SLA 18 - IHD and Heart Failure Flashcards
Which diseases are under the umbrella term coronary heart disease (CHD)?
- angina
- acute coronary syndromes (ACS)
- heart failure
- atrial fibrillation
What is the Health Check Programme (NHS England)?
Everyone aged 40-74 years, who has not already been diagnosed with CVD, diabetes or CKD, is invited every 5 years for a free health check.
Health check includes:
- CVD risk assessment (using QRISK)
- alcohol consumption
- assessment for dementia
- screening for diabetes mellitus
- screening for CKD
What treatment is offered for the primary prevention of CVD to people with an estimated QRISK ≥10%?
20mg atorvastatin OD
Also offer lifestyle advice:
- smoking cessation
- weight loss (if overweight)
- eating a healthy diet
- keeping alcohol consumption within recommended limits
- being physically active
What treatment is offered for the secondary prevention of CVD?
80mg atorvastatin OD
Give the risk factors for CHD.
- older age
- male sex
- family history of CVD
- smoking
- high LDL-C
- lack of physical activity
- unhealthy diet
- alcohol intake above recommended levels
- obesity
- hypertension
- diabetes mellitus
- CKD
- dyslipidaemia
- rheumatoid arthritis
- periodontitis
What is angina?
The pain or constricting discomfort in the chest, neck, shoulders, jaw, or arms caused by an insufficient blood supply to the myocardium.
Pathophysiology of angina.
Atherosclerotic plaques in the coronary arteries cause progressive narrowing of the lumen, and symptoms occur when blood flow does not provide adequate amounts of oxygen to the myocardium at times when oxygen demand increases (e.g. during exercise).
This is a demand ischaemia; no infarct.
Presentation of stable angina.
Typical angina presents with all three of the following features:
- precipitated by physical exertion
- constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms
- relieved by rest of GTN within around 5 minutes
Which symptoms would indicate hospital admission for a person presenting with angina?
- pain at rest
- pain on minimal exertion
- angina that seems to be progressing rapidly despite increasing medical treatment
Sublingual glyceryl trinitrate (GTN):
a) drug class
b) MOA in angina
c) adverse reactions
a) nitrates
b) elevates cGMP in smooth muscle of coronary arteries, causing vasodilation. This increases perfusion of myocardium.
c) headaches; flushing; dizziness
Atenolol
a) drug class
b) MOA in angina
c) adverse reactions
d) contraindications
e) drug interactions
a) beta-blocker
b) antagonises beta-adrenoreceptors on myocardium, slowing heart rate. This lengthens diastole allowing greater perfusion of coronary arteries.
c) bronchospasms; heart block; Reynaud’s; impotence
d) asthma; COPD; hepatic failure
e) beta-blockers plus non-dihydropyridine CCB increases risk of asystole / cardiac failure
Verapamil
a) drug class
b) MOA in angina
c) adverse reactions
d) contraindications
e) drug interactions
a) phenylakylamine CCB
b) antagonises L-type calcium channels in the myocardium, limiting calcium influx into the cells. This prolongs the action potential thus reducing heart rate. Diastole lengthens, allowing increased perfusion of coronary arteries.
c) constipation; bradycardia; heart block; cardiac failure
d) poor LV function; AV nodal conduction delay
e) verapamil plus beta-blocker increases risk of asystole / cardiac failure.
What instructions should be given to a patient when using GTN spray in an angina attack?
- stop what they are doing and rest
- use GTN as instructed
- take a second dose after 5 minutes if the pain has not eased
- call 999 for an ambulance if the pain has not eased within 5 minutes after the second dose, or earlier if the pain is intensifying.
What are the three ACS?
- Unstable angina
- ST-elevated myocardial infarction (STEMI)
- Non-ST-elevated myocardial infarction (NSTEMI)
Pathophysiology of unstable angina.
Atherosclerotic plaque in coronary arteries ruptures and a thrombus forms, causing partial occlusion of the vessel.
This is a supply ischaemia; no infarct.
Pathophysiology of NSTEMI.
Atherosclerotic plaque in coronary arteries ruptures and a thrombus forms, causing partial occlusion of the vessel.
This results in injury and infarct to the sub-endocardial myocardium.
Pathophysiology of STEMI.
Atherosclerotic plaque in coronary arteries ruptures and a thrombus forms, causing complete occlusion of the vessel.
This results in transmural infarct and injury.
Presentation of ACS.
Chest pain:
- retrosternal, crushing, heavy, severe or diffuse
- occur at rest or on activity
- may be constant or intermittent
- radiates to left arm, neck and jaw
Associated with:
- nausea / vomiting
- dyspnoea
- diaphoresis
- light-headedness
- palpitations
- syncope
What is the early management for ACS in primary care?
- morphine
- oxygen
- nitrates
- aspirin 300mg
Arrange emergency referral to hospital via ambulance.
What is cardiac rehabilitation?
Designed to improve cardiovascular health if you have experienced a heart attack, heart failure, angioplasty or heart surgery.
- exercise counselling and training
- education for heart-healthy living (ie. smoking and nutrition advice)
- conselling to reduce stress
What non-pharmacological secondary prevention is offered to patients following an MI?
- cardiac rehabilitation
- lifestyle changes (e.g. smoking cessation, healthy diet, moderate physical activity, weight loss)
What is atrial fibrillation?
A supraventricular tachycardia resulting from irregular, disorganised electrical activity and ineffective contraction of the atria.
Describe the patterns of atrial fibrillation episodes:
a) paroxysmal AF
b) persistant AF
c) permanent AF
a) episodes lasting longer than 30 seconds but less than 7 days, that are self-terminating and recurrent.
b) episodes lasting longer than 7 days, or less than seven days but require pharmacological or electrical cardioversion.
c) episodes that fails to terminate using cardioversion, relapses within 24hrs or lasts longer than 1 year.
Give some causes of atrial fibrillation.
- hypertension
- MI
- congestive heart failure
- rheumatic valvular disease
- congenital heart disease
- thryotoxicosis
Give some modifiable factors that increase risk of atrial fibrillation.
- excessive caffeine intake
- alcohol abuse
- obesity
- smoking
What medications can be prescribed to treat atrial fibrillation?
- beta blockers
- diltiazem / verapamil
- digoxin
- anticoagulants (CHADS-VASc)
Atenolol
a) drug class
b) MOA in AF
c) adverse reactions
d) contraindications
e) drug interactions
a) beta-blocker
b) antagonises b1 receptors on cardiac myocytes, decreasing cAMP and therefore decreasing [Ca2+]i. This lengthens the refractory period and therefore reduces cardiac excitability.
c) bronchospasms; hypotension; GI upset
d) asthma; COPD; heart block; severe hypotension; bradycardia.
e) beta-blocker plus non-dihydropyridine CCB may cause asystole.
Give some complications of AF.
- stroke
- thromboembolism
- heart failure
- tachycardia-induced cardiomyopathy
Presentation of AF.
Symptoms:
- palpitations
- chest pain
- shortness of breath
- dizziness
Signs:
- tachycardia
- irregular pulse
How is AF diagnosed?
- ECG changes
- conduct 24hr ambulatory ECG
Give the ECG changes associated with atrial fibrillation.
- absent p-waves
- wavy isoelectric baseline
- irregular ventricular rate (QRS)
- 160-180bpm
Give some causes of an irregular pulse besides atrial fibrillation.
- atrial extrasystoles
- ventricular ectopic beats
- sinus tachycardia
What is the management of atrial fibrillation in primary care?
- admit people if unstable
- manage reversible causes
- treat arrhythmia with rate control (e.g. beta-blocker)
- CHADS-VASc score (stroke risk)
- ORBIT for bleeding risk
What is the CHADS-VASCs score?
Calculates stroke risk for patients with atrial fibrillation.
Score of 0 (M) or 1 (F) is low risk.
Score of 1 is moderate risk.
Score >2 high risk.
What is the ORBIT score?
Calculates bleeding risk in patients on anticoagulation for atrial fibrillation.
When is referral to cardiology indicated in AF?
- rhythm control is appropriate
- rate control treatment fails
- personal has valvular disease
Define the following classifications of chronic heart failure:
a) heart failure with reduced ejection fraction (HFrEF)
b) heart failure with mildly reduced ejection fraction (HFmrEF)
c) heart failure with preserved ejection fraction (HF-PEF)
a) LVEF <40%
b) LVEF between 41-49%
c) LVEF >50%
Give the equation for ejection fraction.
Stroke volume / EDV
Chronic heart failure classified via LVEF.
Define the New York Heart Association symptomatic severity grades:
a) class I
b) class II
c) class III
d) class IV
a) no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness, or palpitations.
b) slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.
c) marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.
d) unable to carry out any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased.
Give some causes of chronic heart failure.
- coronary heart disease (most common)
- hypertension
- congenital heart disease
- end-stage chronic kidney disease
- nephrotic syndrome
- thyrotoxicosis
Presentation of heart failure.
Symptoms:
- breathlessness
- fluid retention
- fatigue
- decreased exercise tolerance
- light headedness or history of syncope
Signs:
- tachycardia
- laterally displaced apex beat
- heart murmurs
- third or fourth heart sounds
- hypertension
- raised jugular venous pressure
- enlarged liver (engorgement)
Describe the characteristics of the breathlessness that present in heart failure.
- worse on exertion
- present at rest
- orthopnoea
- nocturnal cough
- paroxysmal nocturnal dyspnoea
If symptoms of heart failure are severe, what would the management plan be?
Start a loop diuretic:
- furosemide 20-40mg daily
- bumetanide 0.5-1.0mg daily
- torasemide 5-10mg daily
What investigations can be considered if heart failure is suspected?
- ECG
- CXR
- echocardiogram
- urine dipstick (blood & protein)
Bloods:
- NT-pro-BNP
- U&E
- eGFR
- FBC
- TFTs
- LFTs
- HbA1c
Which blood test is specific to the investigation of heart failure?
NT-pro-BNP
Outline the management of patients who’s results of NT-pro-BNP have come back showing:
a) NT-pro-BNP level above 2000ng/L
b) NT-pro-BNP level between 400-2000ng/L
c) NT-pro-BNP level below 400ng/L
a) refer urgently for specialist assessment and echocardiogram (2 weeks)
b) refer for specialist assessment and echocardiogram (6 weeks)
c) diagnosis of heart failure less likely
How should a person with confirmed heart failure with reduced ejection fraction be managed in primary care?
Where symptoms of fluid overload are present, ensure the patient has been prescribed a loop diuretic and titrate the dose up or down according to symptoms.
Prescribe an ACEi and a beta blocker.
Ramipril
a) drug class
b) MOA
c) adverse effects
d) contraindications
e) drug interactions
a) ACE inhibitor
b) inhibits ACE so prevents the conversion of Ag1 to Ag2, resulting in: reduced ADH and aldosterone release, and vasodilation.
c) dry cough; angioedema; hypotension; renal failure; hyperkalaemia
d) AKI / CKD; pregnancy; angioedema
e) ACEi plus other antihypertensives increases risk of hypotension; ACEi plus NSAIDs reduce efficacy of ACEi.
What factors can affect NT-pro-BNP levels?
May be reduced by:
- BMI >35kg/m2
- diuretics
- ACEi
- beta-blockers
- Afro-Caribbean family origin
May be elevated by:
- age >70 years
- left ventricular hypertrophy, MI or tachycardia
- right ventricular overload
- heart failure
- pulmonary embolism
ie. the test is very non-specific if positive
Give some complications of heart failure.
- cardiac arrhythmias (e.g. AF)
- depression
- cachexia
- CKD
- sexual dysfunction
- sudden cardiac death
What non-pharmacological management options are there for patients with heart failure?
Lifestyle changes including smoking cessation, weight control, increasing physical exercise, low salt diet and fluid restriction.
Provide sources of information and support (e.g. NHS, BHF)
Offer personalised rehabilitation programme.
May offer implantable cardioverter defibrillator if HFrEF <35%.
What are the sick day rules in the treatment of heart failure?
If acutely unwell stop ACEi, diuretics and aldosterone antagonists.
Which drug is used second line in the treatment of chronic heart failure?
For this drug, give:
a) drug class
b) MOA
c) adverse effects
d) contraindications
e) drug interactions
Spironolactone
a) aldosterone antagonist
b) antagonises aldosterone receptors at ROMK and ENaC in the kidney tubules, reducing reabsorption of sodium and increasing secretion of potassium. This leads to more diuresis and thus loss of circulating volume.
c) hyperkalaemia; gynaecomastia
d) hyperkalaemia; Addison’s disease
e) spironolactone plus other hyperkalaemic drugs increase risk of hyperkalaemia.
When would you suspect that a patient is in end stage heart failure?
End-stage heart failure indicates that the patient is at risk of dying in the next 6-12 months. Symptoms include:
- pain
- breathlessness
- persistent cough
- fatigue
- limitation of physical acitivity
- depression / anxiety
- constipation
- oedema
- cognitive impairment
How should a patient with end stage heart failure be managed in primary care?
Liase with cardiologist and consider switching off implantable cardioverter defibrillator.
Ensure patient has advanced care plan.
Provide drugs for symptomatic relief of breathlessness, pain, anxiety / depression, constipation etc.
How is symptomatic breathlessness and pain for end stage heart failure controlled?
Breathlessness: optimise standard treatments (e.g. diuretics). If ineffective, consider prescribing opioids and/or home oxygen.
Pain: cardiac pain so consider prescribing morphine and nitrates.
