CVASC1

Question 2

What are the principles of management of Atrial Fibrilliation? (And Atrial Flutter)

Answer 2

1. Treat the underlying cause/comorbities (Conditions that increase the risk of AF)
2. Decide on Rate or Rhythm control (No significant difference in rate and rhythm control for all cause mortality)
3. Anticoagulation (As soon as Atrial Fibrillation is diagnosed, start anticoagulation therapy; this does not routinely require specialist management).

_{<strong>Rate control:</strong> patients who have GOOD EJECTION FRACTIONS and ASYMPTOMATIC}

_{<strong>Rhythm control:</strong> patients with LV DYSFUNCTION and/or are HIGHLY SYMPTOMATIC}

Question 3

What proportion of AF episodes terminate within 24 hours?

Answer 3

50%

Question 4

What factors does the management strategy of acute Atrial depend upon?

Answer 4

1. Haemodynamic status - stable or not stable?
2. Duration of the AF episode - > 48 hours or shorter?
3. Thromboembolic risk?
4. The patients preference for approach to management?

Question 5

What’s your approach to haemodynamically stable Atrial Fibrillation?

Answer 5

Less than 48 hrs Duration: If using rhythm control - anticoagulation at time of cardioversion and continue longer term

(depending on patients VTE risk)

_{Can be hard to determine exactly when AF commences sometimes.}

Greater than 48hrs Duration: Do not perform acute cardioversion unless ATRIAL THROMBUS has been excluded OR the patient has had anticoagulation for AT LEAST THREE WEEKS

If these parameters have not been met - RATE CONTROL is preferred.

Question 6

What’s your approach to anticoagulation in AF?

Answer 6

1. Does the patient have Valvular AF

(Valvular AF = mod or sev mitral stenosis OR mechanical heart valve)

• If they have valvular AF - warfarin
• If they have NON Valvular AF

Use CHA₂DS₂VAS score todetermine if they need a NOAC (HAS-BLED can identify bleeding risk)

Question 7

When should AF be reffered to the Emergency Department?

Answer 7

hypotension

AF with rapid ventricular rates (generally heart rates >110 beats per minute [bpm] or if very symptomatic)

signs of clinical heart failure

syncope or presyncope

rest angina +/– ischaemic ECG changes.

Question 8

What routine investigations should be ordered in a patient with newly diagnosed AF?

Answer 8

Full blood examination

Urea, electrolytes and creatinine

Calcium, magnesium and phosphate

Thyroid-stimulating hormone

Transthoracic echocardiogram

24-hour Holter monitoring

Polysomnography (in patients with symptomatic atrial fibrillation only)

Question 9

Which patient factors suggest rhythm control MEDICATIONS could be an option?

Answer 9

are physically active

have paroxysmal or persistent AF lasting short periods of time

do not have significant underlying cardiac structural changes (eg severe left atrial dilatation, mitral valve pathology).

“Pill in the pocket” cardioversion - administered by cardiologists - a dose of fleicanide to use when has a paroxysm.

Also best taken with an AV node blocker (eg Bblocker) to prevent flutter.

Question 10

What are potentially reversible precipitants of Atrial Fibrillation?

Answer 10

Hyperthyroidism

Alcohol excess

Electrolyte abnormalities

Sepsis

Question 11

Risk factors of AF and associated diseases (according to AJGP)?

Answer 11

Obesity

Hypertension

Type 2 diabetes/impaired glucose tolerance

Smoking

Obstructive sleep apnoea

Coronary artery disease

Valvular heart disease

Heart failure

Chronic kidney disease

2 x O, 3 x CVrisk, 3 heart, kid

Question 12

How would you work out whether a patient with non-valvular AF should be anticoagulated?

Answer 12

Congestive heart failure, Hypertension, Age >75 years [2 points], Diabetes, Stroke/transient ischaemic attack [2 points/1 point respectively], Vascular disease, Age >65 years).

This has resulted in the following recommendations for both sexes:

CHA2DS2-VA = 0: Oral anticoagulants (OACs) are not recommended

CHA2DS2-VA = 1: OACs should be considered

CHA2DS2-VA = 2: OACs are recommended.

Note that - TIA is one point, and stroke is 2 points

Question 13

What type of medication is warfarin?

Answer 13

Its a vitamin K antagonist

Question 14

What type of medications are Rivaroxaban and Apixaban

Answer 14

They are factor Xa Inhibitors

Question 15

What type of medication is Dabigatran?

Answer 15

Its a direct thrombin inhbitor

D abigaTran

Question 16

Renal considerations for NOACs and Warfarin

Answer 16

CONTRAINDICATED in the following

Dabigatran - less than CrCl 30ml/min (dose reduce between 30 and 50 - 110mg bd)

Rivaroxaban - less than 30ml/min

Abixaban - less than CrCL 25ml/min

Warfarin is not contraindicated - but in severe renal failure you have to use cautiously because of bleeding risk!

Question 17

What are the drug side effects of the NOACS?

Answer 17

ALL three - bleeding, signs of bleeding (Eg anaemia)

Apixaban - can cause abnormal LFT and thrombocytopenia

Rivaroxaban - can cause peripheral oedema, itching and blisters on the skin

Dabigatran - can cause gastritis, dyspepsia and GIT bleeding

Question 19

Dosages of NOACs?

Answer 19

Apixaban 5mg bd

Rivaroxaban 20mg od

Dabigatran 150mg bd (Dose reduce to 110mg bd if EGFR 30-50 or if age over 75 years)

Question 20

When would you dose reduce one of the NOACs?

Answer 20

Dose reduce Dabigatran to 110mg bd if EGFR 30-50 or if age over 75 years)

Question 21

What reccomendations exist for cessation of anticoagulants prior to high bleeding risk surgeries?

Answer 21

Antiplatelet therapies (aspirin and P2Y12s) and Warfarin - stop 5 days before

NOACS- stop 24 -48 hrs before.

Question 22

A patient who is being anticoagulated for AF has a PCI for an MI. What is recommended for discharge on antiplatelts and NOACS/warfarin

Answer 22

has to be tailored to the individuals bleeding risk

They may use risk mitigation formulations like HAS BLED i

Will be prescribed by the cardiology team

Question 23

Target heart rate in rate control?

Answer 23

Less than 110 bpm

Question 24

What meds would you use in rate control?

Answer 24

Metoprolol 25mg bd - can increase up to 100mg bd if needed

If beta blockers are contraindicated:

Either Verapamil 180mg daily (can go up to 480 daily)

BUT verapamil and diltiazem (non-dihydropiridine CCBs) are contraindicated for LV dysfunction(low EF) because they are negatively ionotropic.

SO - if has LV dysfunction and BB are contraindicated - amiodarone 200mg daily.

Question 25

WHen is DIgoxin indicated?

Answer 25

Bascially if everything else doesnt work to control heart rate. Also if patient has **AF and Heart FAILURE** where other drugs are contraindicated or need to be started very slowly.

Question 26

What are the main reasons for considering rhythm control?

Answer 26

SYMPTOM REDUCTION also: EARLY intervention to prevent structural cardiac damage that paroxysms of AF can have on heart - 'AF begets AF' Also: Cardiomyopathy secondary to AF with rapid ventricular response and individuals in who AF can precipitate acute haemodynamic compromise (Aortic stenosis, Systolic dysfunction)

Question 28

What ventricular rate would you expect on ECG with atrial flutter?

Answer 28

A rate of 150 bpm and narrow QRS complexes

Question 29

Management of Atrial Flutter?

Answer 29

Same as acute AF - except often amenable to low voltage DC cardioversion or overdrive pacing and relatively insensitive to anti arrhythmics - so rhythm control considered earlier.

Question 30

Who do the Absoulte cardiovascular risk guidelines apply to?

Answer 30

Gen Pop 45 and over - WITHOUT ESTABLISHED CVD (CVD, stroke, PAD, Renovascular disease). ATSI 35 and over - WITHOUT ESTABLISHED CVD

Question 31

Would you calculate the CVD risk of someone with PAD?

Answer 31

No. They have established CV risk - So treat as per: HIGH RISK. INCLUDES patients with intermittent claudication AND asymptomatic patients.

Question 32

What are RF's for PAD? Modifiable and Non modifiable?

Answer 32

1. DM (Big) 2. Smoking (Big) 3. Dyslipidaemia 4. HTN Non Modifiable: Male, Age and Non Caucasian (Denzel)

Question 33

What's the progression of PAD?

Answer 33

Asymptomatic Intermittent Claudication Critical Limb Ischaemia Acute Critical limb ischaemia

Question 34

What is intermittent claudication?

Answer 34

Reproducible pain, cramping or fatigue in calf, thigh or buttock during exercise Pain or tightness in a muscle on exercise. Relived by rest. ON examination: Reduced or absent peripheral pulses ONLY

Question 35

What is rest pain? What does it suggest?

Answer 35

Rest pain is constant, severe burning pain in the forefoot at rest. Typically Worse at night. It represents critical limb threatening ischaemia (a threat to the viablity of the limb).

Question 36

What are symptoms of proximal obstruction in peripheral artery disease? What is an example of the location of such an obstruction?

Answer 36

Pain in the _buttocks, thighs and calves_. ESP when walking UP HILLS AND STAIRS Persistent fatigue in the entire lower limb. Impotence is possible (Leriche syndrome - Aorto-illiac occlusive syndrome). Location example - Aorto-illiac disease

Question 37

What are the symptoms of PAD with relative obstruction in the thigh (Infrainguinal PAD)? Which vessels are affected and how do they typically manifest?

Answer 37

_PAD in superficial femoris_ - causes calf pain. Claudication Occurs at 200m - 500m. _PAD in profunda femoris._ Claudication occurs at 100m. _Multiple segment involvement._ PAD at 40-50m. **Infrainguinal disease with calf pain only has a favourable prognosis.** *Patient may ride cycle to work cos thigh muscles used.*

Question 38

Differential diagnosis for Intermittent claudication?

Answer 38

1. Peripheral artery disease (atherosclerosis -common in men, smokers, over age 60). 2. Venous Claudication - History of severe DVT or venous insufficiency (Embolisation with recovery ). 3. Neurogenic Claudication - (eg nerve root entrapment, spinal canal stenosis) - still have peripheral pulses 4. Popliteal entrapment syndrome (Age under 40 usually). 5. Burgher disease - affects small arteries, causes rest pain and cyanoisis (claudication is uncommon).

Question 39

What examination findings would you look for in peripheral artery disease?

Answer 39

1. Inspect lower limb for tropic changes - shiny skin, colour change/pallor, changes in hair distribution, muscle wasting. 2. Check and Ankle Brachial Pressure index. If less than **0.9** it indicates _PAD_ If less than **0.8** it indicates PAD with _ulceration risk_ If less than **0.5** it indicates with PAD with _critical limb ischaemia_ _{NB: An ABPI of greater than 1.5 is likely due to non compressible vessels and cannot be used to guided decision making.} 3. Check peripheral pulses. If present, these may disappear with exercise. 4. **Inspect for AAA and Popliteal aneurysm** 5. Perform a Burgher test - looking for postural colour change. 6. Perform a neurological examination looking specifically for changes of diabetic neuropathy.

Question 40

What constitutes a positive Burgher test?

Answer 40

Pallor on elevation of limbs Rubor on dependency It indicates severe chronic ischaemia

Question 41

What investigations should be performed in PAD?

Answer 41

1. FBE - looking for thrombocytopaenia and anaemia 2. Measure Ankle Brachial Pressure to determine Ankle brachial pressure index. If **Symptomatic with an abnormal ABPI - then duplex arterial ultrasound is indicated.** (Stenosis greater than 75% is considered clinically significant). SECOND line Investigation is: Computed tomography angiography - reserved for when ultrasound suggests possibility of _aorto-illiac disease OR for perioperative planning._ Consider Screening for AAA

Question 42

What management steps would you insititute for a patient with intermittent calf claudication?

Answer 42

1. Graduated exercise program 2. Foot Care - Regular foot care by podiatrist and patient themselves. 3. Commence ACE inhibitor with blood pressure target of 140/80 4. Commence HMG CoA Reducatse inhibitor irrespective of cholesterol levels. Lower LDL-C to less than 1.8. 5. Commence aspirin 100mg daily. 6. Support patient to stop smoking. 7. Stop Beta blockers unless the patient has heart faiure or other critical indication. 8. Agressive managment of DM, HTN, Lipids, Weight and smoking cessation. 9. Safety Netting: Educate the patient regarding symptoms and signs of acute limb ischaemia and advice urgent review at an emergency department if the same occurs. 10. Perform Tetanus immunisation

Question 43

When would refer to a specialist if a patient has intermittent claudication?

Answer 43

1. Significant limitation of daily activities. 2. Significant Disease progression as evidenced by symptoms, ABPI or Duplex ultrasonography.

Question 44

What is the main risk in Intermittent Claudication?

Answer 44

Main risk is - risk to life via CV events.

Question 45

What are the signs and symptoms of critical limb ischaemia?

Answer 45

Chronic - Rest pain and Tissue loss (ulceration, gangrene). Acute - PPP PPP Pain, paraesthesiae, perishingly cold, Pallor, Pulseless, Paralysis

Question 46

How would you distinguish an arterial ulcer from a diabetic ulcer?

Answer 46

Arterial - Very painful, distal LL, colour change - turn black as they become gangrenous DM - pressure areas, not painful, bounding pulse

Question 47

Foot pain worse at night and relieved by hanging feet out of bed(dependency)

Answer 47

Ischaemic rest pain

Question 48

How would you manage a patient with symptoms or signs of critical limb ischaemia?

Answer 48

1. REFER any patient with lifestyle limiting claudication, rest pain or gangrene to a vascular surgeon for early consideration of angiography and revascularisation. 2. Revascularsiation - via vascular reconstruction - through bypass graft, endarterectomy, endoluminal intervention etc is treatment of choice 3. Manage pain (often severe) with regular analgesia- Paracetamol 1g QID PRN Oxycodone 5mg qid PO PRN 4. Protect the limb with cage and heel pad but DO NOT ELEVATE THE LIMB 5. Elevating the head of the bed may reduce nocturnal rest pain 6. Review FBC (Manage anaemia if present - as can worsen symptoms). 7. Maintain a high to normal systolic blood pressure to assist with peripheral perfusion. Consider weaning/cessation of beta blocker medications unless harm is outweighed by benefits. 8. If infection is present, take swabs and commence antibacterial therapy according to results of culture and susceptibility

Question 49

How would you recognise and manage acute limb ischaemia?

Answer 49

Patients report a history of **sudden foot pain, pallor or coldness occurring over hours or days**. _Sensory loss or motor deficits signify an acutely threatened limb with limited viability._ ALI requires **urgent revascularisation** because of the lack of peripheral collateral vessels. It is important to **_urgently transfer patients to the nearest emergency department with vascular services_** to avoid treatment delays that occur with outpatient imaging.

Question 50

When would you dose reduce Apixaban?

Answer 50

If **2 or more** of: age ≥*80 years,* body weight ≤*60 kg*, or serum _Cr of ≥_**_133_** µmol/L **lower dose to 2.5 mg bd**

Question 51

When would you dose reduce Dabigatran?

Answer 51

If CrCl 30-50 Then reduce dose from 150 to 110mg bd

Question 52

When would you dose reduce rivaroxaban?

Answer 52

If CrCl 30–49 mL/min: lower dose to 15 mg