HFPEF
b) BNP first; also ECG (98% specific)
c) FBC, U&Es, fasting lipids, glucose, TFTs, cardiac enzymes if acute
d) Alveolar oedema (fluid in fissures), kerley B lines, cardiomegaly (CT ratio >50%), upper lobe diversion, pleural effusions
BNP/ NT-proBNP:
a) A measure of…?
b) If levels are high (BNP >400pg/ml or NT-proBNP level >2,000 ng/L) - management?
c) If levels are raised (BNP 100 - 400 or NT-proBNP 400 - 2000) - management?
d) If levels are normal (BNP <100 or NT-proBNP <400) - management?
a) Myocardial stress
b) 2 week echo
c) 6 week echo
d) Unlikely to be HF
NYHA classification (stages 1-4)
Stage 1: asymptomatic on ordinary physical activity
Stage 2: some symptoms on ordinary physical activity
Stage 3: less than ordinary physical activity leads to symptoms
Stage 4: inability to carry out any activity without symptoms
HF: 3 indications for urgent 2-week cardiology and echo referral
BNP >400, severe symptoms, pregnant, previous MI
HF Management:
a) 5 lifestyle
b) Referral to …?
c) 4 drug classes to treat HF (1 symptomatic)
d) 2 to reduce CV mortality
e) 1 other drug to use if not fully managed by BBs
f) Drugs to avoid in heart failure (3)
a) Nutritional - wt loss if fat, appropriate stable weight if cachectic, alcohol, smoking, low salt diet, exercise
b) Community HF nurse
c) Loop diuretics, ACE, BBs, aldosterone antagonist
d) Statins, aspirin
e) Ivabradine - acts on If channel
f) Non-dihydropyridines (verapamil, diltiazem), lithium, fleicanide, TCAs
ACE inhibitors
a) MoA in HF
b) CIs - give 3
c) Prior to treatment, and at 1, 3 and 6 months (then every 6m) - what blood tests?
d) Alternative if not tolerated
a) Improves LV function
b) history of angio-oedema, bilateral renal artery stenosis, hyperkalaemia (>5 mmol/L), severe renal impairment (serum creatinine >220 μmol/L) and severe aortic stenosis.
c) U&Es and creatinine
d) ARB
Beta-blockers
a) MoA in HF
b) CIs - give 4
c) Monitor what two things with each increase in dose
a) Greater diastolic time
b) Asthma, second- or third-degree heart block, sick sinus syndrome (without pacemaker) and sinus bradycardia (<50 beats per minute (bpm)), Raynaud’s
c) HR and BP
Diuretics
a) 2 commonly used in HF
b) 2 risks of excessive diuresis
c) 2 commonly used in HTN - types
a) furosemide, bumetanide
b) hypotension, renal failure
c) Chlortalidone, indapamide
Aldosterone receptor antagonists
a) 2 common
b) Common side effects -
c) If not tolerated, alternative class (must be monitored strictly if combined with ACE)
a) spiro, eplerenone
b) Breast tenderness, gynaecomastia, sexual dysfunction
c) ARB
Surgical options for HF
CABG, transplant, pacing
Hypertension.
a) Stage 1
b) Stage 2
c) Severe
a) Clinic 140/90, ABPM/HBPM 135/85
b) Clinic 160/100, ABPM/HBPM 155/95
c) 180/110
HTN aetiology.
a) Most common
b) Most common secondary causes
c) 5 endocrine causes
d) 1 extra cause in women
e) Drugs
f) Risk factors: (i) 4 modifiable, (ii) 4 non-modifiable
a) Essential
b) Renal disease - GN, RAS, vasculitis, systemic sclerosis, chronic pyelonephritis
c) Cushings, Conns, Acromegaly, Hyperthyroid, Phaeo
d) HTN in pregnancy, and pre-eclampsia
e) Alcohol, cocaine, antidepressants
f) (i) Weight, salt intake, poor exercise, alcohol use, stress; (ii) FHx, ethnicity, older age, gender (<65 men; >65 women)
HTN diagnosis.
a) If clinic BP reading is 140/90 or more, what should be done?
b) How ABPM is used to diagnosis HTN
c) Those with high end of normal clinic BP values (130-139/85-89) should be monitored how often?
d) Look for a cause, especially in what patients?
a) Take 3 readings - record lowest. If still over 140/90, confirm with ABPM (135/85 or more)
b) Take at least 2 readings every waking hour over a day. Use the average of at least 14 readings: if 135/85 or more, diagnose HTN.
c) Annually
d) Young, treatment-resistant HTN, severe HTN
HTN presentation.
a) Usually.
b) Episodic feelings ‘as if about to die’ or headaches, paroxysmal sweats, palpitations
c) Abdominal or loin bruit
d) Delayed or weak femoral pulses.
e) Weight gain, depression, bruising
f) Weak muscles, polyuria, hypokalaemia.
g) Diarrhoea, weight loss, vision problems
a) Asymptomatic
b) Phaeo
c) Renovascular disease
d) Coarctation
e) Cushing
f) Conn’s
g) Grave’s
HTN may present with signs of end-organ damage.
a) Eyes (3 signs)
b) Kidneys
c) Heart
d) Acute events
a) Hypertensive retinopathy - cotton wool spots, flame haemorrhages, papilloedema,
b) Proteinuria (albuminuria), raised creatinine, deranged U&Es
c) LVH
d) Stroke/TIA, CHD, dissection
Hypertensive crises
a) Malignant/accelerated HTN (hypertensive emergency) - (i) define, (ii) treatment urgency
b) Types of acute end-organ damage
c) Hypertensive urgency - (i) define, (ii) treatment urgency
a) >200/130 with end-organ damage, minutes to hours
b) Encephalopathy, aortic dissection, pappiloedema, pulmonary oedema
c) >180/110 without end-organ damage, days
HTN investigations
a) For end-organ damage (4)
b) For CVD prevention
c) For suspected secondary causes i) Phaeo, ii) Cushing’s, iii) Conn’s, iv) Thyroid, v) RAS
a) 12-lead ECG, fundoscopy, eGFR, renal US, urinalysis, U&Es and creatinine
b) Fasting cholesterol, fasting glucose
c) i) 24-hour urinary metanephrines.
ii) Urinary free cortisol and/or dexamethasone suppression test.
iii) Renin/aldosterone levels.
iv) TFTs
v) Magnetic resonance imaging of the renal arteries.
