IHD, AF and heart failure Flashcards
define angina - inc most common cause
pain (or constricting discomfort) in the chest, in the neck, shoulders, jaw, or arms caused by an insufficient blood supply to the myocardium.
Most commonly caused by atherosclerosis of the coronary arteries leading to decreased oxygen supply to the myocardium
diagnostic criteria for stable angina
Typical angina presents with all 3 features:
1. Precipitated by physical exertion.
2. Constricting discomfort in the front of the chest, in
the neck, shoulders, jaw, or arms.
3. Relieved by rest or glyceryl trinitrate (GTN) within
about 5 minutes.
Atypical angina presents additionally with two of:
- gastrointestinal discomfort,
- and/or breathlessness
- and/or nausea.
Management for stable angina
advice: - Factors that can provoke angina, such as exertion, emotional stress, exposure to cold, or eating a large meal.
prescribe:
1. GTN (sublingual glyceryl trinitrate) - rapid relief of
symptoms and use before performing activities known
to cause symptoms.
2. BBlocker/CCB
3. consider antiplatelet therapy
4. “ ACE-inhibitor
Define ACS - include pathophysiology
Acute myocardial ischemia caused by atherosclerotic coronary artery disease
- Atheromatous plaque ruptures (UA)
- Thrombus formation
- Acute increased occlusion
- Ischaemia
- Infarction if completely occlusive (stemi)
what’s NSTE-ACS and STE-ACS - include ECG changes
NSTE-ACS Unstable angina NSTEMI - ECG for both: ST depression, T wave flattening/inversion -Therefore differentiate by serum troponin
STE-ACS
STEMI
- ST elevation, hyperacute T waves
- Evolve to T wave inversion and pathological q waves
- Changes in specific leads - determine anatomical site
aetiology/risk factors ACS
obv ones
premature menopause
other causes:
sever anaemia
hyperthyroidism
ACS - presentation
Pain in chest
- New onset/abrupt deterioration of stable angina
- At rest - on little/no exertion
- > 15 mins
- Dull, central
Or referred pain (arms, jaw, back)
Associated with:
- Nausea/vomiting
- Dyspnoea
- Sweating
- Palor
Haemodynamic instability - e.g. systolic BP < 90 mmHg
Diagnosis ACS
- Hospital admission/referral for further investigations
to confirm diagnosis
If current chest pain, had chest pain < 12 hrs ago & absent/abnormal ECG, complications signs (signs of HF) - Diagnose in primary care - If symptoms > 72 hrs ago w no complications by:
- 12-lead ECG - pathological Q waves, left bundle
branch block, ST segment/T wave abnormalities an
normal (doesn’t exclude diagnosis)
- High sensitivity blood test for serum troponin I/T - to
differentiate unstable angina and MI’s. Positive
indicates infarction (cardiac myocyte death)
- Following these tests consider specialist referral
within 2 weeks based on clinical judgement
Immediate management - Whilst awaiting for hospital admission - ACS
- Sit the person up
- Only offer supplemental oxygen if (SpO2) < 94% who
are not at risk of hypercapnic respiratory failure.
Use a simple face mask, target SpO2 of 94–98%.
-Treat pain with glyceryl trinitrate (GTN) and/or an
opioid - Aspirin 300mg - send a written record w the pt of this
- resting 12-lead ECG - send results to hospital (don’t delay admission)
secondary prevention - ACS
Advice: Stop smoking/avoid passive smoking Cardioprotective diet Physically active/ avoid prolonged sedentary activities/ weight loss if overweight/obese Alcohol consumption in limits
Cardiac rehabilitation programme - exercise, education, stress management. Initiated before discharge, encourage participation
- Continue prescribing medications initiated in secondary care in agreed shared care arrangement:
- ACEi, dual antiplatelet therapy (aspirin and
clopidegrol/ticagrelor), beta blocker and statin
- ACEi, dual antiplatelet therapy (aspirin and
- Annual influenza immunisation
Check if routine post-MI assessments been set by secondary care
Ask about impact on social life and mental health
5 causes and complications of heart failure each:
causes:
- Hypertension
- Cardiomyopathy, Aortic stenosis, Pericardial effusion,
Congenital heart disease
- High output state: anaemia, septicaemia
- Volume overload: nephrotic syndrome, end-stage
CKD
- Obesity, alcohol
complications:
- Cardiac arrhythmias
Depression
Cachexia especially in those with reduced ejection fraction
Sexual dysfunction
Sudden cardiac death
HF diagnosis - history and examination
symptoms: breathlessness (orthopnoea and Paroxysmal Nocturnal Dyspnoea), fluid retention, fatigue, and lightheaded
examine: history of MI, any family history of cardiac deaths, any substance use, any comorbidities
RF - history of MI, any family history of cardiac deaths, any substance use, any comorbidities
HF diagnosis - investigation
- Measure natriuretic peptide levels (NT-proBNP) - +ve if raised
- 400-2000 - refer urgently in 6mths
- >2000 - “ in 2wks - 12-lead ECG
- consider - X-ray, spirometry/peak flow, blood tests/urinalysis - to investigate causes of HF
immediate referral if valve disease causing HF
HF w reduced ejection fraction M
medications
- Loop diuretic
- ACEi and BB - start one at a time, once stable on one
begin next. slowly titrate up dose till max tolerated
- if not effective at max specialist referral
- consider if statins/antiplatelets required
- offer referral to a specialised exercise group
rehabilitation programme, esp if overweight - immunisations - annual influenza, one off
pneumococcal - follow-ups - every 6 mths if stable, 2 wks if change in condition/drugs: assess pulse, rhythm, nutritional status, HF symptoms, drugs, U&Es , eGFR
HF w preserved ejection fraction M
specialist referral
same M as reduced
end stage HF M
high risk of dying in next 6-12mths
liase w cardiologist if all treatment options been considered and involve MDT
review need for medication - symptom relief instead
pt understanding about situation (realistic goals) and inc family/friends
advanced care plan if pt wants
AF - define inc diff types
supraventricular tachyarrhythmia resulting from irregular, disorganized electrical activity and ineffective contraction of the atria. Causes is re-entrant circuits due to fibrosis.
AF is classified according to the pattern of episodes:
- Paroxysmal AF - episodes >30 seconds but < 7 days that are self-terminating and recurrent
- Persistent AF - > 7 days or < 7 days but requiring pharmacological/electrical cardioversion
- Permanent AF - AF that fails to terminate using cardioversion, AF that is terminated but relapses in 24 hours, or longstanding AF in which cardioversion (treatment to normalise rhythm) has not been indicated/attempted
AF diagnosis - signs/symptoms
suspect if Irregular pulse with any of: Breathlessness Heart Palpitations Chest Discomfort Syncope or Dizziness Reduced exercise tolerance Malaise Polyuria A potential complication of AF such as stroke, TIA or heart failure
AF diagnosis - investigations
Standard ECG No P waves Wavy baseline Irregularly irregular ventricular rhythm Ventricular rate is often 160-180 bpm
Ambulatory ECG - if paroxysmal AF is suspected
Event Recorder ECG - Used in people who have symptomatic episodes > 24 hours apart
To rule out other differentials:
Echocardiogram
Chest x-ray - lung
Blood tests - anaemia, kidney or hyperthyroidism
AF management
manage in primary care if haemodynamically stable*:
-stroke risk - CHADSVAS score
-medication and HASBLED score
follow-up within 1 week of starting treatment to review tolerance, symptom control, heart rate, and blood pressure
-Interventions such as weight loss and treatment of underlying diabetes, hypertension, and sleep apnoea can reduce AF episodes.
- provide info AF association website
referral for cardioversion
- if treatment can’t control rhythm or controlled but symptoms persist,
- *immediate referral (acute emergency) if not haemodynamically stable - >150bpm, SBP < 90mmHg, loss of consciousness, severe dizziness or syncope, ongoing chest pain, or increasing breathlessness, stroke or underlying condition signs
CHADSVAS score
C - history of congestive heart failure - 1 point
H - History of hypertension - resting BP > 140/90 on at least 2 occasions/ if on current antihypertensive treatment. - 1 point
A - Age if 75 or > - 2 points
D - Diabetes Mellitus - 1 point
S - Stroke/ TIA - 2 points
V - Vascular Disease ( prior MI, peripheral arterial disease/aortic plaque) - 1 point
A - Age - 65 - 74 - 1 pt
S - Sex - F - 1 pt
AF medication
Anticoagulant treatment: Apixaban or Rivaroxaban or Warfarin (initially monitor INR daily till in therapeutic range)
First-line treatment for most people AF is a rate-control treatment: target = rest is 60-80bpm and 90-115bpm during exercise
- Beta-blocker ( not solatolol)
- or Non-dihydropyridine Calcium channel blocker
- Digoxin
At follow-up if symptoms not controlled:
- increase dose
- if at max try combo fo 2 of: BB, digoxin or diltiazem (CCB)
causes of AF
Most common causes: Hypertension, Coronary artery disease & Myocardial infarction
Cardiac or valve conditions
Congestive heart failure
Rheumatic valvular disease
Atrial or ventricular dilation or hypertrophy
Pre-excitation syndromes such as Wolff–Parkinson–White syndrome
Non-cardiac conditions Acute infection Electrolyte depletion Cancer Thyrotoxicosis
Dietary & lifestyle factors
Alcohol abuse
Smoking
Medication such as Thyroxine or bronchodilators
