Cardiolology 2 Flashcards

Question

BP targets with Hypertensive treatments?

Answer 1

``` Reduce and maintain BP to the following targets: Age <80 years: • Clinic BP <140/90 mmHg • ABPM/HBPM <135/85 mmHg Age ≥80 years: • Clinic BP <150/90 mmHg • ABPM/HBPM <145/85 mmHg Postural hypotension: • Base target on standing BP Frailty or multimorbidity: • Use clinical judgement Use clinical judgement for people with frailty or multimorbidity. ```

Answer 2

resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherence Consider seeking expert advice or adding a: • low-dose spironolactone4 if blood potassium level is ≤4.5 mmol/l • alpha-blocker or beta-blocker if blood potassium level is >4.5 mmol/l Seek expert advice if BP is uncontrolled on optimal tolerated dose. Beta blockers contraindicated with asthma

Answer 3

``` Offer lifestyle advice. In addition, for the following groups: Age >80 with clinic BP >150/90 mmHg: • Consider drug treatment Age <80 with target organ damage, CVD, renal disease, diabetes or 10-year CVD risk ≥10%: • Discuss starting drug treatment Age <60 with 10-year CVD risk <10%: • Consider drug treatment Age <40: • Consider specialist evaluation of secondary causes and assessment long- term benefits and risks of treatment ```

Answer 4

Heart failure - heart not able to meet cardiac output without increasing diastolic pressure. Poor prognosis - more than 30-40% patients who are diagnosed die within a year Congestive heart failure - heart failure + breathlessness and abnormal sodium & water retention causing oedema. Types Heart failure with reduced left ventricular ejection fraction (LVEF < 40%) & signs/symptoms 0 Heart failure wirh mid-range ejection fraction (40 -49%) + signs 0 Heart failure with preserved ejection fraction (>50%) SIGNS/SYMPTOMS MAJOR CRITERIA - Dyspnoea/orthopnoea (do they wake up breathless , prop up with pillows during night) - Neck vein distension - S3 gallop (abnormal 3rd heart sound occurs in early diastole - abnormal ventricle filling (blood hits distended ventricle - sounds like horse galloping. ) - Cardiomegaly (may find LV Dilation or hypertropy) - Hepatojugular reflux - distention of the neck veins caused by firm pressure over liver. - rales (small clicking, bubbling, or rattling sound in lungs on inhalation) MINOR CRITERA - Tachycardia - Ankle oedema - signs of pleural effusion - Night cough - Hepatomegaly - Chest discomfort - Fatigue , muscle weakness or tiredness. others signs tachypnoea , dull percussion at lung bases , ascities , cachexia , CAUSES - NSAIDS - Liver dysfunction ( too much albumin ?) - confirm ? RISK FACTORS ``` 0 MI 0 Hypertension 0 Diabtetes 0 Dyslipidaemia 0 Old age 0 Male 0 Obesity 0 Left ventricular dysfunction / hypertrophy 0 renal insufficiency 0 valvular heart disease. (stenosis & regurgitation cause ventricular remodelling e.g hypertrophy etc,) 0 AF (arrythmias) 0 Sleep apnoea 0 Hx of HF 0 Elevated natriuretic peptides. 0 Thyroid disorders. 0 cocaine abuse ``` hyperthyroidism cardiomyopathy

Answer 5

0 Trans - thoracic echocardiogram.(TTE - foccused) 0 ECG - (evidence of underlying coronary artery disease, left ventricular hypertrophy, or atrial enlargement; may be conduction abnormalities and abnormal QRS duration) 0 CXR - Kerby B lines - Cardiomegaly - Pleural effusion 0 Natriuretic peptide test (made by heart - high levels in blood indicate heart not pumping well. 2 types : - B(Brain)- Type NP (BNP) - N- terminal pro - brain NP (NT-pro-BNP) above 400pg/ml or ng/L - supports diagnosis Below 400pg/ml - - grey zone - potential for other causes but can still be HF - but HF less likely) (Elevated levels can also be caused by other problems) -if above 2000 ng/L urgently ( 2 WEEKS) - btw 400 - 2000 ng/L - referal & echocardiogram within 6 weeks. NOT FOR DIAGNOSIS - BUT IMPORTANAT INVESTIGATIONS for aggravating facotors /alternative diagnosis ``` 0 FBC 0 Serum electrolytes , creatinine , urea nitrogen 0 Blood glucose 0 LFT - liver 0 TSH 0 Serum lipids 0 serum ferritin 0 transferrin saturation. 0 urinealysis 0 HbA1c) 0 Troponin ``` there are other ones you can consider.

Answer 6

1ST LINE - ACE inhibitor (if ACE not tolerate ARB) (sacubitril in combo with valsartan can also be used - conditions: NYHA class 2 -4 , EF<35%, already taking stable dose of ACE or ARBs.) PLUS - Beta Blocker (primary - carvediol but other can be used) if ACE & ARB not tolerate - Hydralazine + Isosorbide dinitrate. PLUS - lifestyle changes - sodium reduction , etc. ADJUCNT - Diuretics (used for all types of HF with fluid retention e.g Furosemide , etc) Amidarone antagonist (spironolactone or eplerenone - ask specialist if needs to be added) ADJUNCT - Ivabradine (may be an option for patients with :New York Heart Association class II, III, or IV heart failure with: - >75 beats per minute - ejection fraction <35%, and who remain symptomatic despite optimal therapy. - It can be used for those unable to take beta-blockers) ADJUNCT - Digoxin (for worsening severe HF with reduced EF despite First line.) REFACTORY TO OPTIMAL MEDICAL TREATMENT LVEF < 35%, with LV dysfunction 1ST LINE 0 ICD (implantable cardioverter ) or 0 CRT -D - Cardiac resychronisation therapy with pacing 0 CRT - P - with pacing) 2ND LINE - Mechanical circulatory support devices (e.g ventricular assisst devices) 3RD LINE - Cardiac transplantation

Answer 7

Management of risk factors e.g. Hypertension , weight loss , dyslipidemia , glyceamic control in diabetes) PLUS - Diuretic (if signs of fluid overload) PLUS - ACE or ARBs if coexisting hypertension (a beta blocker may be added)

Answer 8

Rapid onset or wrosening of symptoms of heart failure - URGENT TREATMENT SIGNS SYMPTOMS - Similar to chronic HF. plus - Displaced apex beat - elevated JVP - Cold extremeties (sign of poor perfusion - others signs of this can be present) - peripheral oedema (usually bilateral & pitting) RISK FACTORS ``` - Similar to chronic AF plus -Medication - non adherence in chronic HF patients. - Previous Chemo - smoking - excessive alcohol - Fhx of ischeamic HD , Cardiomyopathy. ```

Answer 9

``` similar to chronic HF with slight changes. 0 ECG 0 CXR - Pulmonary congestion Pleural effusion Interstitial or alveolar oedema Cardiomegaly. 0 Naturetic peptides RULE OUT ACUTE HF IF: - B type NP < 100mg/L or - NT pro - BNP < 300mg/L ``` 0 Trans - thoracic Echocardiogram (with raised NT

Answer 10

Before it is determined if they are stable or not. consider Mechanical circulatory support to people: - with potentially reversible severe acute HF - who are potential transplant candidates. Consider Respiratory support - oxyget sat <90% or Pa02 <8Kpa - if cardiogenic pulmonary + severe dyspnoae , acidemia (non invasive ventilary support) Invasive ventilation- if in respiratory failure or have have reduced conciousness or physical exhaustion Pharmological treatment 1ST LINE 0 GIVE IV DIURETICS - After stablisation <40% Beta blocker - (if already one continue (if they dont have these HR< 50, 2nd , 3rd degree AV block, Shock) - Start or restart after these have stabilised. (e.g IV diuretics no longer needed) - if Acute HF with reduced EF - give ACE (or ARB if not tolerated ) + aldosterone antagonist. (Give aldosterone alone if ACE or ARB not tolerated) * monitor renal function , electrolytes , HR , BP , during treatment with any of these. Treat after according to chronic HF. After stablisation EF > 40 % 1ST LINE 0 Loop diuretic (Furosemide ) 0 consider continuing Beta blocker 0 Cardiac rehabilitation

Answer 11

HF with high risk of dying within the next 6 - 12 months. Check to see if all treatments have been cnsidered & involve MDT & check patient understanding of situation. ``` provide symptoms relief - Breathlessness - Pain - Morphine , nitrates Anxiety & depression constipation , nausea & vomiting. ```

Answer 12

1st line- ACE if not tolerated ARbs (For example cough with ACE change to ARBs) 2ne line CAB for any age or ethnicity.

Answer 13

Supraventricular tachyarrhythmia. Parts of the atria are contracting at different times so atrial contraction is disorganised. (seems like atria are quivering) (quivery , irregular fluttery Heartbeat) TYPES 0 New - onset AF 0 Chronic AF SIGNS/ SYMPTOMS 0 Palpitations (heart racing or fluttering in chest - can happen at rest or on activity (last from mins to hours) 0 Chest pain/ discomfort (due to rapid & irregular ventricular rate) 0 Irregular pulse rate 0 Breathlessness/dyspnea 0 Fatigue 0 Anxiety RISK FACTORS - Increasing age - Hypertension - Heart failure - Diabetes - obesity - Coronary artery D - Valve disease (especially mitral vakve , rheumatic heart dsease) - Other cardiac diseases - Heavy , regular alchohol consumption - Other atrial arryhtmias - Cardiac or thoracic surgery - can be a complication - Previous stroke / TIA - Hyperthyroidism

Answer 14

First do manual pulse exam - check for irregular pulse , then perform ECG if irregular pulse detected in suspected patients. 0 ECG - immediate if suspected - diagoses AF. - Will see: a irregular r intervals with many small peaks btw QRS complexes. small peaks correspond to each small area of the atria contracting at different times (chaotic baseline) ------------------> one of the contractions makes it to the ventricles and causes contraction - but this happens at different times each heart beat so irregular R intervals -------> irregular pulse. 0 CXR 0 Transthorcic echo (TTE) - may do but not diagnostic Recommended in those who need/are : - baseline echocardiogram is important for long-term management - considering a rhythm-control strategy that includes cardioversion (electrical or pharmacological) high risk of, or you suspect, underlying structural/functional heart disease (such as heart failure or heart murmur) that influences their subsequent management (e.g., choice of anti-arrhythmic drug] - In whom refinement of clinical risk stratification for antithrombotic therapy is needed. 0 FBC - check for other causes - anaemia , infection etc. 0 Clotting profile (baseline levels) - indetigy inderlying coagulation defect inform treatment with anticoagulants 0 U & E , Creatinine - exlcude renal impairment , hypo/Hyper kalaemia & hypomagnesia 0 Thyroid function test (exclude throtoxicosis) 0

Answer 15

Haemodynamically unstable 1ST LINE Emergency electrical cardioconversion ( returns abnormal HR to normal rhythm) If not already on therapeutic anticoagulants offer : LMWH (enoxaprin etc) or UFH (heparin) ---------------> continued after cardioconversion (if not started on oral should transition to this) Treat underlying cause Haemodymically stable - 1ST LINE - Monotherapy -Rate or rhythm control e.g Beta blockers , CAB or digoxin (digoxin - used if patient does not move around a lot or others not tolerated) -( for onset of AF less than 48hrs ) if > 48hrs - rate control only ( DONT NOT USE CAB IN THOSE SUSPECTED OF AF WITH DECOMPENSATED HF - seek specialist advice on use of Beta blockers in this case) if monotherapy does not work use combination. rate control = any combination of B- blocker , CAB , digoxin without rhythm control) Rhythm control - use of anti- arrthythmic medication , cardioversion or AF ablation or surgery. Consider pharmalogical or electrical cardioversion if needed e.g. flecanide or amiodarone (if no structral or ischeamic HD, amiodarone - if structural heart disease.) If rate not stabilised within 48hrs/ high risk of AF reoccurance e.g. (Prolonged AF structural HD , failed cardioversion ),/ recommended for preventing stroke - give anticoagulants once stablilised - give advice on risk factrs and refferal for follow up.

Answer 16

Long term form of new onset AF. SIGNS/SYMPTOMS - similar to new onset (MAIN ONES - Palpitations , Tachycardia , irregular pulse) Complications of AF - Stroke. RISK FACTORS Similar New onset AF. Investigations - similar to new onset e.g. ECG , Thyroid profile , echocardiogram (to exclude important cardiac patholgies & risk factrs for persitent AF) , Serum U & E. can do : - prolonged ECG if diagnosis is uncertain. - serum transaminases - liver enzymes may be deranged with alcohol abuse.

Answer 17

Permanent AF 1ST LINE - Rate control - monotherapy (BETA blocker - excluding sotalol or CAB - Verapamil or diltiazem) - Digoxin can be used if : - little to no exercise done or other drugs not tolerated. IF MONO THERAPY DOES NOT WORK DO COMBINATION of 2 drugs) (don' t use rate control in those whose AF is reversible , caused by HF , new onset AF, have atrial flutter which is more suited to treatment by ablation) consider rhythm control if rate control not successful or symptoms continue even if HR is controlled.

Answer 18

One of the supraventricular tachycardias ? SAN not working properly - 1. Atrium has various automacitcity Foci which fire in the event of SAN not working (at rate of 60-80 bpm) - there is a particular irritable one which acc fires at a rate of 250-300bpm 0 (ECG - causes may P waves) 2.This excites the AVN - bit AVN node has mechanism (refractory period) to prevent rapid firing so ventricular rate is slower (|150bpm) 0( ECG - causes even spaced QRS complexes) (look at KHAN ACADEMY for rest of explanation) ECG is going to show many P waves with regular R intervals (e.g 3/2/4 P waves to 1 QRS ) Classical pattern - positive P waves in V1 , negative P waves in 2,3, AVF. - looks like a saw tooth pattern SIGNS/SYMPTOMS 0 Palpatations 0 Fatigue or lightheadedness - if underlying condition the causes - worsening of them e.g HF , Pulmonary symptoms (may indicate worsening of symptoms or new - onset atrial flutter) RISK FACTORS - Increasing age - Valvalar dysfunction - Atrial dilation (promotes reetrant circuits) - Atrial septal defects (can cause dilation) - recent cardiac / thoracic procedures - HF - Hyperthyroidism - COPD - Asthma - Pneumonia

Answer 19

ECG - 0 Atrial rates of 240 -320 Bpm) 0 Many P waves to QRS complex 0 Ventricular rate - usually at 150bpm 0 Saw tooth appearence 0 Classic appearence - Positive P wave deflection in V1, negative in 2,3, AVF. ( if negative in V1, Positive in 2,2,AVF - reverse Atrial flutter) 0 Thyroid function test 0 Serum electrolytes 0 CXR - if suspicion of underlying lung disease. can do others : e,g digitalis toxity (if taking digitalis drugs - digoxin) etc.

Answer 20

H UNSTABLE 1ST LINE - Synchronised cardioversion H STABLE 1ST LINE - Beta blocker or CAB or amiodarone (rate control - used in acute setting) * CAB preferred in chronic lung disease - Beta B may provoke bronchospasm. (BB then CAB then Amidarone) 2ND LINE - Synchronised cardioversion. 3RD LINE - Pharmalogical conversion - E.G (ibutilide -1st , Doferilide - 2nd) PLUS - rapid atrial pacing THESE ARE FOR ALL THE LINES FOR H STABLE. PLUS - anticoagulation (Thromboembolic prophylaxis - LMWH or UFH + waraprin or NOACs) - also done in Atrial Fib. PLUS - treat underlying condition Recurrent Atrial Flutter or failure of electric cardioversion 1ST LINE - Catheter ablation PLUS - Anticoagulation ADJUNCT - Anti - arrythmic therapy e.g amiodarone , sotalol (Class 3 anti-arrythmic (K channel blocker), propafenone (Class 1 - sodium channel blocker).

Answer 21

- Atrial Fibrillation(irregular rhythm) - Atrial flutter (regular rhythm but fast) - Paroxysmal supraventricular tachycardia (PSVT) (regular but fast) - Accessory pathway tachycardia - AV nodal reentrant tachycardia

Answer 22

Episodes of rapid heart rate that start anywhere above the ventricles. Paroxysmal - comes and goes (abruptly starts and abruptly stops ) can be precipitated by : - Alcohol use - Caffeine use - Illicit drug use - Smoking - pregnancy TYPES - 0 Atrial tachycardia 0 Atrioventricular nodal reentry tachycardia. SIGNS / SYMPTOMS -

Answer 23

1ST LINE - IV Adenosine - IV verapamil (as alternative - don't use if taking a beta blocker) if no alternative diagnosis and failure of 1ST LINE or H UNSTABLE - Direct current cardioversion RECURRENT Catheter ablation ``` or anti - arrhythmics e.g Class 1 - propafenone , flecainide Class 3 - sotalol (k channel) Class 4 - CAB - Verapamil , diltiazem. ```

Answer 24

Type of Supraventricular Tachycardia rapid regular rhythm arising from a discrete area within the atria. CAUSES - Digoxin Toxicity - Catecholamine excess - Congenital heart disease - Cardiomyopathy SIGNS / SYMPTOMS - Palpatations - Fatigue / weakness - Diziness - Syncope RISK FACTORS - Substance movements - alcohol misuse /withdrawal, cocaine, amphetamines - Digoxin toxicity (might see nausea & vomiting) - aminophylline, beta-agonists, potassium-wasting diuretics, or over-the-counter cold/sinus medications that contain phenylephrine. - Previous cardiac surgery to correct congenital heart defects. - Previous MI, cardiac or great vessel surgery, Congestive heart failure, cardiomyopathy predisposes to Focal AT. - if heart failure is the causes - other symptoms : - Rales - Oedema - SOB (can also indicating worsening COPD) chest pain is uncommon.

Answer 25

0 ECG Heart rate above 100Bpm - One P wave morphology - cause coming from one foci (area in atrium) - P waves can have similar morphology to sinus rhythm if Foci in near SAN - if further away looks more different - P waves : QRS (1:1) 0 Digoxin level - toxicity can cause AT (aswell as other arrythmias) o Theophylline (xanthines - relax muscles around airways) level - drug used to treat SOB , Wheezing , chest tightness etc. 0 CXR - to see if cardiopulmonary disease presents - predisposes to AT. 0 Electrolytes - (can develop AT with digoxin toxicity in the setting hypokalemia) 0 Toxicolgy screen If no response to adenosine or vagal manuovers - differeniate Focal AT from other SVT (ask someone - not sure) Vagal maneuvers - simple actions that stimulate the vagus nerve & slow Supraventricular tachycardia. (e.g bearing down , coughing, put ice cold , wet towel on face etc) 0 TSH

Answer 26

If no change is seen, either the dose/delivery of adenosine was inadequate or rarely, the diagnosis is VT in which the AV node plays no part. A sudden termination is suggestive of AVNRT or AVRT as the AV node is a critical part of the circuit in both; the mean dose of adenosine required for termination is 6 mg. The presence of P-waves with AV dissociation is diagnostic of AT; termination of AT with adenosine is unusual but favours a focal over a re-entrant mechanism.14 TERMINATES ARRTHYMIS WHICH ARE DEPENDENT ON AV NODE. - no response indiactes arrythmias which dont involve AV node e.g Focal Atrial Tachycardia etc

Answer 27

1ST LINE Beta blocker , CAB (avoid in Decompensated HF or H UNSTABLE) 2ND LINE - Ibutilide or amioderone 3RD LINE Direct current cardioversion or Class 1c anti- arrhythmic e.g. propaferonone H UNSTABLE - Direct current cardioversion if Digoxin toxicity the cause - Supportive treatment (withold digoxin , optimise volume status , replace potassium if deficit) SUSTAINED OR RECURRENT - Catheter Ablation CHILD - Anti-arrythmics or catheter ablation

Answer 28

MECHANISM OF ACTION inhibits NA/ATPase to keep sodium in cells so CA/NA exchange cannot work (CA also kept inside myocyte )- increased cardiac contraction - useful to increase contraction in heart failure. Targets vagus nerve and reduce heart rate - useful in A fib INDICATIONS - 0 treatment of arrhythmia - Atrial Fib , Flutter 0 Heart failure SIDE EFFECTS - 0 Hyperkalaemia (NA/K atpase blocked - K not drawn into cells and stays in blood) - can cause arrythmias

Answer 29

DIGOXIN TOXICITY Causes - 0 Renal failure (renally excreted) 0 Hypokalemia 0 Drugs that displace digoxin. SIGNS / SYMPTOMS 0 GI symptoms - nausea & V - Diarrhoea - abdominal pain - anorexia 0 CNS symptoms - legarthy - weakness - confusion(digoxin induced hyperkalemia in the elderly - can cause confusion) - confusion can occur in all age groups & for other reasons. 0 Cardiovascular symptoms - palpitations - syncope - arrhythmias - dyspnoea ``` Uncommon 0 Visual symptoms - Blurred vision - Colour vision disturbances - Diplopia - Xanthopsia (yellow halos around objects ``` RISK FACTORS - Age > 55 - Decreased renal clearence - Hypokalaemia (<3.0 -3.5mmol/L) ( low serum potassium means renal excretion of digoxin is reduced) also ((Digoxin binds to K site on NA/K atpase so low serum conc increases risk of toxicity - less competition for digoxin) - Hyperkalaemia (>5mmol/L) (Diminshes digoxin effectivness) - Hypomagnesaemia - Hypercalcaemia - increases sensitivity to digoxin ``` - Concomitant drug use 0 Verapamil 0 diltiazem (CAB) 0 Amiodarone - SEVERE(decrease renal clearence) 0 Quinidine 0 Ketaconazole, itraconazole (and associted drugs in class) 0 erythromyocin, clathromyocin 0 Ciclosporin (antibiotics can kill GI bacteria - increasing digoxin absorbed by GI. ) 0 Propafenone 0 Spiranolactone(moderate) 0 Doxorubicin 0 2-4 dinitrophenol 0 Corticosteriods -SEVERE 0 Salbutamol 0 Terabutaline. (CAB , Some diuretics (bendroflumezide, thiazide & loop diuretics) - SEVERE) , Erythromycin (other mycin antibiotics -SEVERE- interactions) ``` CONTRAINDICATIONS - Some Supraventriular arrythmias (Wolff - Parkinson - White Syndrome - Ventricular tachycardia/Fib - Hypertrophic obstructive cardiomyopathy (unless concomitant Atria Fib/HF) - Heart conduction problems (intermittent complete heart block or AV heart block) - Myocarditis - Constricitive pericarditis (unless Concomitant HF/AF)

Answer 30

0 ECG - these seen with use of digoxin not just in toxicity - Changed ST segement - Slurred ST segment - (reverse tick ) - T wave changes - Biphasic - intial negative deflection then terminal positive deflection - seen most in V4-V6 - shortened QT interval (less than 0.4 sec - Increased PR interval (increased vagal effects at AV node). 0 Digoxin serum concentration 0 Serum K, Mg 0 Serum Urea & Creatinine.

Answer 31

Acute - low to moderate toxicity (for chronic ingestion - same but no activated charcoal) Stop digoxin 1ST LINE - Activated Charcoal + supportive care (Cardiac monitor , fluids if hypotensive / volume depleted , electrolyte supplementation , oxygen etc. ) ADJUNCT - Potassium replacement (if potassium depleted) ADJUNCT - Observation/ Correction of hyperkalemia (corrected only if life threatening bcc risk of hypokalaemia) USE Digfab (DIGOXIN ANTIBODY FAB FRAGMENTS) not usual calcium glucnoate / chloride as intracellular CA is already high so - risk of arrythmias or cardiac arrest. ADJUNCT - hypomagnesaemia- magesium replacement. SEVERE TOXICITY OR Haemodynamically compromised. 1ST LINE Digxin Binding - Digoxin immune Fab + supportive care (and all other adjunct methods mentioned earlier) * NSAIDS if used in the elderly can cause acute detoration of renal function - digoxin is renally excreted & as narrow therapuetic window-----> toxicity.

Answer 32

``` Lithium Methotrexate corticosteriods anticoagulants (warafarin , Hepain, ripaxoban) streptokinase, urokinase ```

Cardiolology 2 Flashcards

(56 cards)