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GP Training > Cardiovascular health > Flashcards

Cardiovascular health Flashcards

1
Q

What are some causes of acute leg swelling?

A

DVT, superficial thrombophlebitis, joint effusion/haemarthrosis, arthritis, cellulitis, haematoma, Bakers cyst, fracture, acute arterial ischaemia, dermatitis.

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2
Q

Name some causes of chronic leg swelling

A

Gravitational oedema, Heart failure, hypoproteinaemia, idiopathic oedema, reflex sympathetic dystrophy, post-thrombotic syndrome, chronic venous insufficiency, lipodermatosclerosis, lymphoedema, congenital vascular abnormalities.

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3
Q

What is peripheral oedema?

A

Swelling of the ankles/legs or sacrum if bed bound which occurs when the rate of capillary filtration is greater than the rate of drainage.

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4
Q

Why does peripheral oedema occur?

A

Increased capillary filtration due to increased venous pressure, hypoalbuminemia or local inflammation. Decreased rate of drainage due to to lymphatic obstruction.

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5
Q

How can we treat gravitational oedema?

A

Advise elevation of the feet above waist level, support stockings, and avoid standing still. Diuretics are not a long-term solution.

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6
Q

What is pulmonary oedema?

A

Accumulation of fluid in the pulmonary tissues and air spaces.

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7
Q

What are the causes of pulmonary oedema?

A

Cardiovascular:
- Left heart failure
- Mitral stenosis
- MI
- Hypertension
- Pulmonary venous obstruction
- IV fluid overload
Lung:
- Pneumonia
- PE
- Pneumonitis due to inhalation of toxic substances
Other:
- High altitude
- Kidney failure
- Nephrotic syndrome
- Cirrhosis
- Lymphatic obstruction (Tumour)

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8
Q

What are the causes of central cyanosis?

A
  • lung disease resulting in inadequate oxygen transfer
  • Shunting from pulmonary to systemic circulation
  • Inadequate oxygen uptake
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9
Q

Aside from those causing central cyanosis, what else can cause peripheral cyanosis?

A

Physiological (cold, hypovolaemia)
Local arterial disease (Raynauds)

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10
Q

What are mitral facies?

A

Dusky bluish-red flushing of the cheeks which is associated with a low cardiac output.

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11
Q

What is clubbing? Why is it significant?

A

Loss of the angle between the nail fold and plate, bulbous fingertip and the nail fold feels boggy.
Any patient with unexplained clubbing should be referred for an urgent CXR.

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12
Q

Name some causes of raised JVP

A

Fluid overload, right heart failure and CCF, SVC obstruction, Tricuspid or pulmonary valve disease, pulmonary hypertension, Arrhythmia (AF, Atrial flutter or complete heart block), Increased intrathoracic pressure

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13
Q

What are the signs of infective endocarditis?

A

Infective: fever, weight loss, clubbing, splenomegaly, anaemia.
Cardiac: Murmur, +/- heart failure
Vasculitic: Microscopic haematuria, splinter haemorrhages, conjunctival haemorrhages, roth’s spots, oslers nodes, janeways lesions.

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14
Q

What is corneal arcus?

A

Whitish opaque line surrounding the margin of the cornea. Sometimes congenital, more common in >50’s. May be associated with familial hypercholesterolaemia- check lipids.

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15
Q

What is xanthomata?

A

localized collections of lipid-laden cells which appear as yellow coloured lumps. Often caused by increased lipids and found usually on eyelids, skin or in tendons.

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16
Q

What are heart murmurs and are they common?

A

Heard due to abnormalities of flow within the heart and great vessels. Very common and often incidental finding. Always refer for ECHO.

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17
Q

How are heart murmurs described?

A
  • Location
  • Quality
  • Intensity
  • Timing
    -Radiation
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18
Q

What are red flag symptoms associated with murmurs?

A
  • Cyanosis
  • Lethargy
  • Weight loss (Or failure to thrive)
  • Breathlessness
  • Collapse
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19
Q

Name some causes of an ejection systolic murmur

A

Aortic stenosis
Pulmonary stenosis
HOCM
Flow murmurs (children, pregnancy, fever, post exercise)

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20
Q

Name some causes of a pan-systolic murmur

A

Mitral valve regurgitation.
Tricuspid regurgitation.
VSD or ASD

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21
Q

List some causes of an early diastolic murmur

A

Aortic regurgitation
Pulmonary regurgitation
Tricuspid stenosis

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22
Q

List some causes of a mid-diastolic murmur

A

Mitral stenosis
Aortic regurgitation

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23
Q

What are the main three conditions affecting abdominal and peripheral arteries?

A
  • Aneurysms
  • Atherosclerosis (Ischaemia, intermittent claudication, atrophic changes, leg pain)
  • Embolization (acute ischaemia)
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24
Q

What peripheral pulses can be palpated?

A

Brachial, radial, femoral, popliteal, Posterior tibial, Dorsalis pedis.

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25
Q

What are the signs of acute limb ischaemia?

A

Acutely pale, cold and pulseless limb. Refer immediately.

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26
Q

What are sign of chronic ischaemic changes in the limbs?

A
  • Atrophic changes (pallor, cool to touch, hairless, shiny)
  • Elevation causes pallor and venous guttering whereas lowering causes dusky blue/red colouring.
  • Ulceration (check under heel and between toes)
  • Swelling (suggests patient sleeping in a chair to avoid pain)
  • Absent foot pulses
  • Ankle- brachial pressure index <0.95
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27
Q

How is ABPI measured and what do the results mean?

A

Ankle -brachial pressure index.
- Check BP in one arm. Systolic measurement is B.
- Put cuff around lower calf. Inflate and use doppler to assess the max pressure at which a pulse can still be detected. (A)
- Calculate A/B.
- ABPI <0.8 (ischaemia)
- ABPI <0.5 (critical ischaemia)

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28
Q
A
29
Q

What should be asked in the history of new onset chest pain to decide if likely ACS?

A

Pain in chest/ neck/jaw/arm/back lasting longer than 15 minutes
- associated nausea,vomiting,sweatiness, breathlessness or haemodynamic instability.
- risk factors for cardiac disease
- past medical history

30
Q

If suspected ACS and patient is in pain now what should you do?

A
  • admit as emergency
  • relieve pain with GTN
  • aspirin 300mg unless allergic
  • do ECG if possible
  • measure O2 sats and give O2
31
Q

What features are suggestive of angina?

A
  • discomfort that is tight, constricting or dull.
  • discomfort that is retrosternal or left sided.
  • radiation to the left arm, neck, jaw or back
  • brought on by exertion or emotional stress and relieved wishing several minutes by rest.
  • triggered by cold weather or a large meal
32
Q

What are the key risk factors for angina?

A

Smoking
Hypertension, diabetes other CVD
Hyperlipidaemia
CKD
family history of coronary disease (1st degree relative: male <55, female <65)

33
Q

What are the three features of typical angina?

A

1.constricting discomfort in the front of the chest or in the neck, shoulders, jaw or arms.
2. Precipitated by exertion
3. Relieved by rest or GTN within about 5 minutes

34
Q

If people are young with few risk factors but have typical symptoms of angina what should we consider?

A

Cardiomyopathy

35
Q

If we are confident that chest pain is non cardiac in nature what should we do?

A

Give a confident alternative diagnosis and management plan.

36
Q

If a patient has suspected stable angina, what investigations should we do in primary care?

A

Bloods: tbf, renal function, cholesterol, hba1c, TSH.
ECG: common changes include pathological Q waves, left bundle branch block, ST segment and T wave abnormalities.
CXR: only to rule out other pathologies if suspected e.g lung ca

37
Q

For definitive stable angina how should we treat?

A

Start or increase anti-anginal medication
Start/ continue secondary prevention
Refer for non-invasive functional testing if indicated.

38
Q

What is the aim of treatment in angina?

A

Relieve symptoms and reduce CV risk

39
Q

What medication is used for secondary prevention of cardiovascular disease?

A

Antiplatelet: Aspirin or clopidogrel. (NICE says aspirin but clopidogrel if multi vascular disease (2 or more vascular events))
Statin: Atorvastatin 80mg
ACE inhibitor
Do not offer fish oil supplement

40
Q

What is the first line treatment for symptom relief in stable angina?

A

GTN and Beta blockers or calcium channel blockers.

41
Q

Why does SIGN recommend bet blockers first for stable angina?

A

Some evidence to suggest they may improve survival.

42
Q

Which calcium channel blockers can be safely used with beta-blockers?

A

Non rate limiting ones such as nifedipine, amlodipine and felodipine. Take care with rate limiting CCB’s such as diltiazem. Verapamil is contraindicated. Rate limiting CCB’s are contraindicated in heart failure, bradycardia or AV block.

43
Q

If you have inadequate control in first line angina treatment, what next?

A

Use beta blocker and calcium channel blocker together.

44
Q

If both calcium channel blockers and beta-blockers give inadequate angina control what next?

A

Cardiology referral to determine if imaging/testing is required or further medical treatment such as nitrates/nicorandil/ivabradine.

45
Q

What is prinzmetal angina?

A

Vaso-spastic angina. Pain occurs at rest. Caused by narrowing of proximal coronary arteries because of spasm. Cannot be seen on angiogram: Use amlodipine or nifedipine.

46
Q

What is cardiac syndrome X?

A

Angina symptoms in angiographically normal arteries. It’s not fully understood. Possibly micro vessel disease. Reliever if helps. Not for secondary prevention.

47
Q

How should we counsel patients to use GTN?

A
  • Carry GTN at all times
  • If you get pain- stop what you are doing, sit down and rest. Take GTN
  • If pain doesn’t settle in 5 mins take a second puff.
  • If it doesny go in another 5 mins, dial 999.
  • Whilst waiting, take aspirin 300mg if they have it.
48
Q

What level of BNP should indicate urgent (2 week) referral for cardiology review and ECHO?

A

> 2000 as this carries a poor prognosis

49
Q

What level of BNP in an untreated person make heart failure unlikely?

A

<400

50
Q

What factors can reduce levels of BNP?

A

Obesity, African/ Afro-Caribbean background/ drugs (ace inhibitors, beta blockers, angiotensin 2 receptor blockers/ mineralocorticoid receptor antagonists

51
Q

What, other than heart failure, can cause a raised BNP?

A

Age over 70, LVH, ischaemia, tachycardia, right ventricular overload, hypoxaemia, renal dysfunction, sepsis, COPD, diabetes, liver cirrhosis

52
Q

When should diuretics be used in heart failure?

A
  • routinely used for relief of congestive symptoms and fluid retention in people with heart failure.
  • people with heart failure with preserved ejection fraction should be offered a low to medium dose of loop diuretics. People who’s heart failure does not respond to this will need specialist advice.
53
Q

Which calcium channel blockers should be avoided in people with heart failure with reduced ejection fraction?

A

Verapamil, diltiazem and short acting dihydropyridine agents.

54
Q

Which vaccinations should people with heart failure have?

A

Influenza yearly and pneumococcal once

55
Q

What should monitoring for chronic heart failure include?

A
  • clinical assessment of functional capacity, fluid status, cardiac rhythm, cognitive status and nutritional status.
  • review of medication, including need for changes and possible side effects.
  • an assessment of renal function
56
Q

What is the definition of heart failure with preserved ejection fraction?

A

Usually impaired left ventricular relaxation, rather than left ventricular contraction and is characterised by normal or preserved left ventricular ejection fraction with evidence of diastolic dysfunction.

57
Q

What is heart failure with reduced ejection fraction?

A

Heart failure with an ejection fraction below 40%

58
Q

What is the first line treatment for heart failure with reduced ejection fraction?

A

Ace inhibitor and a beta blocker. Use clinical judgement to decide which to start first.

59
Q

When should you not use an ace inhibitor in heart failure?

A

If there is clinical suspicion of haemodynamically significant valve disease until the valve disease has been assessed by a specialist.

60
Q

How do you commence ACE Inhibitors?

A

Start at a low dose and tot rate upwards at short intervals such as one to two weeks.
Measure serum sodium and potassium, and assess renal function, before and 1 to 2 weeks after starting an ACE inhibitor and after each dose increment.

61
Q

When does ACE inhibitor treatment need monitoring?

A
  • once the target or maximum tolerated dose is reached then monthly for 3 months and then at least every 6 months + at any time a person becomes acutely unwell
62
Q

What is the next line treatment in heart failure if ACE inhibitors are not tolerated?

A

Angiotensin 2 receptor blocker- monitoring is the same for ACE inhibitors

63
Q

Which beta blockers are licensed for heart failure?

A

Nebivolol, carvediol and nebivolol.

64
Q

What if someone develops heart failure but are already on a different beta blocker?

A

Switch to one which is licensed for heart failure

65
Q

When can you start a beta blocker in heart failure?

A

Should only be done once the person is stable- without fluid overload or hypotension

66
Q

What should we advise people when starting beta blockers for heart failure?

A
  • there may be a temporary worsening of symptoms during titration but symptoms may improve slowly over 3-6 months
  • seek medical advice if worsening of symptoms
  • not to stop it without speaking to a healthcare professional
67
Q

Why should beta blockers not be stopped suddenly?

A

There is a risk of rebound myocardial ischaemia or infarction or arrhythmias. Specialist advice should be sought before stopping beta blockers.

68
Q

When should you not continue with a titration of beta blockers?

A
  • signs of worsening heart failure
  • symptomatic hypotension or excessive bradycardia (<50)

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