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Cardiology finals KTB > 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
Describe the presentation of ACS
- Severe central crushing chest pain w radiation - Not relieved by rest - Nausea, diaphoresis, agitation - Tachypnoea, tachycardia - Syncope
26
Describe the acute management of STEMI
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
27
Describe the management of STEMI after reperfusion/medical Mx
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
Describe the acute management of NSTEMI
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
What are the complications of MI?
``` Death Arrhythmia Rupture (septum) Tamponade HF ``` ``` Valve pathology (MR) Aneurysm Dressler's syndrome (pericarditis) Emboli Recurrence ```
30
Describe the management of angina
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
What are the indications for CABG?
1. Refractory angina 2. Left main stem stenosis 3. Triple vessel disease 4. Unsuccessful PCI
32
Describe the investigations for a patient presenting with angina
- History and examination - ECG - Bloods: FBC, U+Es, TFTs, HbA1c, lipids - CT angiography - Consider further tests: myocardial perfusion SPECT, stress echo, etc.
33
What are the risks of CABG?
Anaesthetic reactions: nausea, vomiting, allergic reaction Short term: pain, blood loss, palpitations, MI, stroke Long term: infection, death, graft stenosis
34
What are the risks of PCI?
Anaesthetic reactions Immediate: coronary dissection, pain, stent thrombosis, AKI Long term: re-stenosis
35
Define hypertension
Stage 1: 140-159/90-99 Stage 2: 160-179/100-109 Stage 3: >180/110
36
Describe the aetiology of hypertension
``` Primary (essential) Secondary: -RAS and other renal disease -Endocrine: phaeo, Cushing's, Conn's -Coarctation -etc ```
37
Describe the investigations for hypertension
Urinalysis: proteinuria, PCR/ACR ECG: LVH Bloods: FBC, U+Es, TFTs, cortisol, HbA1c, lipids Ambulatory BPM/home BPM: needed for diagnosis Retinopathy screening
38
Define the thresholds for hypertension on HBPM/ABPM
Average weekly readings >135/85
39
Describe the management of hypertension
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
Which hypertensive drugs are preferred in HF? Diabetes?
HF: avoid CCBs. ACEi better Diabetics: ACEi Indapamide > bendroflumethiazide
41
What are the target BPs in HTN management?
<140/90 Frail: <150/90 Diabetics: <130/80
42
Describe the complications of hypertension
``` Stroke: increased risk 9x CVD: increased risk 3x HF CKD Retinopathy + visual loss ```
43
Describe the classification of hypertensive retinopathy
Stage 1: silver wiring, tortuous arteries Stage 2: AV nipping Stage 3: flame haemorrhages and cotton wool spots Stage 4: papilloedema
44
Describe the types of dyslipidaemia
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
Describe the management of dyslipidaemia
Conservative: -Diet and exercise, reduce CV RFs Medical: - Calculate QRISK2 score - >10%: treatment recommended - First line: statin eg. atorvastatin 20mg - 2nd line: ezetimibe
46
Describe the investigations for dyslipidaemia
BMI | Bloods: FBC, U+Es, LFTs, HbA1c, lipids, TFTs
47
What are the important things to consider when prescribing statins?
- 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
What is the normal dose of statins?
Primary prevention (QRISK >10%, T1DM and >40, CKD): -Atorvastatin 20mg Secondary prevention: -Atorvastatin 80mg (CKD: 20mg)
49
Name the different antiplatelets used for IHD prevention + doses
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
Describe the MoA of aspirin
Irreversible COX inhibitor -> prevents release of thromboxane A2 and therefore platelet aggregation
51
Describe the cautions to the use of aspirin
- 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
Describe the MoA of antiplatelets (clopi, tica, prasu)
ADP antagonists-> prevent platelet aggregation independent of COX system -> work synergistically w aspirin
53
Describe the interactions of clopidogrel
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
For how long should antiplatelets be stopped before surgery?
7 days (for clopi). Aspirin is only stopped for high risk surgeries
55
Describe the side effects of ACEis
- Hypotension - Cough: bradykinin release, switch to ARB - Hyperkalaemia (bc of low aldosterone) - Worsening renal failure - Anaphylaxis, angioedema
56
Describe the contraindications to ACEi
- RAS - AKI - Pregnancy and breastfeeding - Caution in CKD (lower doses) * Avoid NSAIDs
57
Describe the dosing of ramipril and losartan
Ramipril: 1.25mg in HF, 2.5mg in other indications. Max 10mg daily Losartan: 12.5mg daily in HF, 50mg in other indications
58
Describe the monitoring of ACEi/ARBs
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
Describe the types of CCBs
Rate-limiting (non-dihydropyridines): verapamil, diltiazem | Non-rate-limiting (dihydropyridines): amlodipine, nifedipine
60
Describe the side effects of CCBs
- Dihydropyridines: leg swelling, flushing, headache, palpitations - Verapamil: constipation, bradycardia, HF
61
Describe the common dosing for CCBs
Amlodipine: 5-10mg PO OD Diltiazem: 90mg PO BD
62
Describe the MoA of loop diuretics
Inhibit the triple transporter in the loop of Henle | -> increased Na/K/Cl excretion + diuresis
63
Describe the side effects of loop diuretics
- Dehydration and hypotension - Hypokalaemia, hyponatraemia - Alkalosis - Hearing loss and tinnitus
64
Describe the common dosing for loop diuretics
- Acute pulmonary oedema: furosemide 40mg IV | - Long-term diuresis: furosemide 20-40mg
65
Describe the side effects of thiazides
- Dehydration and hypotension - Hypokalaemia - Erectile dysfunction
66
Describe the side effects of beta-blockers
- Cold peripheries - Bronchoconstriction - Headache - Fatigue - Erectile dysfunction
67
Describe the interactions with statins
- Amiodarone - Diltiazem - Macrolides (clari): hold statin during course - Grapefruit juice: prevents metabolism

Cardiology finals KTB (4 decks)

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