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Cardiology finals > IHD/metabolic syndrome > Flashcards

IHD/metabolic syndrome Flashcards

1
Q

Define heart failure

A

Reduced cardiac output below the body’s demands

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2
Q

Describe the classification of heart failure

A
  • LHF, RHF, CCF

- Systolic (HFrEF- <40%) vs diastolic (HFpEF)

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3
Q

Describe the pathophysiology of heart failure

A

HFrEF: reduced CO as a result of reduced contractility
HFpEF: reduced CO as a result of impaired filling (reduced compliance)

-> causes fatigue, SOB
+ buildup of fluid: pulmonary or peripheral oedema

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4
Q

Describe how to classify heart failure severity

A 
NYHA classification
I: asymptomatic
II: symptoms on normal levels of activity
III: symptoms on minimal activity
IV: symptoms at rest
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5
Q

Name some causes of HF

A 
CAD 
Hypertension
Valve diseases
Arrhythmias 
Pulmonary disease (por pulmonale)
Other cardiac pathology: carditis, cardiomyopathy, infiltrative disease which can be caused by:

Infection/inflamm: sarcoidosis, Chagas disease, lupus, vasculitis
Toxins: drugs, chemotherapy, Fe overload, alcohol
Metabolic: thyrotoxicosis, anaemia, thiamine def.

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6
Q

Describe the presentation of heart failure

A

General symptoms: fatigue, nocturia, weight loss
LHF: SOB (exertional, orthopnoea, PND), cardiac asthma- dry cough
RHF: peripheral oedema, early satiety

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7
Q

Describe the signs of heart failure (+ associated)

A

Hands/arms: tachycardia, arrhythmias, raised BP, cool and clammy hands
Face/neck: anaemia, cyanosis, raised JVP (>3cm)
Chest: extra heart sounds, murmurs, displaced/thrusting apex, coarse crackles
Rest: sacral or pedal oedema, abdominal distension

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8
Q

Describe the diagnostic process for suspected CCF (chronic)

A

-History and examination
-Observations
-Urine dip (for proteinuria in context of HTN)
-ECG
-Bloods: general screen + BNP + lipids + HbA1c
-CXR
-Echo
Further testing eg. cardiac MRI, stress echo, CT angiography, cardiac angiogram

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9
Q

Describe the signs of HF on CXR

A 
Alveolar shadowing (bat's wing)
Kerley B lines
Cardiomegaly
Diversion to upper lobe vessels
Effusions
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10
Q

Describe the management of chronic CCF

A

Conservative:

  • Diet and exercise
  • Smoking cessation, alcohol reduction
  • Vaccination

Pharmacological:

  • Symptom relief: beta-blocker, ACEi/ARB for rEF
  • Diuretics (loops, thiazides) for pEF or rEF
  • RF control: statin, DM drugs, aspirin
  • >
    • spironolactone, combine ACEi and ARB, vasodilators, digoxin

Invasive intervention:

  • ICD, CRT
  • LVAD
  • Transplant
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11
Q

Which are the best drugs to use in heart failure?

A 
ACEi: lisinopril, ramipril, enalapril 
ARB: losartan, candesartan 
Beta-blocker: bisoprolol, carvedilol 
Diuretics: loops (furosemide), thiazides 
Spironolactone, epleronone 
Anti-angina: amlodipine is safe
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12
Q

Describe the indications for ICD and CRT in heart failure

A

ICD: LVEF <35% plus

  • Sustained VT (symp or asymp)
  • QRS 120-150ms w/o LBBB
  • Risk of sudden death

CRT: LVEF <35% plus

  • Stage IV and prolonged QRS >120ms
  • Any stage with prolonged QRS >150ms
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13
Q

What are the complications of HF?

A 
Decompensation
Sudden cardiac death 
CKD 
Pleural effusions
Anaemia
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14
Q

Describe the presentation of acute HF

A

Acute onset heart failure or acute decompensation of chronic HF

  • > pulmonary oedema: SOB, crackles, hypoxia, acidosis
  • > raised JVP
  • > cold and clammy, hypoperfused, AKI
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15
Q

Describe the causes of acute HF

A
  • New onset: pregnancy, thyrotoxicosis, MI, PE

- Decompensation: sepsis, ischaemia, arrhythmias

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16
Q

Describe the management of acute pulmonary oedema

A
  1. A to E
    - ABG. Sit up and give high flow O2
    - IV access and bloods. ECG and continuous cardiac monitor
  2. Diamorphine 2.5-5mg IV + metoclopramide 10mg IV
  3. Furosemide 40-80mg IV
  4. GTN 2 puffs
  5. Ix: CXR, echo

Next steps:

  • IV nitrates
  • CPAP
  • Inotropes as needed
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17
Q

What are the types of angina?

A

Stable: angina made worse by exertion and relieved by rest within 5 minutes
Unstable: angina occurring at rest or not resolving within 5 minutes of rest

Typical: 3/3
Atypical: 2/3
1) Central crushing chest pain 
2) Provoked by exertion
3) Relieved by rest/GTN
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18
Q

What are the types of IHD? Which are ACS?

A

IHD: spectrum of conditions including stable angina, unstable angina, NSTEMI, STEMI
ACS: unstable angina, MI

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19
Q

Describe the pathophysiology of IHD

A

Myocytes oxygen demand is greater than supply, leading to ischaemia (painful)
In MI, the degree of ischaemia is sufficient enough (severe/long-lasting) to cause myocyte death (infarction), which releases enzymes

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20
Q

What is the difference between an NSTEMI and a STEMI

A

ST elevation on ECG

-NSTEMI is caused by partial occlusion of a vessel, so there is no ST elevation

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21
Q

Describe the coronary circulation

A

Left main stem divides into LAD and LCx
-LAD supplies the septum and LV (anteroseptal)
-LCx supplies the lateral LV apex (anterolateral)
RCA supplies the RV and the SA node (inferior)

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22
Q

Describe the ECG changes in STEMI

A

ST elevation + reciprocal depression depends on the site of the occlusion

  • LAD/anteroseptal: V1-V4
  • LCx/anterolateral: I, aVL, V5-6
  • RCA/inferior: II, III, aVF

+ hyperacute T waves, pathological Q waves
May have new LBBB
-> T wave inversion long-term

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23
Q

Describe the ECG changes in UA/NSTEMI

A

ST depression: usually widespread rather than specific to vascular territories
T wave flattening/inversion (dynamic- not present on old ECGs)
**Dynamic T waves/ST segments

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24
Q

Name some risk factors for IHD

A
  • Hypertension
  • T2DM
  • High BMI
  • Dyslipidaemia
  • Smoking
  • PVD/cerebrovascular disease
  • Illicit drug use esp cocaine
  • Vasculitis
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25
Q

Describe the presentation of ACS

A
  • Severe central crushing chest pain w radiation
  • Not relieved by rest
  • Nausea, diaphoresis, agitation
  • Tachypnoea, tachycardia
  • Syncope
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26
Q

Describe the acute management of STEMI

A

A to E

  • 2-4L O2
  • IV access and bloods inc. trops. ECG and continuous cardiac monitor

Acute medications:

  • Morphine 5-10mg IV + metoclopramide 10mg
  • GTN spray 2 puffs x5 mins
  • Aspirin 300mg
  • Beta-blocker atenolol 5mg IV

STEMI:

  • PCI if within 12 hours and suitable: give prasugrel if not anticoagulated, or clopi if anticoagulated. Give unfractionated heparin.
  • If no PCI: thrombolysis w streptokinase, plus ticagrelor
  • If no reperfusion: ticagrelor
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27
Q

Describe the management of STEMI after reperfusion/medical Mx

A

Investigations:

  • RFs: bloods inc lipids, HbA1c
  • Assess LV function w echo

Conservative Mx:
-Cardiac rehab program: diet, exercise, smoking, etc

Medications:

  • Continue DAPT for 12 months post MI. Aspirin for life
  • Clopi only if aspirin not tolerated
  • Continue beta-blocker for 12 months
  • Start ACEi
  • Start statin
28
Q

Describe the acute management of NSTEMI

A

A to E

  • 2-4L O2
  • IV access and bloods inc. trops. ECG and continuous cardiac monitor

Acute medications:

  • Morphine 5-10mg IV + metoclopramide 10mg
  • GTN spray 2 puffs x5 mins
  • Aspirin 300mg
  • Fondaparinux 2.5mg SC

Assess GRACE score

  • Low risk: consider angiography. Ticagrelor + aspirin
  • High risk: angiography. Prasugrel if PCI, otherwise ticagrelor/clopi.
29
Q

What are the complications of MI?

A 
Death
Arrhythmia
Rupture (septum)
Tamponade
HF
Valve pathology (MR)
Aneurysm 
Dressler's syndrome (pericarditis)
Emboli
Recurrence
30
Q

Describe the management of angina

A

Conservative:
-Lifestyle Mx

Medical:

  • Acute: GTN spray (2 puffs, repeat 5 mins)
  • Preventative: beta-blocker, CCB -> nitrates, ivabradine, etc
  • RF modification: statin, aspirin, antihypertensives

Surgical/interventional: revascularisation

  • Angiography + stenting (PCI)
  • CABG
31
Q

What are the indications for CABG?

A
  1. Refractory angina
  2. Left main stem stenosis
  3. Triple vessel disease
  4. Unsuccessful PCI
32
Q

Describe the investigations for a patient presenting with angina

A
  • History and examination
  • ECG
  • Bloods: FBC, U+Es, TFTs, HbA1c, lipids
  • CT angiography
  • Consider further tests: myocardial perfusion SPECT, stress echo, etc.
33
Q

What are the risks of CABG?

A

Anaesthetic reactions: nausea, vomiting, allergic reaction
Short term: pain, blood loss, palpitations, MI, stroke
Long term: infection, death, graft stenosis

34
Q

What are the risks of PCI?

A

Anaesthetic reactions
Immediate: coronary dissection, pain, stent thrombosis, AKI
Long term: re-stenosis

35
Q

Define hypertension

A

Stage 1: 140-159/90-99
Stage 2: 160-179/100-109
Stage 3: >180/110

36
Q

Describe the aetiology of hypertension

A 
Primary (essential)
Secondary: 
-RAS and other renal disease
-Endocrine: phaeo, Cushing's, Conn's
-Coarctation 
-etc
37
Q

Describe the investigations for hypertension

A

Urinalysis: proteinuria, PCR/ACR
ECG: LVH
Bloods: FBC, U+Es, TFTs, cortisol, HbA1c, lipids
Ambulatory BPM/home BPM: needed for diagnosis
Retinopathy screening

38
Q

Define the thresholds for hypertension on HBPM/ABPM

A

Average weekly readings >135/85

39
Q

Describe the management of hypertension

A

Conservative:
-Diet and exercise, stop smoking

Medical: for grade 2/high CVD risk

  • First line: ACEi/ARB for <55s, CCB for >55s/black
  • 2nd line: add CCB (if ACEi) or ACEi/thiazide (if CCB)
  • 3rd line: combo of ACEi/CCB/thiazide
  • 4th line (resistant HTN): add spironolactone/BB
  • Refer

Monitoring:

  • U+Es before treatment w ACEi/ARB, repeat after 2-4 weeks
  • Review bloods yearly
40
Q

Which hypertensive drugs are preferred in HF? Diabetes?

A

HF: avoid CCBs. ACEi better
Diabetics: ACEi
Indapamide > bendroflumethiazide

41
Q

What are the target BPs in HTN management?

A

<140/90
Frail: <150/90
Diabetics: <130/80

42
Q

Describe the complications of hypertension

A 
Stroke: increased risk 9x
CVD: increased risk 3x 
HF
CKD
Retinopathy + visual loss
43
Q

Describe the classification of hypertensive retinopathy

A

Stage 1: silver wiring, tortuous arteries
Stage 2: AV nipping
Stage 3: flame haemorrhages and cotton wool spots
Stage 4: papilloedema

44
Q

Describe the types of dyslipidaemia

A

Primary:

  1. ^ CMs: familial hyperchylomicronaemia
  2. ^ LDL: polygenic, familial hypercholesterolaemia
  3. ^ IDL: familial dysbetalipoproteinaemia
  4. ^ VLDL: familial hypertriglyceridaemia
  5. ^ CMs, VLDL: familial mixed hyperlipidaemia

Secondary:

  • Hypercholesterolaemia: nephrotic syndrome, hypothyroidism, anorexia
  • Hypertriglyceridaemia: DM, alcohol, CKD
45
Q

Describe the management of dyslipidaemia

A

Conservative:
-Diet and exercise, reduce CV RFs

Medical:

  • Calculate QRISK2 score
  • > 10%: treatment recommended
  • First line: statin eg. atorvastatin 20mg
  • 2nd line: ezetimibe
46
Q

Describe the investigations for dyslipidaemia

A

BMI

Bloods: FBC, U+Es, LFTs, HbA1c, lipids, TFTs

47
Q

What are the important things to consider when prescribing statins?

A
  • Myopathy risk: advise to seek medical attention if any muscle pain, tenderness, weakness
  • Liver function: check before treatment + 3mos + 12mos
  • Teratogenicity
  • Interaction with other medications
  • Monitoring: aim for 40%+ reduction in non-HDL at 3mos
48
Q

What is the normal dose of statins?

A

Primary prevention (QRISK >10%, T1DM and >40, CKD):
-Atorvastatin 20mg
Secondary prevention:
-Atorvastatin 80mg (CKD: 20mg)

49
Q

Name the different antiplatelets used for IHD prevention + doses

A

Aspirin: 75mg 2˚ prevention, 300mg treatment dose (ACS for 2 weeks)
Clopidogrel: 75mg 2˚ prevention, 300mg treatment dose (ACS)
Ticagrelor: 180mg as treatment
Prasugrel: 60mg for PCI patients
**Bleeding risk is least w clopi < tica < prasugrel

50
Q

Describe the MoA of aspirin

A

Irreversible COX inhibitor -> prevents release of thromboxane A2 and therefore platelet aggregation

51
Q

Describe the cautions to the use of aspirin

A
  • Bleeding risk: give w PPIs in at risk
  • Pregnancy: avoid in the 3rd trimester due to premature closure of PDA
  • Sensitivity: risk of allergy and bronchospasm, caution in asthma but not contraindicated
  • Life-threatening OD
  • Children: assoc w Reye’s syndrome. Do not give (unless in Kawasaki’s disease)
52
Q

Describe the MoA of antiplatelets (clopi, tica, prasu)

A

ADP antagonists-> prevent platelet aggregation independent of COX system -> work synergistically w aspirin

53
Q

Describe the interactions of clopidogrel

A

Clopidogrel is a prodrug that requires activation by liver CYP system.
Potential interactions include: omeprazole, cipro, erythromycin, SSRIs.
PPI cover should be with lansoprazole or pantoprazole!

54
Q

For how long should antiplatelets be stopped before surgery?

A

7 days (for clopi). Aspirin is only stopped for high risk surgeries

55
Q

Describe the side effects of ACEis

A
  • Hypotension
  • Cough: bradykinin release, switch to ARB
  • Hyperkalaemia (bc of low aldosterone)
  • Worsening renal failure
  • Anaphylaxis, angioedema
56
Q

Describe the contraindications to ACEi

A
  • RAS
  • AKI
  • Pregnancy and breastfeeding
  • Caution in CKD (lower doses)
  • Avoid NSAIDs
57
Q

Describe the dosing of ramipril and losartan

A

Ramipril:
1.25mg in HF, 2.5mg in other indications.
Max 10mg daily

Losartan:
12.5mg daily in HF, 50mg in other indications

58
Q

Describe the monitoring of ACEi/ARBs

A

Measure U+Es after 1-2 weeks

  • If Cr increase by 30% or eGFR decrease by 25%
  • > stop drug
  • If K >5, stop any other K raising drugs and measure again, if not dropped -> stop
  • If K >6 -> stop
59
Q

Describe the types of CCBs

A

Rate-limiting (non-dihydropyridines): verapamil, diltiazem

Non-rate-limiting (dihydropyridines): amlodipine, nifedipine

60
Q

Describe the side effects of CCBs

A
  • Dihydropyridines: leg swelling, flushing, headache, palpitations
  • Verapamil: constipation, bradycardia, HF
61
Q

Describe the common dosing for CCBs

A

Amlodipine: 5-10mg PO OD
Diltiazem: 90mg PO BD

62
Q

Describe the MoA of loop diuretics

A

Inhibit the triple transporter in the loop of Henle

-> increased Na/K/Cl excretion + diuresis

63
Q

Describe the side effects of loop diuretics

A
  • Dehydration and hypotension
  • Hypokalaemia, hyponatraemia
  • Alkalosis
  • Hearing loss and tinnitus
64
Q

Describe the common dosing for loop diuretics

A
  • Acute pulmonary oedema: furosemide 40mg IV

- Long-term diuresis: furosemide 20-40mg

65
Q

Describe the side effects of thiazides

A
  • Dehydration and hypotension
  • Hypokalaemia
  • Erectile dysfunction
66
Q

Describe the side effects of beta-blockers

A
  • Cold peripheries
  • Bronchoconstriction
  • Headache
  • Fatigue
  • Erectile dysfunction
67
Q

Describe the interactions with statins

A
  • Amiodarone
  • Diltiazem
  • Macrolides (clari): hold statin during course
  • Grapefruit juice: prevents metabolism

Cardiology finals (4 decks)

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