Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Yr3: GP > IHD & Heart Failure > Flashcards

IHD & Heart Failure Flashcards

1
Q

If a person with chest pain does not require immediate admission or referal what investigations should you consider & why?

A
  • ECG: check for abnormalities
  • Blood glucose: risk factor
  • Lipids: risk factor
  • U&Es: CKD is risk factor
  • FBC: check for anaemia which may be precpitating angina
  • TFTs: hyperthyroidism may precipitating angina
  • LFTs: check for cholecystitis as cuase of chest pain
  • Amylase: pancreatitis as cause of chest pain
  • CRP & ESR: infection as cause
  • CXR: check for pulmonary pathology or heart failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

State some risk factors for CVD, include:

  • Modifiable
  • Non-modifiable
  • Comorbidities that increase risk
A

Risk factors

  • Non-modifiable:
    • Age
    • Gender- male
    • Family history
    • Ethnic background (south asian, sub-saharan african)
  • Modifiable:
    • Smoking
    • High non-HDL cholesterol
    • Low HDL cholesterol
    • Sedentary lifestyle
    • Alcohol intake
    • Obesity
    • Unhealth diet
  • Comorbidities:
    • Hypertension
    • Diabetes
    • CKD
    • AF
    • RA, SLE, systemic inflammatroy disorders
    • Serious mentalhealth disorders
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Discuss the presentation of angina- include typical and atypical angina

A
  • Typical angina presents with all of the following:
    • Precipitated by physical exertion
    • Constricting discomfortin the front of chest, neck, shoulders, jaw or arms
    • Relieved by rest or GTN within about 5 minutes
  • Atypical angina presents with two of the above features
  • Additional symptoms may include GI discomfort/nausea& vomitting, breathlessness, sweating etc..
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What investigations would you do in primary care if you suspect stable angina?

Where do you refer them to for further investigations?

What information & treatment may you give whilst awating results from diagnnostic testing?

A
  • Do ECG to rule out any myocardial ischaemia at present or previous infarction
  • Check for risk factors/comorbidities:
    • BMI
    • BP
    • Lipids
    • HbA1c
  • If person has typical or atypical angina pain refer to specialist chest pain service to confirm or exlcude the diagnosis of angina.
  • Prescribe sublingual GTN and consider aspirin 75mg. Provide safety netting advice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Discuss the managment of stable angina, include:

  • Conservative
  • Pharmacological
A

Conservative

  • Explain diagnosis, long term course of angina & educate on factors that can provoke angina e.g. exertion, emotional stress, cold, large meal
  • Lifestyle changes: stop smoking, reduce alcohol, weight loss, increase physical activity
  • If take PDEi for ED advise must not take GTN for at least 24hrs after last dose of PDEi. If have angina attack must call 999 and not use GTN
  • Saftey net: seek medical help if sudden worsening or increase in frequency

Pharmacological

  • ALL- GTN (sublingual glyceryl trinitrate)
  • ALL- asprin 75mg daily CVD prevention (if already on clopidogrel for stroke or PAD then leave on that)
  • ALL- statin 20mg atorvastatin
  • Consider ACE inhibitor in diabetics
  1. Beta blocker or non-dihydropyridine CCB
  2. Switch from BB to CCB and vice versa
  3. Both BB & CCB
  4. Consider treatment such as isosorbide monotitrate, ivabradine, nicorandil, ranolazine

**AND obviously treat any other comorbidities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When should you refer someone with stable angina to a specialist?

A
  • Previous Mi, CABG, PCI and develop angina
  • ECG shows evidence of previous MI or other significant abnormality
  • Newly diagnosed AF and stableangina
  • Heart failure and angina
  • Any suggestions of hypertrophic cardiomyopathy
  • Doubt about diagnosis
  • Presence of several risk factors or strong famly history
  • Doubt about diagnosis
  • If person has poorly controlled angina symptoms despite treatment
    *
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Discuss the monitoring & follow up required for pts with stable angina

A
  • Review response to treatment 2-4 weeks after changing or starting drug treatment
  • Routine review every 6 months to 1 year depending on stability of angina & comorbidites
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What should be included in a stable angina review?

A
  • Check for ongoing symptoms- clarify when symptoms occur, have symptoms worsened
  • Assess CVD risk and identify any modifiable risk factors
  • Check for complications of anginaor treatment (check HR, BP, sign & symptoms of heart faillure, screen for low mood & depression)
  • Review medications: adherence, symtpom control, correct use
  • Re-iterate advice that should have been given: manage CVD risk, physical exertion, when to seek medical attention…
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Discuss when dihydropyridine and non-dihydropyridine CCBs are used in stable angina

A
  • If only taking CCB: rate limiting CCBs are preferred as dihydropyridines can cause reflex tachycardia which may worsen anginal symptoms
  • If taking BB & CCB: prescribe a dihydropyridine as risk of heart block if take BB and rate limting/non-dihydropyridine CCB
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

State some risk factors for ACS- include modifiable, non-modifiable and cormorbidites that increase risk

A

Risk factors

  • Non-modifiable:
  • Age
  • Gender- male
  • Family history
  • Ethnic background (south asian, sub-saharan african)

Modifiable:

  • Smoking
  • High non-HDL cholesterol
  • Low HDL cholesterol
  • Sedentary lifestyle
  • Alcohol intake
  • Obesity
  • Unhealth diet
  • Comorbidities:
  • Hypertension
  • Diabetes
  • CKD
  • AF
  • RA, SLE, systemic inflammatroy disorders
  • Serious mental health disorders
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Discuss signs and symptoms of ACS

A
  • Central, crushing chest pain
  • Radiate to neck, jaw, shoulder and/or arm
  • Associated sweating
  • Associated nausea & vomitting
  • SOB
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Which pts with suspected ACS would you admit to hospital?

A
  • Current chest pain
  • Signs of complications e.g.pulmonary oedema
  • Pain free but had chest pain in last 12hrs and have abnormal ECG or ECG not available
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Which patients with suspected ACs would you refer for urgent same day assessment at a rapid access chest pain clinic?

A
  • Currently pain free but had chest pain in last 12hrs and have normal ECG and no complications
  • Chest pain in past 12-72hrs wtih no complications
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Which patients with suspected ACS would you refer to rapid acces chest pain clinic within 2 weeks?

A

Currently pain free and their chest pain was more than 72hrs ago and they have no complications, suspected underlying malignancy, lung or lobar collapse or pleural effusion (basically any other suspected cause of chest pain).

*HOWEVER, as always use clinical judgement: interpreation of ECG and troponin should also guide how urgent this referrral should be

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Look at Yr3 Medicine: Cardiology ACS for more info on ACS; primarily managed in secondary care intially

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Remind yourself of immediate management of ACS

A
  • Morphine
  • Oxygen
  • Nitrates
  • Aspirin 300mg & ADP receptor antagonist
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Remind yourself of management (after MONA) of:

  • STEMI
  • NSTEMI
  • Unstable angiina
A
  • STEMI: PCI if available within 120mins or thrombolysis if not
  • NSTEMI & unstable angina: beta blocker, anticoaguation with LMWH and consider IV nitrates if pain continues
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Following an MI, what medications should someone be sent home with?

A
  • Beta blocker e.g. bisoprolol
  • ACE inhibitor or ARB
  • Statin
  • Dual antiplatelets (aspirin 75mg and ADP receptor antagonist)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Remind yourself:

  • Definition of heart failure
  • Two types
A
  • Inability of heart to maintain adequete circulation due to structural or functional impairment of ventricular filling or ejection
  • Types:
    • Heart failure with preserved ejection fraction (filling problem)
    • Heart failure with reduced ejection fraction (contraction problem)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

State some causes of heart failure highlighting the most common

A
  • Myocardial disease
    • CAD (MOST COMMON)
    • Hypertension
    • Cardiomyopathies
  • Valvular heart disease
  • Pericardial disease
    • Constrictive pericarditis
    • Pericardial effusion
  • Arrhythmias
  • High output states
    • Anaemia
    • Thyrotoxicosis
    • Phaeochromocytoma
    • Sepsis
    • AV shunts
    • Thiamine deficiency
  • Volume overload
    • CKD
    • Neprhotic
  • Drugs
    • Alcohol
    • Cocaine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

State some signs & symptoms of heart failure

A

Symptoms

  • Breathlessness: on exertion, orthopnoea, PND
  • Swelling due to fluid retention
  • Fatigue
  • Light headedness/history of syncope

Signs

  • Tachycardia
  • Irregular pluse if AF present
  • Laterally displaced apex beat
  • Hypertension
  • Raised JVP
  • Hepatomegaly
  • Tachypnoea
  • Bibasal crepitations
  • Stoney dull percussions of pleural effusions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Symptoms of heart failure are classified according to severity using New York Heart Association (NYHA) functional classification; describe this classification

A
23
Q

Dicsuss how you should go about diagnosing heart failure in priamary care

A
24
Q

Whilst awaiting for confirmation of diagnosis of heart failure, what can you do?

A
  • Review medications and if appropriate stop or reduce any drugs that may worsen heart failure
  • Provide diuretics for symptomatic relief e.g. furosemide 20-40mg
25
Q

State some potential causes, other than heart failure, that can cause raised pro-NT BNP

A
26
Q

Discuss the management of heart failure with preserved ejection fraction

A
  • Advice: condition, its prognosis, risk factors, lifestyle changes, self-care advice (weigh yourself at home, monitor salt intake, stop smoking etc)
  • Offer diuretic: up to 80mg furosemide if necessary to reduce fluid overload
  • Manage comorbidities
  • Refer to cardiac rehabilitation if suitable
  • Ensure vaccinations up to date: annual influenza and once only pneumococcal vaccination
27
Q

Discuss the management of heart failure with reduced ejection fraction

A
  • Education on condition, lifestyle changes, self-care advice (weigh yourself at home, monitor salt intake, stop smoking etc…)
  • Pharmacological:
    1. Diruetics
    2. ACE inhibitor & beta blocker but only start one drug at a time- once person is stable on first drug start second drug! (can use ARB if can’t tolerate ACEi)
    3. Add mineralocoritcoid receptor antagonist e.g. spironolactone, eplerenone
    4. Consider specialist treatment e.g. ivabradine hydralazine and nitrate… (see image)
28
Q

Beta blockers & ACE inhibitors are used to treat HF with reduced ejection fraction; you must start one drug first then initiate the second once pt is stable on the first. Discuss how you would decide which to start first

A

ACE inhibitor:

  • Diabetes melitus
  • Signs of fluid overload (as beta blocker may worsen)

Beta blocker:

  • If has angina
29
Q

State some potential complications of heart failure

A
  • Arrhythmias e.g. AF
  • Depression
  • Cachexia
  • CKD
  • Sexual dysfunction
  • Sudden cardiac death
30
Q

What % of people with heart failure die within 5yrs?

A

50%

31
Q

Discuss when you should refer a person with heart failure to specialist

A

* if don’t respond to beta blocker & ACE inhibitor need referral

32
Q

Discuss what follow up/monitoring is required for someone with heart failure

A
  • If condition or drugs have changed should have follow up within couple of weeks
  • At least every 6 months if stable
33
Q

What should be included in a heart failure follow up/review?

A
  • Symptoms & signs
  • Assess functional capacity
  • Psychosocial needs- include screening for depression
  • Review medications: adherence & side effects
  • Check vaccinations up to date
  • Observations
  • Examiine for fluid status
  • Monitor U&Es (ever 6 months) and consider pro-NT BNP monitoring
34
Q

State some drugs you should avoid in HF

A
  • Drug with negative inotropic effects (e.g. beta blockers)
  • Drugs that increase salt & fluid retention (e.g. NSAIDs, corticosteroids, thiazolidinediones)
35
Q

When should you suspect end stage HF?

A

End stage heart filaure is when person is at risk of dying within next 6-12 months. Common symptoms for end stage heart failure include:

  • Pain
  • Breathlessness
  • Persistent cough
  • Fatigue
  • Limitation of physical activity
  • Depression & anxiety
  • Constipation
  • Anorexia & nausea
  • Oedema
  • Insomnia
  • Cognitive impairment
36
Q

How should you manage end stage heart failure?

A
  • Liase with cardiologist if there is uncertainty about use of further treatments to make sure all treatment options have been considered; including deactivation of ICD if appropriate
  • Explore pts understanding
  • Involve MDT
  • Make sure they have advanced care plan if they want one
  • Drugs for symptomatic relief such as those in palliative care
37
Q

State some causes of AF

A
38
Q

State some symptoms & signs of AF

A

Symptoms

  • Breathlessness
  • Palpitations
  • Chest discomfort
  • Syncope or dizziness
  • Reduced exercise tolerane
  • Malaise

Signs

  • Tachycardia
  • Irregularly irregular heart beat
  • Other signs associated with cause e.g. hypertension
39
Q

Discuss how you would manage a pt with AF who is:

  • Haemodynamically unstable
  • Haemodynamically stable
A
  • Haemodynamically unstable= urgently admit to A&E
  • Haemodynamically stable= consider management in primary care or refer to acute medical unit fo immediate cardioversion depending on clinical judement & preference (e.g. if AF started <48hrs ago could cardiovert)
40
Q

Describe what we mean when we say a haemodynamically unstable AF pt

A
  • HR >150bpm
  • Hypotensive (systolic BP <90mmHg)
  • Loss of consciousness
  • Severe dizziness or syncope
  • Ongoing chestpain
  • Increasing breathlessness
41
Q

Discuss what investigations you should do in primary care if you suspect AF

A
  • ECG- confirm diagnosis
  • Try to idenfity underlying cause e.g. BP reading, CRP for infection, TFTs, U&Es for electrolyte derangement etc…
42
Q

Discuss when you would refer someone with AF to a cardiologist

A
  • Underlying cardiac condition causing AF e.g. WPW, valvular disease, suspected heart failure
  • If AF has reversible cause e.g. chest infection for consideration of pharmacological or electrical rhythm control
  • If heart failure thought to be primarily caused or worsned by AF
  • Rate control treatment fails to control symptoms within 4 weeks
43
Q

What is the HASBLED tool?

A

HASBLED tool assess risk of major bleeding when anticoagulation is being considered

44
Q

What is the CHA2DS2VASc score?

A

Used to assess a person’s stroke risk in pts with AF

45
Q

What do the following results of the CHA2DS2VASc score indicate:

  • >2
  • >1 in males
A
  • >2 anticoagulation is indicated
  • >1 in males anticoagulation should be considered
46
Q

Outline the principles of management in AF

A
  • If cause is reversible treat it
  • Rate control
  • Rhythm control (consider if pt suitable for cardioversion if not long term rhythm control)
  • Anticoagulation
47
Q

Discuss the pharmacological management of AF in primary care

A

Rate control

  • Beta blocker (other than sotalol)
  • or a rate limiting CCB
  • Can use digoxin if sedentary

Anticoagulation

  • DOACs: apixaban, dabigatran, rivaroxaban, warfarin

Rhythm control

  • Options include immediate cardioversion (electrical or pharmacological with flecanide or amiodarone) or long term pharmacological rhythm control such as :
    • Beta blockers are first line for rhythm control
    • Dronedarone is second line for maintaining normal rhythm where patients have had successful cardioversion
    • Amiodarone is useful in patients with heart failure or left ventricular dysfunction
48
Q

What advice should you give to pts wtih AF?

A
49
Q

What follow up is required after initating or altering rate control?

A

Within 1 week of starting or altering dose of rate control follow up pt:

  • symptoms (fatigue, palpitations, breathlessness).
  • Ask about any ADRs; can they tolerate these ADRs? Check observations: HR & BP.
50
Q

Discuss the target HR for rate control in AF

A
  • 60-80 at rest
  • 90-115 during moderate exercise
  • HOWEVER, target heart reates can be adjused depending on level of exercise person can manage
51
Q

What follow up is required after staring anticoagulation, consider what is required when start:

  • Warfarin
  • DOAC
A

Warfarin

  • Warfarin: monitor INR daily or on alternate days until INR between 2-3 on two consecutive occasions.
  • Then monitor twice weekly for 1-2 weeks followed by weekly measurements until at leat two INRs are in therapeutic range (2-3)
  • After this, monitoring depends on stability of INR: monitor up to once every 12 weeks

DOACs

  • Review after 1 month
  • Review every 3-6 months (depending on pt)
52
Q

How often should you review pts with AF?

What should be included in your review?

A
53
Q

State some complications of AF

A
54
Q

ENSURE YOU REVISE YR3 MEDICINE CARDIOLOGY AS DECKS THERE HAVE MUCH MORE INFO ON THESE CONDITIONS. THIS FOCUSES ON PRIMARY CARE MANAGEMENT

A

Yr3: GP (21 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions