IHD, HF and AF - prework Flashcards
1
Q
Angina - aetiology/RF
A
- Atherosclerosis
- Coronary artery vasospasm
- Microvascular dysfunction
- Extracoronary factors - aortic stenosis, hypertrophic cardiomyopathy, significant anaemia
2
Q
Symptoms of angina
A
- Chest pain - left sided, radiate to left arm/neck, may not be present in elderly/diabetics
- Dyspnoea - equivalent angina
- Nausea
- Lightheadedness
- Fatigue
- Precipitated by physical exertion
3
Q
Investigations of angina
A
- ECG
- FBC, U&E, LFTs, Lipid profile, TFTs, HbA1C
- CT coronary angiogram
- Non-invasive functional imaging - looking for myocardial ischaemia (eg stress echo or myocardial perfusion scan)
- Invasive coronary angiography
4
Q
Advice for angina
A
- Healthy diet
- Exercise - within limit of symptoms
- Stop smoking
- Optimise treatment of other co-morbidities
- Healthy weight
- Limit alcohol
- Get DVLA advice if job involves driving
- Can have GTN before sex if this precipitates it
- Treatments of ED are generally contraindicated
- Flight advice - no restriction if symptoms only occur with significant activity
5
Q
Medication for angina
A
- Aspirin and statin for all patients
- Sublingual glyceryl trinitrate to abort angina attacks
- Beta blocker or CCB 1st line (if CCB monotherapy use diltiazem or verapamil) - if symptoms remain, titrate to max dose
- If symptomatic on monotherapy add alternative (eg beta blocker + CCB (BUT NOT BB AND VERAPAMIL)
- 3rd line - long acting nitrate, ivabradine, nicorandil or ranolazine - only add when awaiting assessment for PCI or CABG or if cannot tolerate BB or CCB add on to monotherapy
6
Q
Nitrate tolerance in angina?
A
- Many patients who take develop tolerance and experience reduced efficacy
- If tolerance develops, take second dose of isosorbide mononitrate after 8hrs and not 12 hrs - allows levels to fall low for extra 4 hrs
7
Q
Monitoring and f/u of angina
A
- Every 6monts-1yr depending on severity/control
- Assess CVD risk
- Check HR and BP and for signs of HF
- Review medication
- Check for ongoing symptoms
8
Q
ACS RF
A
- Increasing age
- Male
- FH
- Smoking, diabetes, HTN, high cholesterol, obesity
9
Q
Atypical symptoms of ACS
A
- Epigastric pain
- Fatigue
- Syncope/presyncope
10
Q
Signs of ACS
A
- Hypotensive/hypertension
- Sweating
- Tachy/bradycardia
- Tachypnoea
- Hypoxia
11
Q
Investigations ACS
A
- ECG
- Troponin
- Baseline bloods - FBC, U&E, LFTs, lipids and glucose
- CXR - pulmonary oedema/other causes of chest pain
- Echo - once stable to assess LV function
12
Q
Medication for ACS - ALL
A
- Aspirin 300mg
- O2 if sats <94%
- Morphine if severe pain
- Nitrates - sublingual or IV, given if ongoing chest pain/hypertension, caution if hypotensive
13
Q
Management ACS - STEMI specific
A
- All of ‘all’ section
- PCI if presentation within 12hrs of symptom onset and can be delivered within 120 mins thromboylysis can be given (if after 12 hrs, still consider if ongoing ischaemia)
- Dual antiplatelet therapy if PCI - prasugrel if not on any other anticoag, clopidogrel if are
- PCI - radial access need UFH + bailout glycoprotein IIb/IIIa inhibitor
- PCI - femoral access Bivalirudin with bailout GPI
- OR thrombolysis - usually with LMWH/fondaparinux
14
Q
Management of ACS - NSTEMI/unstable angina specific
A
- All from ‘all’ criteria
- Fondaparinux if not high risk of bleeding and not having angio immediately
- If immediate angi or Crt >265 umol/L then give UFH
- Calculate GRACE score
Give PCI in:
* Immediately if unstable eg hypotnesive
* Within 72hrs if GRACE score more than 3%
* Consider in all patients if ischaemia experienced after admission
PCI drugs for NSTEMI/UA:
* UFH (regardless if given fondaparinux)
* Dual antiplatelet - prasugrel/ticagrelor if not taking another anticoag, clopidogrel if are
If no PCI:
* DAPT - ticagrelor if not high bleed risk, clopidogrel if are
15
Q
Post ACS medications
A
- Aspirin 75mg, ACEi, aldosterone antagonist for those with HF
- Beta blocker
- Cardiac rehab
- Dual antiplatelet - ticagrelor or clopidogrel for 12 months
- S - atorvastatin 80mg
16
Q
Advice post MI - general
A
- diet: advise a Mediterranean style diet, switch butter and cheese for plant oil based products.
- Do not recommend omega-3 supplements or eating oily fish
- exercise: advise 20-30 mins a day until patients are ‘slightly breathless’
- sexual activity may resume 4 weeks after an uncomplicated MI.
- Reassure patients that sex does not increase their likelihood of a further MI. PDE5 inhibitors (e.g, sildenafil) may be used 6 months after a MI.
- They should however be avoided in patient prescribed either nitrates or nicorandil
17
Q
Atrial fibrillation - investigations
A
- Palpate radial pulse
- ECG
- 24hr/event ECG
- Bloods - LFTs, U&Es, TFTs, FBC, Ca2+ an Mg2+. blood glucose
- Echocardiogram - underlying cardiac disease
- CXR - suspect resp disease contributing to AF?
18
Q
RF - AF
A
SMITH
* Sepsis
* Mitral valve pathology
* Ischaemic HD
* Thyrotoxicosis
* Hypertension
19
Q
AF management - options
A
- Rate control - eg BB, CCB (verapamil) or digoxin
- Rhythm control - DC cardioversion, amiodarone, flecainide
- Anticoagulation - DOACs
- Can combine two rate if choosing rate control, on max dose and still uncontrolled, if this still is not controlling refer within 4 weeks to cardiology
20
Q
AF management - scenario based
A
- Haemodynamic compromise - immediate DC cardioversion
- Stroke - aspirin 300mg for 2 weeks, followed by DOAC/warfarin
- Less than 48hrs of symptoms - rhythm or rate control (usually rhythm)
- More than 48hrs/uncertain onset - immediate rate control, delayed rhythm control (3 weeks later after anticoag) THEN if Clear reversible trigger - rhythm but if not rate is 1st line
- Paroxysmal AF - rate control or pill in pocket approach eg flecainide
21
Q
Anticoagulation for AF
A
- New onset of AF no other anticoags - heparin until assess need for long term anticoag
- Patients who presented within 48hrs of AF who started on heparin can stop this as long as normal sinus rhythm within 48hrs and low risk of recurrence
- All other patients should be assessed for long term anticoag - CHADS2V2ASc and HASBLED
22
Q
Follow up for AF
A
- 1 week after rate control initiation or any changes to rate control
- Uncontrolled symptoms –> cardiology referral and seen within 4 weeks
- Annual review of symptoms, medication, review need for anticoag
- Blood tests for medication monitoring as required
23
Q
Heart failure - investigations
A
- NT-pro-BNP
- High (>2000ng/L)- transthoracic echo within 2 weeks
- Raised (400-2000) - within 6 weeks
- ECG
- Consider CXR, bloods, urinalysis, peak flow and spiro
24
Q
Heart failure - management
A
- 1st line - ACEi and beta blocker (bisprolol, carvedilol or nebivolol)
- 2nd line - aldosterone antagonist (eg spironolactone or eplerenone), OR angiotensin II receptor blocker OR hydralazine + nitrate; if intolerant to acei/arb
- 3rd line - cardiac resynchronisation therapy, digoxin or ivabradine (must have HR >75 and EF <35%)
- Diuretics for fluid overload
- Annual flu and one off pneumococcal
25
Other drugs for HF
* Sacubitril Vaslartan - symptomatic despite ACEi/ARB - with reduced EF
* Only initiate following ACEi/ARB washout period
26
Criteria for cardiac reschronisation therapy
* Wide QRS and heart failure
* Improves symptoms and reduces hospitalisation in NYHA class III patients
27
When to esp consider digoxin for HF?
If AF alongside
28
HFpEF - ACEi and BB
No evidence of effect on mortality
29
NYHA classification of HF
* **Class I - no symptoms**, no limitations, ordinary physical exercise does not cause dyspnoea, fatigue or palps
* **Class II - mild symptoms**, slight limitation of physical activity, comfortable at rest but ordinary activities can cause fatigue, dyspnoea or palps
* **Class III - moderate symptoms** - marked effect on physical acitivty, comfortable at rest but less than ordinary activities produces symptoms
* **Class IV - severe symptoms**, unable to carry out any physical acitivty without discomfort, present even at rest
30
HFpEF vs HFrEF
31
