Cardiovascular Flashcards

Question

You calculate the CVS risk for a patient with hypertension and get 10-20%, what treatment avenues should be explored?

Answer 1

○ Individualised lifestyle advice ○ Commence BP lowering +/- statin Further assessment in 1-2 years

Answer 2

○ Intensive lifestyle advice ○ BP lower + Statin + antiplatelet Annual review

Answer 3

``` • Diet: Reduce salt, fats and sugar • Physical activity: 30 min a day, green prescription • Weight: BMI <25 • Smoking cessation: ABC Reduce alcohol intake ```

Answer 4

1. ACEi (half dose e.g. Cilazapril 2.5mg) 2. Increased ACEi (full dose e.g. Cilazapril 5mg) 3. Thiazide (half dose) (CONTRAINDICATED IN GOUT) 4. Add Calcium Channel Blocker (half dose e.g. Amlodipine 5mg 5. Increase thiazide to full dose 6. Increase CCB to full dose

Answer 5

``` ○ Thiazide (half dose) ○ ACEi (half dose ○ Increase thiazide (full dose) ○ Increase ACEi (full dose) ○ Add CCB (half dose) Increase CCB (full dose) ```

Answer 6

In resistant hypertension when K+ is less than 4.5

Answer 7

Usually reserved for when there is inadequate control with other three main classes, or if there is a specific indication e.g. increased sympathetic drive, ACEi/ARB intolerance, heart disease

Answer 8

``` Cardiac • Arrhythmia ○ Tachyarrhythmia Supraventricular tachycardia (Afib/Aflut), Ventricular tachycardia (sinus tachycardia, ANVRT, AVRT), Supraventricular extrasystole, ventricular extrasystole ○ Bradyarrhythmia (rarer) Sinus bradycardia, sinus pauses, second- and third-degree AV block • Structural heart disease ○ Valvulopathy ○ Cardiomyopathy Non-cardiac • Psychosomatic ○ Anxiety, panic attacks ○ Depression, somatization disorder • Systemic ○ Hyperthyroidism ○ Hypoglycaemia ○ Fever ○ Anaemia ○ Hypovolaemia ○ Phaeochromocytoma • Medications/drugs ○ Alcohol, cocaine, heroin, amphetamines, caffeine, nicotine, synthetic drugs ○ Recent withdrawal of B-blockers Vasodilators, anticholinergics, hydralazine ```

Answer 9

``` Circumstances prior to beginning of palpitations • Activity Rest, sleeping, exercise, change in posture, after exercise • Position Supine/Standing • Predisposing Factor Emotional stress, exercise, squatting/bending Onset of palpitations • Sudden vs gradual • Preceding symptoms Chest pain, SOB, vertigo, fatigue etc During episode • Describe what you notice • Fast or slow? • Regular or irregular • Tap rhythm out on table • Duration End of episode • Sudden vs gradual • Associated symptoms Background • Age of first episode • Number of previous episodes • Prior treatment • Frequency in last year/month • Previous cardiac disease • Previous psychosomatic disorders • Previous systemic diseases • Previous thyroid dysfunction • FHX: cardiac disease, tachycardia, SCD • Medications Drug abuse ```

Answer 10

``` Heart Failure Hypertension Ischaemic Heart Disease PE Mitral valve disease Pneumonia Hyperthyroid (thyrotoxicosis) Caffeine Alcohol Post-op Hypokalaemia Hypomagnesaemia ```

Answer 11

Atrial fibrillation Ventricular ectopics Heart-block with ventricular escape Atrial flutter

Answer 12

``` ECG U&Es (baseline/K+/Mg2+) Cardiac enzymes CXR LFT TFT Echo ```

Answer 13

Call for help ABCDE approach DC cardioversion (if haemodynamically unstable/unconscious) Pharmacological cardioversion: Amiodarone

Answer 14

IV infusion 5mg/kg over first hour with ECG monitoring, subsequent infusion given if required up to maximum of 1.2g in 24 hours. Infuse via a large or central vein in 5% glucose solution Need to rule out hyperthyroidism

Answer 15

Before treatment: ECG, CXR, TFT, LFT, K+, PFT[DLCO] 6 months: TFT, LFT Annually: ECG, CXR

Answer 16

Correct Mg2+ and K+ Rhythm Control (DC cardioversion/Flecainide (CI: Structural heart disease, IHD)/Amiodarone) Rate Control (1st-line: B-blocker or CCB) Start thromboprophylaxis (LMWH>Warfarin or Dabigatran) Use no anticoagulation if stable sinus rhythm has been restored, no risk factors for emboli and if AF recurrence likely

Answer 17

``` Do not cardiovert unless TOE has proven no intracardiac thrombus Rate Control (1st-line: B-blocker or CCB) If rhythm control is required, must be anticoagulated for >3 weeks first before elective cardioversion ```

Answer 18

Rate control just as good as rhythm control! Rate control - 1st line: B-blocker or CCB (CCB: Diltiazem, not verapamil!) - If this fails, add digoxin (Digoxin is very effective but really hard on kidneys, beware in kidney disease; need to monitor levels) - If this fails, try amiodarone Rhythm control - May be appropriate if; ○ Symptomatic/Unstable ○ Congestive Heart Failure ○ Younger patient ○ First presentation ○ Persistence despite corrected precipitant - DC cardioversion or - Elective Pharmacological Cardioversion ○ 1st line: Flecainide (CI: structural heart disease/IHD) - Refractory cases ○ AVN ablation with pacing ○ Pulmonary vein ablation ○ Maze procedure Anticoagulation - CHA(2)DS(2)VASc and HASBLED

Answer 19

``` SVT is a narrow complex tachycardia arising from above the ventricles. Sinus tachycardia • Physiological sinus tachycardia • Inappropriate sinus tachycardia • Sinoatrial node re-entrant tachycardia (SANRT) Atrial tachycardia • Focal atrial tachycardia • Multifocal atrial tachycardia* • Atrial flutter* • Atrial fibrillation* Atrioventricular arrhythmia • AVNRT Slow-fast (common), Fast-slow (uncommon), Slow-slow (atypical) • AVRT (WPW) Junctional tachycardia (rare) *=irregula ```

Answer 20

Sonsider transiently blocking AVN, if SVT is actually of atrial origin, AV node blockade will unmask rhythm, so then treat that rhythm e.g. AF AV node block can be achieved by... ○ Vasovagal manoeuvres (Valsalva or carotid sinus massage) ○ IV Adenosine (6mg IV push > 12mg after 1-2 min if ineffective > 12mg again if ineffective after 1-2 min ) ○ If ineffective, use CCB (Verapamil) (2.5-5mg IV over 1-2 minutes > repeat every 5-10 minutes up to total dose 15mg; Give slowly as can cause hypotension; Never give if 1) also taking B-blocker 2) ?digoxin toxicity or 3) wide complex tachycardia) ○ If ineffective, try vagal manoeuvre again If ineffective contact CCU ?DC cardioversion

Answer 21

Physiological Drug-induced (B-blockers, amiodarone, CCB's, digoxin) Cardiac (Heart block, IHD, valvular disease, cardiomyopathy) Non-cardiac (Vasovagal, Hypothyroidism, adrenal insufficiency, hyperkalaemia, hypoxia, hyperthermia, increased ICP (Cushings triad))

Answer 22

Junctional bradycardia | All types of heart block but mostly type 1 and type 2

Answer 23

``` Those at risk of hyperlipidaemia • Family history of hyperlipidaemia • Corneal arcus <50 years old • Xanthomata/Xanthelasmata Those at risk of CVD • Known CVD • Family history of CVD <60 years old • DM or impaired glucose tolerance • Hypertension • Smoker • Increased BMI • Low SES Indian/Asian background ```

Answer 24

``` Common primary hyperlipidaemia (70% of hyperlipidaemia; Increased LDL only) Familial primary hyperlipidaemia (Multiple types) Secondary hyperlipidaemia (Caused by Cushing's syndrome, hypothyroidism, nephrotic syndrome or cholestasis; Increased LDL) Mixed hyperlipidaemia (Increased LDL and triglycerides; Caused by DM, metabolic syndrome, alcohol and CKD) ```

Answer 25

Lifestyle advice (aim BMI <25-20, diet, increase exercise) 1st line: Statins 2nd line: Ezetimibe 3rd line: Alirocumab

Answer 26

Occurs due to an autoimmune mechanism related to molecular mimicry. Production of cross-reactive antibodies gives immune recognition and response against pathogen, but produce antibodies which recognise both host and microbial antigens. - Human cardiac myosin and streptococcal M protein are likely important antigens in the pathogenesis of rheumatic heart disease. Antibodies cross react with collagen or cardiac valvular endothelia antigens, then T cells infiltrate leading to inflammation (arthritis) or long-term damage (carditis then RHD) - Auto antibody-mediated neuronal cell signalling in cerebrospinal fluid may be part of pathogenesis in chorea Recurrent ARF attacks due to repeated streptococcal infections leads to increased scar formation in the valve. After initial attacks of ARF and carditis, the valve scars and then is neovascularised which perpetuates disease.

Answer 27

Major - Arthritis ○ Mono arthritis or asymmetrical migratory polyarthritis ○ Most common presenting complaint in ARF (75% of first presentations) ○ Extremely painful and unable to weight bear ○ Polyarthritis is usually asymmetrical and migratory - Carditis ○ Tachycardia, murmurs (mitral or aortic regurgitation), pericardial rub, CCF, Cardiomegaly, conduction defects. - Sydenhams chorea ○ GAS bacteria react with basal ganglia to cause this. ○ Involves jerky, uncontrollable and purposeless movements of hands, arms, shoulder, face, legs and trunk. ○ Can be a standalone criterion - Erythema marginatum (rare) ○ Rash with red, raised edges and clear centre, occurring mainly on the trunk, thighs and arms. ○ Not itching or painful - Subcutaneous nodules ○ Rare (<2% of cases) ○ Small, mobile, painless nodules on extensor surfaces of joints and spine Minor - Fever >38C - Arthralgia - Hx of ARF - Raised CRP (>30mg/L) or ESR (>50mg/L) Prolonged PR interval on ECG

Answer 28

``` FBC ?WBC ESR/CRP Blood cultures if febrile Anti-strep serology (ASO, Anti-DNase B) CXR ECG ?PR prolongation ECHO ``` Tests for considering alternative diagnosis include serology for reactive arthritis, ANA ?autoimmune arthritis Rpeat blood culture ?IE, joint aspirate ?septic arthritis, joint XRay, choreform movements - copper levels, caeruloplasmin, ANA, drug screen and consider MRI or CT head

Answer 29

Admission to hospital ASAP after symptom onset Confirm diagnosis Refer to rheumatic fever register once diagnosis made for prophylaxis program and public health for contact tracing otify Public health service Antibiotics: - Oral penicillin V 250mg 2-3 times daily while diagnosis is being established - First dose IM benzathine penicillin 900mg or 450mg if <30kg should be given in patient and education given about secondary prophylaxis. Can stop oral penicillin once this dose is given. Repeat every 28 days Penicillin allergy: Erthromycin ethylsuccinate 40mg/kg per day in 2-3 divided dose, maximum 1g/day Ongoing management of symptoms - Arthritis/arthralgia ○ 1st line: Paracetamol ○ 2nd line: NSAID (Naproxen) - Fever (no specific treatment required) - Carditis/Heart Failure ○ Heart failure medication if required ○ Valvular surgery - Sydenham’s Chorea ○ Generally self limiting within weeks (almost all patients by 6 months) Sever chorea: carbamazepine PO 7-20mg/kg/day TDS or valproic acid 15-20mg/kg/day TDS. Both for several weeks and then trial off medication

Answer 30

Secondary Prophylaxis - 1st line: IM benzathine penicillin every 4 weeks - 2nd line: Oral penicillin twice daily - 3rd line: Oral erythromycin twice daily if allergy Time period - ARF + no/mild carditis: Minimum 10 year or until 21 years old (which ever is longer) - ARF + moderate carditis: Minimum 10 years after most recent episode or untill 30 years (which ever longer) - ARF + severe carditis: Minimum 10 years after most recent episode or until 30 years (whichever is longer) then review by specialist to consider lifelong

Cardiovascular Flashcards

(56 cards)