HTN + AF

Question 1

How to diagnose AF?

Answer 1

ECG - loss of p waves

Question 2

When is TTE used?

Answer 2

(transthoracic echocardiography) For people with AF if: High risk of heart disease Cardioversion is being considered Baseline echo is needed for management plan

Question 3

When is a TOE used?

Answer 3

Transoesophageal echocardiography Used in people with AF when: TTE demonstrates abnormality TTE is difficult to perform

Question 4

When should anticoagulants be considered in AF?

Answer 4

CHAD2VASC2 Over 65 Diabetes HF Peripheral arterial disease Coronary heart disease Stroke, TIA, VTE

Question 5

Warfarin regime for AF

Answer 5

Slow loading regime - reaching therapeutic levels in 3-4 weeks 1-2mg initially Average daily maintenanec = 5mg INR to be measured daily until within therapeutic range (2-3), then twice weekly for 1-2 weeks, then every 12 weeks

Question 6

Why are NOACs good, what monitoring is needed?

Answer 6

No need for regular INR tests Baseline clotting screen, renal + liver function before treatment Assess every 3 months Repeat tests once a year

Question 7

Management of acute AF

Answer 7

Emergency electrical cardioversion if haemodynamically unstable Rate or rhythm control if stable Anticoagulate with heparin

Question 8

How is HTN diagnosed?

Answer 8

Ambulatory BP monitoring or home BP monitoring

Question 9

Classification of severity of HTN

Answer 9

Stage 1: 140/90 in clinic Stage 2: 160/100 in clinic Severe: 180/110 in clinic Accelerated: 180/110 + signs of papilloedema/ retinal haemorrhage

Question 10

RF for HTN

Answer 10

Age Males Genetics Social deprivation Anxiety Smoking, poor lifestyle

Question 11

What does HTN increase the risk of?

Answer 11

HF CHD Stroke CKD Peripheral artery disease Vascular dementia

Question 12

How do you assess CV risk?

Answer 12

BP, total cholesterol + HDL Estimate 10 year risk using QRISK2

Question 13

Management for HTN <55

Answer 13

1st line: ACEi or ARB 2nd line: ACEi or ARB + Ca channel blocker 3rd line: ACEi or ARB + Ca channel blocker + thiazide diuretic

Question 14

Management for HTN >55 or black person

Answer 14

1st line: Ca channel blocker 2nd line: ACEi or ARB + Ca channel blocker 3rd line: ACEi or ARB + Ca channel blocker + thiazide diuretic

Question 15

What is the CHA2DS-VASc score + what are the RF?

Answer 15

Score to assess risk of stroke in someone with AF Congestive HF HTN >75 (2 DM Stroke/ TIA (2) Vascular disease Age >65 Sex (female)

Question 16

What is the HAS-BLED score?

Answer 16

Score to assess 1 year risk of major bleeding in pts taking anticoagulants for AF HTN Abnormal renal + liver function Stroke Bleeding Labile INR Elderly Drugs/ alcohol

Question 17

What is the definition of AF?

Answer 17

Cardiac arrhythmia with absolutely irregular RR intervals No distinct P waves on ECG Rapid + chaotic atrial activity

Question 18

What are the different classifications of AF?

Answer 18

Initial episode: >30s on ECG Paroxysmal: recurrent >2 episodes that terminate within 7 days Persistent: continous >7 days Long standing persistent: continuous AF >12 months Permanent: decision made by pt and clinician

Question 19

AF related symptoms

Answer 19

Palpitations SOB Fatigue Dizziness Syncope

Question 20

What is the link between AF + stroke?

Answer 20

AF increases stroke risk by 5% Associated with larger infarcts, increased disability + death

Question 21

When to offer anticoagulation in AF?

Answer 21

CHA2DS2VASC score >2 = offer warfarin or novel anticoagulant Score >1 = consider anticoagulation Score 0 = do not offer

Question 22

What needs to be given if AF >48 hours before cardioversion?

Answer 22

Minimum 3 weeks warfarin before + 4 weeks after

Question 23

What is catheter ablation?

Answer 23

Electrical isolation of pulmonary veins Prevents triggers of AF Blocks PV ectopics from entering left atrium Needs to have warfarin for 3 weeks before + 4 weeks after

Question 24

Caution with amiodarone

Answer 24

Thyroid risk = TFTs

Check LFTs due to hepatotoxicity

Pulmonary toxicity - CXR

Corneal whirls

Amiodarone has long half life

Question 25

Interactions of digoxin

Answer 25

Interactions with diuretics = causes hyperkalaemia (particularly furosemide)

Question 26

Mechanism of action, uses, SE + CI of indapamide

Answer 26

Thiazide like diuretic, alternative to CCB. Inhibit Na+/ Cl+ co-transporter in distal convuluted tubule. Useful to combine with ACEi + ARBs as these cause hyperkalaemia CI in oedema + HF SE: Impotence, hyponatraemia, hypokalaemia (causing cardiac arrhythmias) Can increase plasma glucose

Question 27

Mechanism of action, uses, SE + CI of beta blockers

Answer 27

Used for CVD, HF, AF, SVT, HTN Beta 1 blockers - reduce force of contraction + speed of conduction in the heart Prolong refractory period at AV node SE: fatigue, cold extremities, headache, GI S+S, impotence CI in asthma

Question 28

Mechanism of action, uses, SE + CI of ARBs

Answer 28

Used in HTN, HF, CVD, diabetic nephropathy + CKD Block action of angiotensin 2 on AT1 receptor Reduces peripheral vascular resistance, lowering BP. Less likely to cause angioedema so good in Africans SE: hypotension, hyperkalaemia, renal failure CI: pregnancy, renal artery stenosis, AKI

Question 29

Mechanism of action, uses, SE + CI of ACEi

Answer 29

HTN, HF, CVD, diabetic nephropathy + CKD Block action of ACE to prevent conversion of angiotensin 1 to 2 SE: hypotension, dry cough, hyperkalaemia, angioedema CI: pregnancy, AKI, renal artery stenosis NSAIDs increase risk of renal failure Take first dose before bed

Question 30

Mechanism of action, uses, SE + CI of CCB

Answer 30

HTN (amlodipine), SVT (diltiazem + verapamil) Vasodilation of arterial smooth muscle SE amlodipine: ankle swelling, flushing, headache, palpitations SE verapamil: constopation, bradycardia, heart block, HF Diltiazem - any of these SE Diltiazem + verapamil CI in HF Amlodipine CI in severe aortic stenosis

Question 31

Stage 1 + 2 HTN + management

Answer 31

* Stage 1 = 140/90 = lifestyle + diet (unless comorbidity), review in 2-4 weeks * Stage 2 = 160/100 AND 150/95 ABPM = begin medical management

Question 32

Describe management of AF

Answer 32

Rate control first * Beta blocker 1^st line * Diltiazem 2^nd line * Digoxin if sedentary * Combine Except (when not to use rate control): * whose atrial fibrillation has a reversible cause * who have heart failure thought to be primarily caused by atrial fibrillation * with new-onset atrial fibrillation * with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm Rhythm control * If over 48hrs, electrical * Use amiodarone 4 weeks before + 12 months after electrical * Drug treatment: BB or amiodarone if HF * Dronedarone after successful cardioversion 2^nd line

Question 33

What is the pill in the pocket?

Answer 33

BB or flecanide

Question 34

How do you treat HTN with CKD?

Answer 34

High BP in CKD – ACEi (regardless of age or race)

Question 35

What is the target BP for DM?

Answer 35

\<140/80 or 130/80 if there are any complications of DM present