Cardiovasculsr Flashcards
(136 cards)
1
Q
What is the primary goal of hypertension management according to NICE guidance?
A
To reduce the risk of cardiovascular disease and stroke.
2
Q
True or False: Lifestyle changes are the first-line treatment for hypertension.
A
True.
3
Q
What is the first-line medication for hypertension in patients under 55 years old?
A
Angiotensin-converting enzyme (ACE) inhibitors.
4
Q
Fill in the blank: In patients aged 55 and over, the first-line treatment for hypertension is __________.
A
Calcium channel blockers.
5
Q
What should be monitored regularly in patients on antihypertensive medications?
A
Blood pressure and renal function.
6
Q
Which class of drugs is recommended if the initial treatment for hypertension is not effective?
A
Add a second drug from a different class.
7
Q
What lifestyle modification can significantly lower blood pressure?
A
Weight loss.
8
Q
True or False: The NICE guidelines recommend a target blood pressure of less than 140/90 mmHg for most adults.
A
True.
9
Q
What is the recommended follow-up period for patients after initiating antihypertensive treatment?
A
4 to 8 weeks.
10
Q
In hypertension treatment algorithm what should diabetics be started on? (Regardless of age or ethnicity)
A
ACE/ARB
11
Q
In hypertension treatment algorithm what should black people be started on? (Regardless of age)
A
CCB (as long ad they aren’t diabetic in which case it’s ACE/ARB which trumps all)
12
Q
In black people what would be your second stage of treatment for HTN
A
ARB (added in orefenrce to ACE). Use as a second line after CCB
13
Q
When using CCB IN DM only use…
A
Long acting preparations
14
Q
What is step 4 of HTN
A
Resistance HTN
spirinolactobe is K <4.5
Alpha/beta blocker if K>4.5
15
Q
If combining a CCB and BB what type of CCB should you use inc examples
A
Dihudropyridine e.g. amlodioine, felopdine or slow release nifedipine
16
Q
What should be used for diagnosis?
A
ABPM (home readings if unable to tolerate)
17
Q
When is it postural hypotension?
A
Systolic drop 20 or diastolic 10
18
Q
What are the BP targets if <80 (clinics and ABPM/home)
A
140/90 (home 135/85)
19
Q
What are the BP targets if >80 (clinics and ABPM/home)
A
<150/90 (145/85)
20
Q
What are the BP targets if CKD
A
ACR <70 then <140/90
If ACR >70 then 130/80
21
Q
When does hypertension become type 2?
A
150/95 (home/ABPM)
22
Q
For patients with stable coronary after disease in anti hypertensive treatment what range of BO has the lowest CV mortality
A
120/70-139/79 (J shaped curve)
23
Q
When do you measure U+E with ACE/ARB
A
Before starting, 1-2weeks after starting or dose change then annually once stable
24
Q
What is the risk with ACE/ARB
A
Hyperkalaemia and renal impairment ( stop if creatine rises >30% or K >5.5
25
What is the risk with diuretics? (Not K sparing)
Hypokalaemia, hyponatraenia and dehydration
26
Why are B Blockers dangerous in diabetics
May mask hypoglycaemia symptoms
27
What is the Marburg score used for?
Risk stratification for chest pain: <2 LOW risk, 3 Intermediate risk, >4 High risk
## Footnote
The Marburg score helps in assessing the likelihood of cardiac issues related to chest pain.
28
What are the characteristics of chest pain that suggest it is cardiac?
Known vascular disease, precipitated by exertion, patient thinks it's cardiac
## Footnote
These factors help clinicians determine the likelihood of chest pain being related to cardiac issues.
29
What factors make it unlikely for chest pain to be cardiac?
Reproducible on palpation, presence of cough
## Footnote
These signs suggest that the chest pain may not be of cardiac origin.
30
What are the characteristics of typical angina?
Central pain lasting 5-15 minutes, provoked by exertion or emotional stress, relieved by rest or nitrates
## Footnote
Typical angina presents with specific symptoms that help in its identification.
31
What routine investigations should be conducted to rule out conditions exacerbating angina?
Blood tests, 12 lead ECG
## Footnote
These tests help in identifying underlying causes that may worsen angina.
32
What ECG changes are consistent with coronary disease?
Pathological Q waves, left bundle branch block, regional ST/T change
## Footnote
These ECG findings are indicative of coronary artery issues.
33
What precautions should be taken regarding Ivabridine?
Increased CV death in symptomatic patients
## Footnote
This highlights the risks associated with the use of Ivabridine in certain patient populations.
34
What is a rare but severe side effect of Nicorandil?
Unresponsive gastrointestinal ulcerations
## Footnote
This risk is increased in patients predisposed to such complications, especially those using NSAIDs.
35
In terms of angina it is a clinical diagnosis driven by the characteristics of chest pain. How many to be non-anginal, atypical or typical
Non-anginal <1
Atypical -2
Typical- all three characteristics
36
What are the lifestyle modifications involved in the management of angina?
* Physical activity
* Stopping smoking
* Diet
* Weight control
## Footnote
These modifications are essential for overall cardiovascular health.
37
What is the primary drug therapy for symptom relief in angina?
Short-acting nitrate (usually GTN)
## Footnote
GTN stands for Glyceryl Trinitrate.
38
What is the purpose of revascularisation in angina management?
* Improve symptoms if symptoms are NOT controlled with drugs
* Improve prognosis if symptoms ARE controlled with drugs
## Footnote
Revascularisation may involve procedures like angioplasty or bypass surgery.
39
What should be done if a patient experiences pain while exercising?
* Stop activity and rest
* Use GTN
* Repeat dose after 5 minutes if pain persists
* Call 999 if pain persists after second dose
## Footnote
Patients should always carry GTN with them.
40
What are the first-line agents for angina management?
* Beta-blocker
* Calcium channel blocker (CCB)
## Footnote
Selection should be based on comorbidities, contraindications, and patient preference.
41
What is the recommended statin dosage for managing lipids in angina?
Usually atorvastatin 80mg
## Footnote
The target for LDL is ≤2mmol/l or non-HDL ≤2.6mmol/l.
42
What is the daily dosage of aspirin recommended for angina patients?
75mg daily
## Footnote
Consider comorbidities and risk of bleeding when prescribing.
43
What should be considered when adding a third drug for angina management?
* Symptomatic despite 2 drugs AND awaiting revascularisation
* Revascularisation not appropriate/wanted
## Footnote
Do NOT add a third drug if symptoms are controlled on 2 agents.
44
Fill in the blank: The role of long-acting nitrates, nicorandil, ranolazine, and ivabradine is to be used if symptomatic and if _______.
Neither first-line therapy is tolerated
## Footnote
Also applicable if symptomatic on a single first-line agent and unable to take 2 first-line agents.
45
What are the MHRA warnings associated with ivabradine and nicorandil?
* Ivabradine - 2014
* Nicorandil - 2016
## Footnote
These warnings highlight safety concerns regarding these medications.
46
What is the role of ACE inhibitors in angina management for patients with diabetes?
Reduces cardiovascular events/deaths
## Footnote
ACE inhibitors are preferred in the absence of evidence for ARBs.
47
What tool is used to assess a person's 10-year risk of cardiovascular disease?
QRISK
## Footnote
QRISK should be assessed every 5 years.
48
Who does not need risk assessment using QRISK?
High-risk individuals
## Footnote
Includes: People ages 84+, those with established CVD, eGFR <60, albuminaemia, and PVD.
49
List some conditions that indicate a high risk for cardiovascular disease.
* Established CVD
* eGFR <60
* Albuminaemia
* PVD
* Familial hypercholesterolemia
* Polycythaemia vera
* Type 1 diabetes mellitus
50
At what age do men have a higher risk of cardiovascular disease compared to women?
Prior to age 75
## Footnote
After 75, women have a higher risk.
51
Which demographic has a much higher risk of cardiovascular disease?
South Asians
52
What ratio is used in QRISK3 instead of serum cholesterol level?
The cholesterol to high density lipoprotein (HDL) ratio
## Footnote
This ratio is considered a better indicator of cardiovascular risk.
53
What family history factor is used in QRISK3?
A family history of angina or heart attack in a first degree relative aged under 60 years
## Footnote
This factor helps assess the risk of cardiovascular events.
54
Is Type 1 or 2 diabetic status required in the QRISK3 calculation?
Yes
## Footnote
However, no consideration is given to impaired fasting glycaemia.
55
List some variables included in the QRISK3 calculation.
* Chronic kidney disease
* Hypertension on treatment
* Atrial fibrillation
* Migraines
* Rheumatoid arthritis
* Systemic lupus erythematosus
* Severe mental illness
* Atypical antipsychotic medication
* Steroid tablets
* Erectile dysfunction
## Footnote
These variables contribute to the assessment of cardiovascular risk.
56
True or False: QRISK3 considers impaired fasting glycaemia.
False
## Footnote
QRISK3 does not take impaired fasting glycaemia into account.
57
What are the 4 pillars of drug therapy for reduced ejection fraction heart failure?
* ACEI/ARB or ARNI
* Beta-blocker
* MRA (spironolactone/eplerenone)
* Gliflozins
58
What does NICE recommend for all patients with reduced ejection fraction heart failure?
* A (ACEI/ARB or ARNI)
* B (Beta-blocker)
59
When should an MRA be added according to NICE?
If patients are still symptomatic on A and B
60
What is an MRA?
Mineralocorticoid receptor antagonist, such as spironolactone or eplerenone
61
What is the role of diuretics in heart failure care?
To manage fluid overload
62
What are the foundations of care in heart failure management?
* Health promotion
* Depression management
* Smoking cessation
* Annual flu jab and one-off pneumococcal
* Self-weighing if at risk of admission/decompensation
* Cardiac rehabilitation
* End-of-life planning if advanced disease
63
What is one of the biggest pitfalls in CHF care?
Forgetting to titrate up A and B to maximum tolerated dose
64
What is another significant pitfall in CHF care?
Failing to monitor MRAs
65
What irregular pulse findings should prompt suspicion of AF?
Palpitations, chest discomfort, syncope, dizziness, breathlessness
## Footnote
These symptoms are key indicators for detecting atrial fibrillation.
66
When should a patient with new/known AF be admitted?
If acutely unwell, decompensated fast AF, haemodynamically unstable, or having a stroke/TIA
## Footnote
These conditions indicate a need for immediate medical attention.
67
What is the primary investigation to confirm AF diagnosis?
ECG
## Footnote
A 12-lead ECG is preferred until newer technologies prove accuracy.
68
What blood tests are considered sensible before starting a DOAC?
FBC, U&Es, TSH, LFTs
## Footnote
NICE suggests no blood tests, but these are prudent for assessing patient status.
69
When is an echocardiogram indicated in AF management?
If there is structural/functional heart disease or cardioversion is planned
## Footnote
An echo can help assess the likelihood of successful cardioversion.
70
When should a patient with AF be referred to a specialist?
Immediately if acutely unwell, if rhythm control is needed, or if treatment fails to control symptoms
## Footnote
Referral should occur within 4 weeks of treatment failure or recurrence.
71
How often should patients on anticoagulants be reviewed?
Annually or more frequently if a clinical event occurs
## Footnote
This includes reassessing ORBIT and the need for anticoagulation.
72
What renal function test should be checked for patients on DOAC?
Creatinine clearance using the Cockcroft-Gault formula
## Footnote
This is essential for ensuring safe dosing of DOACs.
73
If on warfarin what percentage of time should they have been in therapeutic range the last year?
65%+
74
If not on anticoag when should you reassess and what do you use?
CHA2DS2Vasc
At age 65 or if develop significant comorbidity (DM, HF, CHD, PAD, Stroke/TIA or systemic emboli)
75
What is the main purpose of the CHA,DS,Vasc score?
Assessing stroke risk in those with AF
76
What should be done if CHA,DS,Vasc score is 0?
Do NOT offer anticoagulation
77
Which anticoagulant is considered first line for atrial fibrillation?
DOACs
78
What is the recommendation for patients with CHA,DS,Vasc score of 1 who are male?
Consider anticoagulation
79
True or False: Age alone should be a reason to withhold anticoagulation.
False
80
What should be done if a patient has a CHA,DS,Vasc score of 2 or more?
Offer anticoagulation
81
What is the significance of falls in relation to anticoagulation?
Falls rarely cause major hemorrhage
82
Fill in the blank: If high bleeding risk, benefits of anticoagulation may not outweigh the _______.
bleeding risks
83
What is the role of the ORBIT score in anticoagulation decisions?
Assess bleeding risk
84
What should be done for patients on warfarin diagnosed with AF years ago?
Discuss the option to switch to a DOAC
85
Name a contraindication for using DOACs.
* Low creatinine clearance
* Antiphospholipid syndrome
In which case use warfarin
86
What are modifiable factors that increase bleeding risk?
* Harmful alcohol consumption
* Drugs that increase bleeding risk
* Uncontrolled hypertension
* Reversible causes of anemia
* Poor control of INR
87
What are the criteria in CHA2DS2Vasc
88
What is the interpretation of risk with ORBIT score
0-2 low risk
3-medium ris
4-High risk
89
Is AF onset is within the last 48h what should be offered?
Cardioversion(electrical or chemical) without anticoagulation
Chemical is usually either flecanide
90
Should everyone in general get rhythm or rate control in AF. Give examples
Rate - B blocker e.g. bisoprolol (can use any)
or CCB e.g. diltiazem (avoid CCB IN HF)
91
What is the rhythm control criteria
New onset AF
AF with reversible cause
Heart failure caused by AF
Atrial flutter when patient may be suitable for ablation to restore sinus rhythm
Rhythm control more suitable based on clinical judgement E.g. younger patients or those with structurally normal heart
92
What rate control should be used in AF if the person has a sedentary lifestyle?
Digoxin
93
In GP is someone needs rhythm control you can start in surgery True or False
False- refer
94
What do the aim of rate control
Pulse <110 and symptom free
95
In mono therapy for rate control in AF in unsuccessful what next?
Dual therapy with any two of beta-blocker/diltiazem/digoxin
If ineffective then refer for rhythm control/ablation
96
P wave is the atrium depolarising. How long is is the normal conduction to the ventricles?
0.12-0.2 (PR interval 3-5 squares)
97
Why Amiodarone may be used of LV impatiemment or heart failure or for a limited time after electrical cardioversion
may aid remodelling of atrial pathways
98
If cardioversion fails in AF which needs rhythm control then what next?
Left atrial ablation
99
What is the recommended dose of Apixaban for AF?
5mg BD; 2.5mg BD if 2+ of (80+, <60kg, serum creatinine 133+) or creatinine clearance 15-29mL/min
## Footnote
BD stands for 'bis in die' or twice daily dosage.
100
What is the dosing regimen for Apixaban in DVT/PE treatment?
10mg BD for first 7 days, followed by 5mg BD for a minimum of 3 months; after 3 months, recommended dose is 2.5mg BD
## Footnote
DVT stands for Deep Vein Thrombosis, and PE stands for Pulmonary Embolism.
101
What is the prophylaxis dose of Apixaban post hip/knee surgery?
2.5mg BD, started 12-24h post surgery; knee for 2 weeks, hip for 4 weeks
## Footnote
Prophylaxis aims to prevent DVT and PE in surgical patients.
102
Who should not have the Wells score applied for DVT assessment?
Females who are pregnant or within the puerperal period (six weeks post gestation)
## Footnote
The Wells score is a clinical decision rule to assess the probability of DVT.
103
What is the most serious complication of DVT?
Pulmonary Embolism (PE)
## Footnote
PE occurs when a clot from the deep veins travels to the lungs.
104
What management should be included for people likely to have DVT?
Proximal vein leg ultrasound within 4 hours; if not possible, d-dimer and interim therapeutic anticoagulation with results available within 24 hours
## Footnote
Timely diagnosis is critical in managing DVT to prevent PE.
105
What should be done if DVT is unlikely based on initial assessment?
D-dimer test (results in 4 hours); if positive, proximal leg vein ultrasound
## Footnote
A negative d-dimer can help rule out DVT in low-risk patients.
106
How much does the risk of DVT increase after long haul flights?
2-4 times
## Footnote
The risk increases with duration of travel and multiple flights within a short period.
107
Does travel by other transport carry a similar risk for DVT?
Yes
## Footnote
Other forms of travel can also contribute to the risk of developing DVT.
108
What is the relationship between the frequency of episodes of paroxysmal AF and risk?
The greater the frequency, the higher the risk; however, many episodes may be silent.
109
What factors influence the decision for long-term rhythm control in paroxysmal AF?
* Infrequent but symptomatic paroxysms
* Known precipitants (caffeine, alcohol)
* No history of LVSD/valve disease/IHD
* Systolic BP >100
* Resting pulse rate >70 bpm
110
What is the recommended approach if a patient answers 'YES' to all control strategy factors? (AF)
LONG-TERM RHYTHM CONTROL
111
What is the recommended approach if a patient answers 'NO' to any control strategy factors?
'PILL IN THE POCKET'
112
What is the primary goal of long-term rhythm control in paroxysmal AF?
Aim to hold in sinus rhythm.
113
What is the first-line treatment for paroxysmal AF?
Beta-blockers (not sotalol)
114
List alternative treatments for paroxysmal AF for patients instead of beta-blockers (not sotolol)
* Amiodarone (if heart failure/LV impairment)
* Sotalol (with caution in renal impairment/low BMI)
* Dronedarone
115
What is the aim when aborting an AF attack? I.e pill in the pocket
To take a single dose of a drug (e.g., flecainide) at the onset of symptoms.
116
What is considered if drug treatment for paroxysmal AF is unsuccessful or not tolerated?
Consider left atrial ablation.
117
True or False: Left atrial ablation is always successful and long-lasting.
False
118
What is the significance of a resting pulse rate greater than 70 bpm in the management of paroxysmal AF?
It is one of the factors influencing the decision for long-term rhythm control.
119
What is the recommended dosage of Clopidogrel for peripheral artery disease?
75mg
## Footnote
Clopidogrel is also used in cerebrovascular disease.
120
What does an ABPI value less than 0.5 suggest?
Chronic limb-threatening ischaemia
## Footnote
This requires urgent referral for specialist vascular assessment.
121
What does an ABPI value of 0.9 or less indicate?
Presence of peripheral arterial disease
## Footnote
Values between 0.91 and 0.99 may also indicate peripheral arterial disease.
122
What is considered a normal ABPI value?
Between 1.0 and 1.4
## Footnote
Values greater than 1.4 suggest arterial calcification.
123
What should be considered for the treatment of intermittent claudication when supervised exercise is ineffective?
Nattidrotural oxalate
## Footnote
This is for patients who prefer not to be referred for angioplasty or bypass surgery.
124
What is the significant risk for patients with rest pain in PAD
Approximately 25% dying within a year
## Footnote
Also, 33% may require a major lower limb amputation.
125
What ABPI value indicates that compression stockings can be safely worn?
0.8-1.3
## Footnote
Compression stockings should be avoided for values greater than 1.3 due to likely calcified/incompressible arteries.
126
Fill in the blank: An ABPI value greater than 1.4 may suggest the presence of _______.
Arterial calcification
127
True or False: Patients with an ABPI value of less than 0.5 do not require urgent referral.
False
## Footnote
Patients with an ABPI less than 0.5 should be referred urgently for specialist assessment.
128
When should antibiotics be considered for leg ulcers?
Only if purulent exudate/odour, increased pain, cellulitis and pyrexia
## Footnote
Antibiotics do not improve healing unless there is an active infection.
129
What is the recommended antibiotic treatment for leg ulcers if needed?
Fluclox or clarithromycin for 7 days
## Footnote
If slow healing occurs, another 7 days may be considered.
130
What can be used for non-healing leg ulcers to reduce bacterial load?
Antimicrobial reactive oxygen gel
## Footnote
This treatment helps reduce the bacterial load in chronic ulcers.
131
What is the diagnosis criteria for an Abdominal Aortic Aneurysm (AAA)?
>3cm
## Footnote
AAA is diagnosed when the aortic diameter exceeds 3 cm.
132
What is the screening recommendation for AAA in men?
Screening all men age 65 - one off
## Footnote
This is a preventive measure to identify AAA in a high-risk population.
133
What action is taken for AAA measuring <3cm?
<3cm no further scan
## Footnote
No additional follow-up is necessary for aneurysms smaller than 3 cm.
134
What is the follow-up for AAA measuring 3-4.4 cm?
Surveillance, repeat scan in a year
## Footnote
Monitoring is essential for small aneurysms to detect any growth.
135
What is the follow-up for AAA measuring 4.5-5.4 cm?
Surveillance, repeat scan in 3 months
## Footnote
Medium-sized aneurysms require more frequent monitoring.
136
What is the recommendation for AAA measuring 5.5 cm or larger?
Referred to vascular surgeon
## Footnote
Large aneurysms typically require surgical evaluation and management.
