Heart Failure, Angina, AF Flashcards
HF management
Arrange admission if the person has severe symptoms.
People with heart failure due to valve disease should be referred for specialist assessment and given advice regarding follow up.
Confirmed heart failure with reduced ejection fraction:
If fluid overload - loop diuretic.
Offer an ACEi/AIIRA and a beta-blocker
If still symptomatic — offer a mineralocorticoid receptor antagonist (MRA) in addition to ACEi (or) and beta-blocker.
Consider if an antiplatelet drug and/or statin is indicated eg coronary heart disease.
Ensure comorbidities are optimally managed.
Exercise-based group rehabilitation programme.
Annual influenza and a once-only pneumococcal vaccination.
Give general information about heart failure and its management.
Assess the person’s nutritional status - BMI
Confirmed heart failure with preserved ejection fraction:
If necessary, offer a loop diuretic — to relieve symptoms of fluid overload.
Refer if no response to diuretic therapy.
Dapagliflozin and empagliflozin are options for heart failure with preserved or mildly reduced ejection fraction on the advice of a specialist.
Then from anti-platelet onwards everything same.
HF diagnosis
If chronic heart failure suspected:
Measure NT-pro-BNP
If the NT-pro-BNP level is above 2000 ng/L refer urgently to specialist and for echocardiography within 2 weeks.
If the NT-pro-BNP level is between 400–2000 ng/L refer for specialist and echocardiography within 6 weeks.
If NT-pro-BNP is less than 400 ng/L (47 pmol/L), diagnosis of heart failure is less likely.
Chronic heart failure can be difficult to diagnose because the symptoms and signs are often non-specific.
Ask about typical symptoms:
Breathlessness — on exertion, at rest, on lying flat (orthopnoea), nocturnal cough, or waking from sleep (paroxysmal nocturnal dyspnoea).
Fluid retention (ankle swelling, bloated feeling, abdominal swelling, or weight gain).
Fatigue, decreased exercise tolerance
Lightheadedness or history of syncope.
RF:
Coronary artery disease, hypertension, AF, and DM.
Drugs, including alcohol.
Family history of heart failure or sudden cardiac death under the age of 40 years.
Examine:
Tachycardia and pulse rhythm.
A laterally displaced apex beat, heart murmurs, and third or fourth heart sounds (gallop rhythm).
Hypertension.
Raised jugular venous pressure.
Enlarged liver
Respiratory signs such as tachypnoea, basal crepitations, and pleural effusions.
Dependent oedema (legs, sacrum), ascites.
Obesity.
Stable angina
Symptoms
Chest pain on exertion
Chest tightness - can radiate
Breathlessness
Can occur anytime
RF
Smoking
High cholesterol
FH
Obesity
Management
Manage co-morbidities, lifestyle
Sublingual GTN take as needed
Oral nitrates
Long term - CCB
Secondary prevention - Aspirin
Can add statin, ACEi
Investigations -ECG
Referral - symptoms inc, new onset, younger - send to chest pain clinic/ cardiology for angiography
Secondary
PCI
Coronary bypass graft
Follow-up
6 months to a year - assess CVS RF - BP, HR, compliance with meds
Safety-netting
Unstable angina - chest pain at rest - urgent cardiology referral
Symptoms persisting after 2nd dose for GTN
MI symptoms - crushing and radiating pain
AF diagnosis
Paroxysmal - 30s
Valvular
Spontaneous
Persistent
RF- hypertension, HF, COPD, CKD, smoking, alcohol, obesity
Atrial fibrillation (AF) may be suspected if a person is symptomatic or detected incidentally if they have an irregular pulse on examination or irregular heart rhythm on ECG.
Suspect a diagnosis of AF in a person with an irregular pulse, with or without any of the following:
Breathlessness, Palpitations, Chest pain, Dizziness, Fatigue, sleep disturbance.
Potential complication of AF, such as stroke or transient ischaemic attack.
Possible underlying cause or risk factor eg hypertension.
Self-initiated mobile irregular pulse notifications.
Examine:
Check pulse and auscultate heart apex. Also look for murmur.
Check blood pressure manually.
Examine the lungs to assess for pulmonary oedema and/or an underlying cause.
Check for other signs of heart failure such as ankle or leg oedema.
Note: be aware that the absence of an irregular pulse makes a diagnosis of AF unlikely, but its presence does not reliably indicate AF.
Arrange ECG to confirm the diagnosis of AF in a person with or without symptoms.
AF is confirmed if - absence of P waves, irregular atrial activations, irregularly irregular R-R intervals and a narrow QRS complex. HR often averages between 90–170 bpm.
If a person has suspected diagnosis of paroxysmal AF which is not detected on standard ECG, arrange ambulatory electrocardiography or
referral
Consider arranging additional investigations, depending on the likely underlying cause(s).
Arrange blood tests for full blood count, thyroid function tests, HbA1c, lipids, urea and electrolytes and renal function, liver function tests, and magnesium, depending on clinical judgement.
Arrange a chest X-ray if lung pathology is suspected
Arrange a transthoracic echocardiogram if heart failure or heart murmur
HF investigations
Arrange a 12-lead ECG in all people.
Possible tests include:
Chest X-ray.
Blood tests such as U&E, eGFR, FBC, iron studies (transferrin saturation and ferritin), thyroid function tests, liver function tests, HbA1c, and fasting lipids.
Urine dipstick for blood and protein.
Lung function tests (peak flow and/or spirometry).
Assess for and manage any underlying causes where appropriate.
HF specialist drugs
If symptoms still persist - specialist:
Replacing the ACEi with sacubitril valsartan if the ejection fraction is less than 35%.
An SGLT-2 inhibitor (empagliflozin or dapagliflozin).
Ivabradine for sinus rhythm + HR over 75 bpm and ejection fraction less than 35%.
Hydralazine and nitrate (especially if of African-Caribbean descent).
Digoxin for people in sinus rhythm to improve symptoms.
HF follow-up
The follow up interval should be short (days to 2 weeks) if clinical condition or drugs have changed. At least every 6 months if stable.
What to check:
Consider monitoring NT-pro-BNP levels (depending on local availability) to guide optimum drug treatment.
Monitor the serum urea, electrolytes, and eGFR every 6 months.
Ask about symptoms - If the person has syncope or presyncope (unless clearly due to postural hypotension), refer to a cardiologist as this may be due to ventricular tachycardia, particularly in HF-REF.
Check the person’s pulse rate and rhythm and examine the heart:
If an arrhythmia is suspected, arrange a 12-lead ECG or 24-hour ECG monitoring.
If symptoms have deteriorated and the pulse is regular, consider ECG for the atrial tachycardia.
Assess fluid status by checking for:
Changes in body weight.
Oedema (abdomen, sacrum, genitalia, and ankles).
Raised jugular venous pressure.
Fine lung crepitations.
Hepatomegaly
Postural drop in blood pressure (a postural decrease of more than 20 mmHg suggests hypovolaemia).
Assess the person’s functional capacity — ask about ability to perform everyday activities using the New York Heart Association classification.
Assess cognitive status and any psychosocial needs.
Assess BMI
Review medications
Provide advice about contraception and pregnancy.
AF when to refer
Management- hospital if severe, complications
CHADVAS score? - more than 2 five anti-coag
If 1 - anti-coag/ aspirin
If above 80 - case basis, mostly only do rate control.
Before start - FBC, U and E
If valvular - warfarin only
Anti-coagulation (non-valvular) - DOAC
Rate control - beta blockers, CCB, digoxin
Manage if inc risk of bleeding - OBIT score - HTN
Follow up - adherence, warfarin - monitor INR, HR, BP, driving, lifestyle
FBC, U and E - every 6 months
Safety netting - stroke - FAST
HF - breathless, fatigue, oedema
Constant chest pain
Arrange emergency admission if:
New-onset and haemodynamically unstable, Severe symptoms, Concomitant heart failure, A serious cause
Arrange hospital admission or seek urgent specialist if:
Within 48 hours.
Arrange cardiology referral or seek specialist cardiology advice if a person has:
More than 48hrs - Uncertainty about management, other heart condition
AF management
What drug treatment should I initiate in primary care?
Anticoagulation and rate-control
Assess the person’s stroke risk using the CHA2DS2-VASc stroke risk score.
Assess the person’s bleeding risk using the ORBIT bleeding risk score if starting anticoagulation. Manage risk eg:
Uncontrolled hypertension, falls risk, Reduced creatinine clearance.
Antiplatelet, SSRI or NSAID, Excessive alcohol, anaemia.
DOAC first-line if CHA2DS2-VASc score of 2 or above, and consider DOAC for CHA2DS2-VASc score of 1. Apixaban, dabigatran etc.
If a DOAC is contraindicated offer warfarin.
Do not offer anticoagulation to a person aged under 65 and no risk factors other than their sex.
Do not offer rate control as first-line if AF with: reversible cause, Heart failure caused by AF, New-onset AF.
Offer beta-blocker or a rate-limiting CCB (diltiazem or verapamil) first-line.
Consider prescribing digoxin monotherapy if a person is sedentary with non‑paroxysmal AF, or if other drug options are contraindicated.
Anticoagulant drugs
Warfarin - monitor INR
Sub-optimal anticoagulation control indicated by:
Two INR values higher than 5, or one INR value higher than 8, within the past 6 months. Two INR values less than 1.5 within the past 6 months.
Rate-control drugs
Arrange to review the person within one week of starting to assess symptom control, resting heart rate, blood pressure, adherence, and adverse effects.
How should I review a person with paroxysmal, persistent, or permanent AF?
Review annually once symptoms are controlled.
Ask about any symptoms at rest, during exercise, and impact on quality of life.
Examine the person to assess the resting heart rate and rhythm, and check manual blood pressure.
If the person is already taking an anticoagulant drug:
Reassess CHA2DS2-VASc annually.
Reassess ORBIT annually.
If the person is taking rhythm-control drugs that were started by a cardiologist, such as amiodarone or sotalol, arrange appropriate monitoring in primary care.
Stable angina diagnosis
Stable angina should be suspected on the basis of the clinical assessment, and the typicality of chest pain.
Typical angina = all three:
Precipitated by physical exertion.
Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
Relieved by rest or GTN within about 5 minutes.
Atypical angina presents with two of the above features.
In addition, atypical symptoms include GI discomfort, and/or breathlessness, and/or nausea.
RF:
Increasing age, Male, CVS risk factors.
Diagnosis less likely = Pain that is continuous, unrelated to activity, brought on by breathing, with dizziness, palpitations, tingling, or difficulty swallowing.
If the person has typical or atypical anginal pain, refer them to a specialist chest pain service to confirm.
For people in whom stable angina cannot be excluded on clinical assessment, organize a resting 12-lead ECG - abnormal ECG makes the diagnosis of coronary artery disease more likely, but does not confirm stable angina.
If the person has confirmed coronary artery disease (CAD), but a diagnosis of stable angina cannot be excluded from clinical assessment, refer for diagnostic testing.
Provide GTN for symptoms while waiting for specialist referral.
SAn management
Drug treatment for symptom relief:
Prescribe sublingual GTN for the rapid relief and for use before performing activities known to cause symptoms.
Instruct the person that if they experience chest pain they should:
Stop what they are doing and rest.
Use their glyceryl trinitrate spray or tablets as instructed.
Take a second dose after 5 minutes if the pain has not eased.
Call 999 for an ambulance if the pain has not eased 5 minutes after the second dose.
Prescribe a beta-blocker or a calcium-channel blocker (CCB) as first-line regular treatment to reduce the symptoms of stable angina.
If both beta-blockers and CCBs are contraindicated consider monotherapy with one of the following drugs.
A long-acting nitrate (such as isosorbide mononitrate).
Nicorandil.
Ivabradine.
Ranolazine.
Review 2–4 weeks after starting.
Drug treatment for secondary prevention:
Consider antiplatelet treatment- 75 mg daily.
Consider treatment with an ACEi for people with stable angina and diabetes mellitus.
Offer a statin.
Offer antihypertensive treatment.
Refer SAn
Consider hospital admission as they may have unstable angina:
Pain at rest (which may occur at night)/ minimal exertion.
Indications for early referral to a cardiologist include:
Previous MI, coronary artery bypass graft, etc and development of angina.
ECG evidence of of significant abnormality eg previous MI
Other heart conditions eg heart failure, AF and angina
An ejection systolic murmur suggesting aortic stenosis.
SAn follow up
Review every 6 months to 1 year.
Assess cardiovascular disease risk
Check the person’s heart rate and blood pressure.
Check for signs and symptoms of heart failure (for example breathlessness, fatigue, or ankle swelling).
Taking treatment for symptom control - beta-blocker or CCB.
Secondary prevention as appropriate.
Reiterate how to use glyceryl trinitrate
When should I refer a person with established angina?
If the person has poorly controlled angina symptoms.
If the person’s symptoms are satisfactorily controlled consider referral for functional or non-invasive anatomical testing to identify whether they are at high risk, and might benefit from revascularization.
AF summary
Suspect - Symptomatic + irregular pulse
Assessment - ECG, BP - bedside
Labs - FBC, HBA1C, U&E, LFT
MANAGMENT
ADMIT - IF HAEMODYNAMICSLLY UNSTABLE, REVERSIBLE TRIGGERS EG PNEUMONIA, HF
LESS THAN 48 AND STABLE
WPW SYNDROME
Refer - heart problems
Manage
CHADVASC SCORE
ORBIT
DOAC IF CHADVASC GREATER THAN 2, MEN 1
Rate control - B BLOCKER, DILITIAZEM
FOLLOW UP IN ONE WEEK
