CVS Flashcards
1
Q
Mitral Facies
A
bluish discolouration of the cheeks associated with low cardiac output (form of peripheral cyanosis)
2
Q
A patient with unexplained clubbing should?
A
be referred for urgnent CXR
3
Q
Pulsus Paradoxus occurs in?
A
(pulse weakens on inspiration- 10mmHg)
asthma
cardiac tamponade
pericarditis
4
Q
Pulsus Tardus (slow-rising)
A
shock
pericardial tamponatde
aortic stenosis
5
Q
ABPI measurement?
A
BP in one arm
Inflate cuff around lower calf
Doppler- record maximum pressure @ which pulse is heard
ankle pressure/ brachial pressure
6
Q
Interpretation of results?
A
ABPI < 0.8 ischaemia
ABPI < 0.5 Critical Ischaemia
7
Q
What can cause falsely elevated readings in ABPI?
A
Arterial calcification due to DM
8
Q
Selection of patients for primary intervention of CVD?
A
Patients> 75yrs
Familial Monogenic Dyslipidaemia
Most patients with DM
CVD 10 yr risk >20%
9
Q
If patients close to threshold for intervention, consider;
A
Low socio-economic group BMI > 40 Aready taking hypertensives and anti-lipid? Recently stopped smoking? Antipsychotic medications? CKD? RA? SLE? HIV?
10
Q
A consistent difference of >10mmHg when measuring BP in both arms indicates?
A
Independent Risk Factor for CVD
Treat risk factors
Use higher reading
11
Q
Why should you check radial/brachial pulse before measuring blood pressure?
A
Not an accurate measurement if irregular pulse present
12
Q
Prevalence of white coat HTN?
A
10%
13
Q
When to offer ambulatory BP monitoring?
A
BP > 140/90mmHg on two occassions
14
Q
If BP > 180/110 mmHg, how should you proceed?
A
Start antihypertensives immediately
15
Q
When should you refer a patient with severe HTN (>180/110) for urgent same day specialist assessment?
A
Accelerated HTN (BP>180/110mmHg +/- papilloedema +/- retinal haemorrhage) Phaeochromocytoma ( postural hypotennsion, tachycardia, headache, pallor, palpitations, diaphoresis)
16
Q
ABPM is considered abnormal if?
A
Average Daytime (20mins) >135/85mmHg Average Night-time > 120/70mmHg
17
Q
Instructions for HBPM?
A
4-7 consecutive days
2x/d (morning and evening) seated
2 reading >1min apart
Discard day 1 readingaverage of the 6days
18
Q
Postural Hypotension?
A
Drop in systolic and diatsolic BP >20mmHg on standing
19
Q
Measuring Postural Hypotension?
A
Measure seated
Measure after 1min standing
20
Q
Managemet of Postural Hypotension?
A
Review Meds: sedatives, diuretics
Optimize tx: CVD, Parkinsons, DM
Advise: care
21
Q
Percentage of people >60 yrs with HTN?
A
60%
22
Q
Risk factors for essential/primary HTN?
A
Alcohol
Obesity
23
Q
Causes of secondary HTN?
A
Renal disease
Endocrine: Cushings (+ steroid use),Phaeochromocytoma, Acromegaly, Hyperparathyroidism, Conn’s
Pregnancy
Coarctation of the aorta
24
Q
Non-Dipping on ABPM is associated with?
A
Increases risk of end organ damage (LVH, Renal damage)
25
>10% dipping @ night is associated with?
Increased risk of CVD events
26
Further Assessment of patients with HTN includes?
Identify target organ damage
Examine: heart, fundi- silver wiring, AV nipping, flame haemorrhages, cotton wool spots
Bloods: U&E, HbA1C, Lipid Profile,
Urine:RBCs, Protein, ACR
CV Risk Estimation
ECG +/- Echo if LVH
27
Lifestyle advice: Alcohol intake should be reduced to?
<21units/week Males
| <14units/week Females
28
each 2mmHg increase in BP is associated with a ___% increased risk of mortality IHD and a _____% risk of mortality stroke
7%
| 10%
29
Prescribe Statin if;
HTN complicated by CVD, irrespective of cholesterol/LDL
Primary prevention in patients >40yrs with HTN and 10yr CVD risk > 20%
30
General rules for antihypertensive drug treatment:
Drug not tolerated: stop, move on
| Drug tolerated but BP not dropped: Add next step
31
Antihypertensive treatment targets in patients without CKD or diabetes?
```
140/90
>80yrs 150/90
ABPM/HBPM:
<135/85
>80yrs 145/85
```
32
Antihypertensive Treatment targets in diabetics?
Uncomplicated T2DM: <140/80
Uncompplicated T1DM: <135/85
Complicated: <130/80
33
Antihypertensive Treatment targets in CKD?
<130/80
34
Review Intervals for patinets with hypertension?
```
Starting treatment: 1mnth
Controlled: 3mnths
Uncontrolled: Repeat BP reading.
If sustained: alter meds
Repeat mnthly
```
35
Referal hypertensive patients if?
```
Accelerated HTN
Renal Impairment
Suspected secondary Htn
Patients <40yrs
Difficult to treat BP
Pregnancy
```
36
B blockers are not used as initial tx for HTN except;
Women of childbearing potential
Patients w/t increased sympathetic drive
Patient w/t contraindications to ACEi/ARBs
37
If initial tx is with B-Blocker and second drug needed, what should you prescribe and why?
Non rate limiting CCB- amlodipine, felodipine
| decrease risk of DM
38
How should Triglycerides be interpreted?
Independent risk factor for CVD
| >5 High Risk
39
Ratio of total cholesterol:HDL >6
High Risk
40
% of patients with increased cholesterol that drops to normal on repeat measurement?
25%
41
Testing for Hyperlipidameia?
>/= 2 samples
Fasting: Initiating treatment or screening Familial dyslipidaemia
Non-Fasting: Screening and follow-up
42
When should you consider treatment of high lipids with a statin?
Lipids remain high despite low cholesterol diet and 10yr CVD risk >20%
43
Screening for familial hyperlipidaemia is indicated if?
First degree blood relatives >18yrs every 5yrs if;
FHx- familial hyperlipidaemia
FHx-premature CVD (M<55yrs, W,65yrs)
44
A patient with hypothyroidism has hyperlipidameia, how should you proceed?
Treat Hypothyroidism first (levothyroxine)
May resolve lipid abnormality
Increased risk of myositis with statins
45
If cholesterol level >5mmol/L, low-cholesterol diets result in decrease cholesterol by ___%
8.5% @ 3mnths
46
In patients with a BMI>30, weight decrease by ___kg causes a 7% decreasein LDL and 13% increase in HDL
10kg
47
Stain treatment?
Primary Prevention:
>20% 10yr risk CVD
>75yrs
DM >40yrs or with additional risk factors
Secondary Prevention:
Hx CVD irrespective of lipids
48
Before starting statin treatment assess?
```
Fasting lipid profile (Initiating tx)
Fasting blood glucose
Renal Function
Liver Function
TSH if dyslipidaemia
```
49
Statins are contraindicated for?
Pregnant women
Breastfeeding Women
Active liver disease
(Transaminases that are not increase 3x are not a contraindication)
50
Statins interact with what types of drugs?
Warfarin (increase effect )
Increased risk of myositis wheen taken with?
Other lipid lowering drugs (Fibrates, Anion Exchange resin, Nicotinic Acid, Ezetimibe)
Macrolide antibiotics (Erythromycin)
CCB
Ciclosporin
51
NNT with statin in primary prevention to prevent 1 adverse event is
34.5
52
NNT with statin in secondary prevention to prevent 1 adverse event is
13.8
53
Prevalence of myositis as an adverse effect of statin use?
11/100000
54
If a patient on statin therapy presents with myositis, how should you proceed?
Check CK level
>5x upper limit withdraw therapy
Normal = 22-198
55
Prevelance of peripheral neuropathy as an adverse side effect of? statin use?
12/100000 person years
56
Patients on simvastatin should be advised to exclude what from their diet?
grapefruit juice
57
80mg of simvastatin is only recommended in patients with?
```
severe hypercholesterolemia (>240)
high risk of CVD
```
58
Regarding hyperlipidaemia, refer patients who have;
Familial Hypercholesterolaemia
High TGs (independent RF)
Hypercholesterolaemia resistant to tx/ difficult to tx
59
Diagnosis of unstable angina?
```
History:
New onset intermittent chest pains Crushing central pain
radiates to Jaw/neck pain
Pain on exertion
stops with rest/ GTN sprays
```
60
How would you exclude arteritis in the scenario of central chest pain?
ESR blood test
61
Referal of patients with suspected stable angina to a rapid access chest pain clinic?
Confirm angina
Perform exercise ecg
Educate-tretament
62
The % of patients with unstable angina that will suffer an MI in <1mnth
15%
63
The incidence of unstable angina?
6/10000
64
CABG > PCI, for treatment of unstable angina, in which cases?
DM
>65yrs
LAD artery disease
Complex 3x vessel disease
65
Side effects of GTN?
Flushing
Headches
Light-headedness
66
GTN education on use?
1-2 puffs as needed for pain and before exercise
Repeat after 5min if pain persists
Pain persists 5min after 2nd dose- call emergency ambulance
67
When should you consider surgery for management of angina?
Not managed with two anti-anginal drugs
68
When should you consider adding a third anti-anginal drug?
Symptoms are not well controlled with two anti anginal drugs and patient not suitable for surgery
69
How would you check if a patient is B-Blocked?
Resting HR <65bpm
| Exercise < 90bpm
70
Which B Blockers should be used in paients with asthma or COPD?
Cardio-selective
| Atenolol, Bisoprolol, Metoprolol, Nebivolol
71
What should you tell a patient that wants to stop their B Blocker?
Do not stop suddenly or run out
| Tail off over 4 weeks
72
The use of 75mg aspirin as secondary prevention in patients with angina decreases mortality by?
34%
73
Secondary Prevention of CHD mortality involves what types of treatment?
Aspirin/clopidogrel
Statins
Ace Inhibitors
74
Following MI, what medications should a patient be on?
-Modify Risk Factors:
Statin
B-Blocker/Rate Limiting CCB
- ACE Inhibitors/ ARB
- Aspirin/Clopidogrel
75
How many deaths does initiation of a B-Blocker following MI prevent?
12/1000/yr
76
ACE Inhibitors prevent death <1mnth following MI in how many patients?
5/1000 treated
77
How soon should aspirin be started following MI and why?
<24hrs
| prevents 80 vascular events over 2y/1000patinets treated
78
When should clopidogrel be prescribed in addition to aspirin?
For 12mnths: NSTEMI/unstable angina
For 1mnth: STEMI w/t no stenting
For 3mnths: STEMI w/t bare metal stenting
For 12mnths: STEMI w/t drug/eluting stent
79
Patients following acute MI w/t symptoms and signs of heart failure and EF < 0.4?
Start Aldosterone antagonist (spironolactone) within 3-14days of MI, after ACE Inhibitor
80
Return to work guide following (uncomplicated) MI?
Sedentary:4-6wk
Light Manual:6-8wk
Haevy Manual:3mnth
81
Physical Activity Guide following MI?
2wk: stroll in garden
2-6wk: walk 0.5mile/day upto 2miles @ 6wks
6wks: 2miles <30mins
*sexual Activity after 6wks
82
% of patients that are depressed after MI
50%
| 25% after 1 yr
83
Dressler Syndrome?
2-10wks following MI
Recurrent fever, chest pain, pleural/pericardial effussion
Tx: Steroids and NSAIDS
84
Causes of falsely decreased natriuretic peptide?
```
Obesity
Diuretics
ACE inhibitors/ ARBS
B Blockers
Aldosterone antagonists- spironolactone
```
85
Causes of falsely Increased natriuretic peptide?
```
MI
Baseline higher in women and >70yrs
COPD, PE
Renal Impairment
DM
Liver Failure
Sepsis
```
86
Grading of severity of Heart Failure (NYHA Classification)
I: No limitation
II:Slight Limitation, Comfortable @ rest
III: Marked Limitation-less than ordinary activity. Comfortable @ rest
IV: Discomfort @ ret
87
A patient suspected of having heart failure should be referred for specialist review and echo < 2wks if?
Previous MI
| BNP >400
88
If BNP measured is 100-400 how should you proceed?
Refer for specialist review and echo <6wks
89
Management of Chronic Heart Failure?
Review every 6mnths
Screen for Depression (>40%)
Restrict Fluid Intake
Pneumococcal and Influenza Vaccine
Medications:
ACE Inhibitors (ramipril, perindopril)
B Blockers
90
Other drugs to consider in Chronic Heart Failure?
- Anticoagulation: AF, Hx TE, Left ventricular aneurysm, Intrathoracic Thrombus
- Aspirin: Atherosclerotic arterial disease
- Statins Hx CVD, >20% 10yr CVD Risk, DM, >75yr
- Amlodipine: angina and HTN
91
Which drugs should be avoided in chronic heart failure?
Rate Limiting CCB: Verapamil, Diltiazepam
| Short Acting Dihydropyridine CCB:
92
Referral of patients with chronic heart failure to cardiology?
```
Initial Dx
Unable to be managed @ home
Not controlled by 1st Line meds
Severe Heart Failure ( >50% mortality within 1yr)
Angina, AF
Valve Disease or Diastolic dysfunction
Co-morbidity
Planning Pregnancy
```
93
Second Line agents in treatemtn left ventricular systolic dysfunction (specialist supervision)
-Aldosterone antagonists - spironolactone
-Hydralazine and Nitrate
ARB + ACEi + B Blocker
94
Digoxin is used to treat?
Worsening or severe heart failure due left ventricular systolic dysfunction
95
If a patient is on amiodarone to treat arrhythmias associated with heart failure, you should monitor?
TFTs (hyper/hypo)
LFTs
every 6mnths
96
When should an echo be performed on someone with tachycardia?
<50yrs
Murmur detected
Heart Failure detected
97
Red Flag symptoms ass. w/t tachycardia?
Pre-existing cardiovascular disease
FH of syncope, arrhythmia or sudden death
Arrhythmia ass. w/t falls/syncope
98
You have just diagnosed a patient with ventricular tachycardia after performing a first line resting ECG. How do you proceed?
Bluelight Emergency
Give O2 +/- IV Lidocaine
If no pulse - treat as arrest
99
AF increases the risk of stroke by?
| Percentage of patients >80 yrs with AF?
5x
| 8%
100
Anticoagulation (warfarin/ LMWH) decreases stroke risk by how much in patients with AF?
60%
101
Routine Investigations for AF?
ECG
CXR
Bloods: TFTs, FBC, U&E
102
Pill-in the Pocket approach to paroxysmal AF?
B Blocker prn
No Hx of LV dysfunction, valvular ischaemic heart disease
BP >100mm Hg
HR > 70bpm
103
Patients with AF should be referred to cardiology if?
Fast rate and compromised by arrythmia (chest pain, hypotension, >mild heart failure
Canditae for cardioversion
Uncertainty about diagnosis or treatment
Symptoms uncontrolled
104
Chronic AF treatment?
Rate Control:
- Monotherapy: B Blcker or rate limiting CCB
- Combination Therapy: BBlocker, Diltiazem, Digoxin
Rhythm Control:
Cardioversion?
-B Blocker, Amiodarone, Ddronedarone
Anticoagulation: CHADSVASC Score
105
Digoxin only considered as monotherapy for rate control in AF if?
Patient very sedentary
106
Candidates for cardioversion include?
```
Heart Failure ass. w/t AF
New onset (<7d)
Atrial Flutter suitable for ablation
AF secondary to treated/ corrected precipitant
-Rate control ineffective
```
107
How long after pacemaker insertion can a patient not drive?
1mnth
108
Stokes Adams attacks?
Cradiac arrest due to AV Block
| Sudden LOC +/- limb twitching- cerebral anoxia
109
Untreated 2nd or 3rd degree heart block has a mortality of approx?
approx. 35%
110
New murmur and a fever indicates?
Endocarditis until proven otherwise
111
Patients at high risk of developing infective endocarditis?
```
Acquired valvular heart disease
Valvular Replacement
Structural Congenital heart disease
HOCM
Hx Infective Endocarditis
```
112
Causes of infective endocarditis?
Infective: strep viridans, straph aureus
Non-infective: SLE, Malignancy
(M>A>T>P)
113
How would you diagnose intermittent claudicaton?
```
Good Hx (muscular, cramp-like pain on walking, relieved immediately by rest)
+ ABPI <0.95
```
114
Peripheral Ischaemia in the superficial femoral artery causes intermittent claudication where?
The calf muscle
115
Intermittent Claudication in the calf, thigh or buttocks is a result of?
Disease of the aorta or iliac artery
| Weak or absent femoral pulse/bruit
116
Duplex USS is used for?
To determine the site of the ischaemia
117
Nerve Root Compression vs. Peripheral Ischamia
Sciatica- bilateral, prolonged standing + exercise, not rapidly relieved by rest
118
Percentage of patients with intermittent claudication that progresses to critical limb ischaemia over 10yrs
20%
119
Patients with Intermittent claudication have how much of an increased risk from death of MI/stroke
3x
120
Treatment for patients with IC?
Exercise
Reduce CVS risk factors
Aspirin (all patients)
Foot Care
121
Referral to vascular surgery?
Critical Limb Ischaemia (deteriorating claudication, nocturnal rest pain, ulceration, gangrene)
Severe Symptoms
No better after exercise training
Uncertainty about dx
122
Secondary Causes of Varicose Veins
DVT
AV Fistula
Pelvic Tumour
Pregnancy
123
Long Saphenous Vein Distribution is where
The thigh and medial calf
124
Before advising compression hosiery what should you assess?
ABPI > 0.8 to exclude significant arterial disease
125
Women with varicose veins taking the CHC or HRT are at increased risk of?
How should this be treated?
Thrombophlebitis (severe pain, erythema, pigmentation over and hardening of the vein)
NOT DVT
Tx: Crepe Bandaging, NSAID, Ice Packs, Elevation, Low dose aspirin
126
Thrombophlebitis migrans is associated with?
Pancreatic carcinoma
| Recurrent tender nodules affecting veins throughout the body
127
Refer for urgent duplex scanning if a thrombophlebitis..
Extends up the long saphenous vein to the saphenofemoral junction
128
A varicose vein present as a lump in the groin, has a positive cough reflex and disappears on lying down, is likely to be?
Saphena Varix
129
Incidence of DVT
1 in 1000/yr
130
Causes Increased D-Dimer
```
DVT
Malignancy
Pregnancy
Wound Healing
Recent Trauma
Inflammation
Sepsis
Liver Transplantation
```
131
If you suspect a patient has a DVT how should you proceed?
Referal to rapid access clinic
| Delay: LMWH
132
Dx of DVT?
Confirmed with imaging
133
If Wells score <2 how should you proceed?
D-Dimer
If, +ive treat as medium/high risk (>2)
USS
134
If a patient has a DVT with unknown cause you should consider?
Thrombophilia if <45yrs
| Malignancy if >45yrs
135
Managemant of DVT?
LMWH (IV) 4days + INR 2.5 >2days
Warfarin (outpatient) 3-6mnths after DVT
Graduated Elastic Compression Stockings 2yrs
136
The risk of PE from untreated DVT is?
20%
137
What is post thrombotic syndrome?
Chronic venous HTN following DVT, causing limb pain, swelling, ulcers, venous gangrene, lipodermatosclerosis
138
DVT may occur?
```
Proximally (above the knee)
Calf Veins
Cerebral Sinus
Veins of the arm
Retinal Veins
Mesenteric Veins
```
