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General Practice > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

Define HYPERTENSION.

A

Hypertension is clinically defined as a systolic blood pressure > 140mmHg and diastolic blood pressure > 90 mmHg, in a patient > 18 years of age.

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2
Q

Outline the grades of HTN.

A

NORMAL - SBP < 120 mmHg; DBP < 80 mmHg
HIGH NORMAL - SBP 120- 139 mmHg; DBP 80 - 89 mmHg
GRADE I HTN - SBP 140 - 159 mmHg; DBP 90 - 99 mmHg
GRADE II HTN - SBP 160 - 179 mmHg; DBP 100 - 109 mmHg
GRADE III HTN - SBP > 180 mmHg; DBP > 110 mmHg
ISOLATED HTN - SBP > 140 mmHg but DBP < 90 mmHg

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3
Q

Identify causes of SECONDARY HYPERTENSION.

A

MERC

M - MEDICATIONS
✔️ NSAIDS
✔️ corticosteroids
✔️ oral contraceptive pill

E - ENDOCRINE
✔️ primary hyperaldosteronism (Conn's Syndrome)
✔️ phaeochromocytoma 
✔️ Cushing's Syndrome
✔️ hyperthyroidism

R - RENAL
✔️ renal artery stenosis
✔️ polycystic kidney disease

C - CARDIOVASCULAR
✔️ coarctation of the aorta

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4
Q

Define the ABSOLUTE CARDIOVASCULAR RISK assessment.

A

Absolute cardiovascular risk assessment is a tool used to stratify the risk that an individual will experience an adverse cardiovascular event within the next FIVE YEARS.

It should be calculated every TWO years in adults > 45 years of age (>35 years of age if ATSI).

The components that make up the ACR include both modifiable and non-modifiable factors, such as: 
✔️ age 
✔️ gender
✔️ ATSI status
✔️ diabetes mellitus
✔️ smoking status
✔️ blood pressure
✔️ HDL: total cholesterol ratio
✔️ LVH on ECG

Based on the calculations, risk is classified as either:

  1. mild (<10% risk)
  2. moderate (10-15% risk)
  3. high (>15%)

The ACR is used to guide management of both hypertension and dyslipidemia.

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5
Q

How is HYPERTENSION diagnosed?

A

Hypertension requires two seperate readings on two seperate occasions of BP > 140 / 90 mmHg.

Methods for measurement include:

  1. clinic readings
  2. home readings
  3. ambulatory / 24 hour halter monitor
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6
Q

Outline some investigations appropriate for HYPERTENSION.

A

BEDSIDE Ix
✔️ ECG
✔️ urine dipstick (for proteinuria)
✔️ random BGL

LABORATORY Ix
✔️ FBC + WCC
✔️ inflammatory markers
✔️ UECs + eLFTs
✔️ fasting lipids
✔️ fasting BGL
✔️ TFTs
✔️ iron studies + B12 + folate

IMAGING / FUNCTIONAL Ix
✔️ echocardiogram
✔️ ambulatory monitoring / halter monitor
✔️ exercise stress test
✔️ coronary angiogram
✔️ fundoscopy
✔️ abdominal / pelvic CT (to view renal artries and the kidney).

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7
Q

Identify the aim blood pressure for patients with HTN.

A

< 140 / 90 mmHg (if no renal disease or end-organ complications).

< 130 / 80 mmHg in the following patient groups: 
✔️ diabetes mellitus
✔️coronary artery disease
✔️ chronic kidney disease
✔️ proteinuria > 300 mg per day 
✔️ stroke / TIA

< 125 / 75 mmHg if proteinuria > 1g per day

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8
Q

For LOW RISK patients, outline the appropriate management of hypertension.

A

✔️ offer lifestyle advice
✔️ commence pharmacotherapy is BP consistently > 160 / 100mmHg
✔️ re-check blood pressure in TWO MONTHS if > 140 to 159 mmHg SBP

BP to be monitored every TWO YEARS.

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9
Q

For MODERATE RISK patients, outline the appropriate management of hypertension.

A

✔️ offer intensive lifestyle advice
✔️ commence pharmacotherapy if BP > 160 / 100mmHg
✔️ commence pharmacotherapy if history of premature CVD, ATSI, South Asian, Maori or Middle Eastern descent
✔️ consider pharmacotherapy if SBP between 140 to 159 mmHg or DBP between 90 to 99 mmHg
✔️ review BP in SIX MONTHS if SBP between 130 to 139 mmHg or DBP between 80 to 89 mmHg

BP to be monitored every 6 to 12 months

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10
Q

For HIGH RISK patients, outline the appropriate management of hypertension.

A

✔️ offer intensive lifestyle advice
✔️ commence pharmacotherapy

BP to be monitored every 6 to 12 weeks.

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11
Q

Which populations are automatically HIGH RISK for ABSOLUTE CARDIOVASCULAR RISK?

A 
✔️ diabetes mellitus > 60 years
✔️ ATSI patients > 74 years
✔️ moderate or severe CKD
✔️ diabetes mellitus with proteinuria 
✔️ familiar hypercholesterolemia
✔️ serum cholesterol > 7.5 mmol / L
✔️ previous CKD, stroke or IHD / MI
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12
Q

Outline lifestyle advice for management of hypertension.

A 
✔️ smoking cessation 
✔️ reduced / appropriate alcohol consumption 
✔️ optimise BMI / weight loss
✔️ physical activity 30 mins per day
✔️ high fibre diet
✔️ reduce salt intake < 4 g per day
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13
Q

Outline appropriante pharmacological management of hypertension.

A

First line pharmacotherapy:
✔️ ACE-i or ARB
✔️ thiazide diuretic
✔️ calcium channel blocker

Second line pharmacotherapy:
✔️ beta-blocker

All patients with HTN should be commenced on ACE-i or ARB (given no contraindications).

If blood pressure remains uncontrolled, introduce CCB. Titrate up dose of one or both medications.

If blood pressure still remains controlled, consider adding thiazide diuretic.

✔️ ACE-I / ARB + CCB –> appropriate for management of HTN and dyslipidemia
✔️ ACE-I / ARB + thiazide diuretic –> appropriate for heart failure and post-stroke
✔️ ACE-I / ARB + beta-blocker –> appropriate for post MI and congestive cardiac failure patients

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14
Q

Contraindications for ACE-I / ARBs?

A 
✔️ pregnancy 
✔️ hyperkalaemia
✔️ angiooedema 
✔️ bilateral renal artery stenosis
✔️ renal function eGFR < 30
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15
Q

Define ATRIAL FIBRILLATION.

A

AF is a supra-ventricular arrhythmia characterised by (1). absence of P waves (2). irregularly irregular rhythm

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16
Q

What are some causes for ATRIAL FIBRILLATION?

A

P - pulmonary causes (e.g. COPD, chronic PE, OSA)
I - ischemia (e.g. IHD, CAD)
R - rheumatic heart disease / valvular pathologies (e.g. aortic stenosis)
A - anaemia
T - thyrotoxicosis
E - endocrine abnormalities (e.g. hypokalaemia)
S - sick sinus syndrome

17
Q

Classification of AF?

A

✔️ paroxysmal AF - episodes last < 1 week
✔️ persistent AF - episodes last > 1 week
✔️ long-term persistent - episodes last > 12 months
✔️ permanent AF - resistant to cardioversion

18
Q

Outline management protocol for AF?

A

RACE

R - rate control
A - anticoagulation
C - cardioversion or flecanide / amiodarone
E - etiology / underlying cause

19
Q

What are options for RHYTHM CONTROL in the management of AF?

A 
There are three options for rhythm control in AF: 
1. medications
✔️ flecanide
✔️ sotalol
✔️ amiodarone
2. catheter ablation
3. electrical cardioversion
20
Q

What are some options for RATE CONTROL in the management of AF and when should rate control be considered over rhythm control?

A 
Rate control should be considered in the following circumstances: 
✔️ younger patients
✔️ severe CHF
✔️ significant symptoms
✔️ paroxysmal / persistent AF
Options for rate control include: 
1. medications
✔️ beta-blockers
✔️ calcium channel blockers
2. AV node ablation 
3. permanent pace-maker
21
Q

What are the components that make up the CHADSVASc score and how should it be interpreted?

A 
C - congestive heart failure
H - hypertension
A - age > 75 years (2 points)
D - diabetes mellitus 
S - stroke / TIA (2 points)
V - vascular disease
A - age > 64 years
Sc - sex category (female)

CHADSVASc is used to stratify risk of a patient with AF experiencing a stroke, and therefore, whether it is appropriate for them to commence on pharmacotherapy .

Score 0 - no need for anticoagulation
Score 1 - consider anticoagulation
Score 2 - commence anticoagulation with warfarin (valvular AF) or a NOAC (non-valvular AF)

22
Q

What components make up the HASBLED score?

A

H - hypertension
A - abnormal liver or renal function tests
S - stroke
B - bleeding history
L - labile INR
E - elderly (>65 years or age)
D - drugs (e.g. antiplatelets, NSAIDs, clopidogrel)

23
Q

Define CONGESTIVE HEART FAILURE.

A

CHF occurs when cardiac output is insufficient to meet metabolic demands.

It is characterised by:
✔️ insufficient forward flow –> ischemic symptoms
✔️ black flow –> fluid overload symptoms

24
Q

SYSTOLIC HEART FAILURE
✔️ ejection fraction
✔️ mechanism / pathology
✔️ aetiology

A

EJECTION FRACTION < 40%

MECHANISM - insufficient contraction of myocardium during systole results in cardiac output less than metabolic demands of the body; reduced forward flow results in “back flow” symptoms

AETIOLOGY
✔️ ischemic heart disease
✔️ essential hypertension
✔️ diabetes mellitus
✔️ valvular pathologies
✔️ cardiomyopathies
✔️systemic disease (e.g. scleroderma)
25
Q

DIASTOLIC HEART FAILURE
✔️ ejection fraction
✔️ mechanism / pathology
✔️ aetiology

A

EJECTION FRACTION > 40 %

MECHANISM - insufficient relaxation of the myocardium during diastole leads to poor filling; contraction is appropriate, therefore, ejection fraction is normal or increased

AETIOLOGY 
✔️obesity 
✔️ HTN
✔️ DM
✔️infiltrative disease
✔️AF
✔️ pericardial disease
26
Q

Outline the classification of CHF based on the NYHA.

A

CLASS I - dyspnoea with exertion (as appropriate); nil limitation on life
CLASS II - dyspnoea with moderate exertion
CLASS III - dyspnoea with mild exertion
CLASS IV - dyspnoea at rest; unable to perform ADLs

27
Q

Investigations for CHF?

A

BEDISDE Ix
✔️ 12-lead ECG

LABORATORY Ix
✔️ FBC
✔️ WCC
✔️ inflammatory markers
✔️ UECs
✔️ eLFTs
✔️ BNP
✔️ troponin + CK (if angina present) 
✔️ TFTs
✔️ fasting lipids (to calculate absolute cardiovascular risk)
IMAGING Ix / FUNCTIONAL Ix
✔️ CXR
✔️ echocardiogram 
✔️ coronary angiogram
✔️ exercise stress test
28
Q

Lifestyle modification for CHF?

A

✔️ smoking cessation
✔️ reduce / eliminate alcohol consumption
✔️ appropriate exercise (30 mins per day)
✔️ optimise BMI (5 to 10% weight loss)
✔️ reduce salt intake < 4 g per day
✔️ fluid restriction < 1.5 L per day
✔️ management of co-morbidities (e.g. HTN, dyslipidemia, AF)

29
Q

Outline appropriate pharmacological management of CHF.

A

All patients should be commenced on ACE-I or ARB plus Beta-Blocker (e.g. bisoprolol).

Aldosterone antagonist (e.g. spironolactone) may be added for extra symptom control.

Loop diuretic (e.g. frusemide) can be added at any time for relief of fluid overload (e.g. dyspnoea).

Digoxin is last line medication only if appropriate.

30
Q

Identify potential precipitants for acute exacerbation of CHF.

A 
✔️ non-compliance to medication
✔️ arrhythmia
✔️ electrolyte abnormalities 
✔️ anaemia
✔️ ischemia
✔️ infection
✔️ adverse drug reactions
✔️ fluid overload 
✔️ hyper or hypo thyroid.
✔️ dietary indescretions
31
Q

Outline the key components of management of ACUTE EXACERBATION of heart failure.

A
  1. identify / eliminate precipitating factors
  2. frusemide 40mg IV
  3. morphine
  4. oxygen
  5. nitrates / GTN
  6. positioning
32
Q

Side effects of ACE-I?

A

✔️ dry cough
✔️ rash
✔️ hyperkalaemia
✔️ angioedema

NOT to be used in pregnancy.

33
Q

Side effects of ARBs?

A 
✔️ dizziness
✔️ headache
✔️ orthostatic hypotension
✔️ hyperkalaemia
✔️ acute angular glaucoma
34
Q

Side effects of CCB?

A 
✔️ dizziness and headache
✔️ peripheral (ankle) oedema 
✔️ palpitations
✔️ constipation
✔️ urinary incontinence
35
Q

Side effects of THIAZIDE diuretic?

A 
✔️ sexual dysfunction
✔️ dyslipidemia
✔️ hyperglycaemia 
✔️ hypokalaemia + hyponatremia
✔️ rash
36
Q

What are the lipid targets for DYSLIPIDEMIA?

A

Total Cholesterol < 4.0 mmol / L
LDL Cholesterol < 2.0 mmol / L
HDL Cholesterol > 1.0 mmol / L
Trigylcerides < 2.0 mmol / L

37
Q

Side effects of STATIN medication?

A 
✔️ rhabdomyolysis (must check CK)
✔️ muscle aches and pains
✔️ myopathy
✔️ hepatotoxicity (must check LFTs)
✔️ gastrointestinal side effects

General Practice (9 decks)

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