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Flashcards in Cardio Deck (58)
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1

List the possible causes of HTN

1. Essential HTN
2. Malignant or accelerate phase HTN (visual disturbance, headaches, retinal haemorrhages)
3. Secondary HTN
- Diabetic nephropathy
- Polycystic kidney disease
- Renovascular disease
- Conn's syndrome
- Phaeochromcytoma
- Acromegaly
4. Drugs
- Steroids
- OCP
-NSAIDS
5. Pregnancy

2

Treatment of HTN

Refer to flow for targets
1. Lifestyle advice
- weight reduction
- low salt diet
- reduce alcohol
- increase exercise
- stop smoking

2. Pharmacological management
Step 1 if under 55 and not afro Caribbean
-ACEi or ARB
- if yes CCB

Step two
- + thiazide diuretic/ CCB/ ACEi or ARB

Step three
- All three of the above combined

Step four
SEEK expert advice is not controlled on four drugs at optimal doses.
- low-dose spironolactone4 if blood potassium level is ≤4.5 mmol/l
- alpha-blocker or beta-blocker if blood potassium level is >4.5 mmol/l

3

Pharmacology of ACEi

Prevent the conversion of angiotensin I to angiotensin II.
- Angiotensin II = vasoconstrictor
- Reduces vascular resistance
- Dilate the efferent glomerular arteriole

DOSE
start @ 1.25mg in heart failure
start @ 2.5mg normal people
U&E's two weeks after starting
Take at bed

4

Side effects of ACEi

Hypotension
Dry cough
Hyperkalameia due to lower aldosterone levels = potassium retention

5

Pharmacology of ARBs

Block the action of angiotensin II on the AT1 receptor

Dose
Losartan is common choice
12.5mg in heart failure
50mg in other indications
First dose before bed

6

Pharmacology of CCB

Decrease Ca2t entry into the vascular and cardiac cells
Relaxation and vasodilation of the arterial smooth muscle
Reduce myocardial oxygen demand by reducing cardiac cells contractility

DOSE
Hypertension: 5-10mg daily (amlodipine)
Angina: 90mg (diltiazem- non dihydropyridine)
SVT: Verapamil 40-120mg

7

Side effects of CCB

Ankle swelling
Flushing
Headache
Palpations

8

Pharmacology of thiazides

Inhibit the Na+/Cl- co transporter in the DCT of the nephron
Prevents reabsorption of sodium
Fall in extracellular volume

DOSE
Bendro and Indapmide = 2.5mg daily

9

Side effects of thiazides and thiazide like

Hyponatraemia
Hypokalaemia
Impotence in men

10

Pharmacology of Spirolactone

Aldosterone antagonist
Competitively bind to the aldosterone receptor
Increases sodium and water exception through preventing activation of the ENAc channels

Dose
100mg daily

11

Side effects of spirolactone

Hyperkalamia
Gynaecomastia

12

Define acute coronary syndrome

Unstable angina + evolving MI
Path: plaque rupture, thrombosis and inflammation

13

Risk factors of ACS

Modifiable
- HTN
- DM
- Smoking
- High cholesterol
- Obesity

Non-Modifiable
- Age
- Male
- FH (< 55yrs )

14

IX in suspected ACS

Bloods
- Troponin T/I ( Present from 6hrs, repeated every 6hrs)
- FBC
- U+Es
- Glucose
- Lipids and clotting
ECG
CXR
- Cardiomegaly
- Pulmonary oedema
- Aortic rupture

15

Complication of MI

Death
Pump Failure
Pericarditis
Rupture
- Cardiac tamponade ( Becks triad of low BP, high JVP and muffled heart sounds)
- Papillary muscle rupture ( Pulmonary oedema)
- Arrhythmias
- Ventricular aneurysm
Embolism
- Dresslers syndrome

16

Define Dresslers Syndrome

Auto antibodies avs the myocyte sarcolemma
Present 2-6 wks with recurrent pericarditis
Fever
Anaemia
High ESR

Rx: NSAIDS or steroids

17

Classification of angina

Stable: induced by effort
Unstable: occurs at rest, evolving MI
Decubitus: occurs lying down
Syndrome X: angina + ST elevation on exercise test no evidence of atheroscelorsis, small vessel disease

18

Ix for chest pain

Bloods
ECG ( usually normal, may show
- ST depression
- Flat inverted t waves
- Past MI
Stress ECHO
Perfusion scan
Angiography ( Gold standard)

19

Treatment for angina

1. Lifestyle
- Stop smoking
- Wt loss and exercise
- Healthy diet

2. Medical ( 2nd prevention)
- Aspirin 75mg
- ACEi
- Statins ( simavastatin 40mg)
- Control HTN

Anti anginals for episodes
- GTN spray + either
a) B blocker (atenolol 50-100mg)
b) CCb verapamil 80mg

- ISMN 20-40mg BD

3. Interventional
- PCI
if high risk of re stenosis give clopidogrel or use drug electing stent

4. Surgical CABG
- If L main stem disease or triple vessel disease

20

Pathophysiology of Heart failure

1. Reduced cardiac output
- Compensation
- Frank starling
- RAS and ANP/BNP release

2. Progressive decline in CO
- impaired contractility and functional valve regurgitation
- hypertrophy and myocardial ischaemia
- RAS activation with NA+ and fluid retention, increase venous pressure, oedema

21

Types of heart failure

Heart failure with reduced ejection fraction (HFrEF): defined as heart failure with an ejection fraction less than 40%.

Heart failure with preserved ejection fraction (HFpEF). Usually relaxation rather than contraction of the left ventricle is affected, and ejection fraction is normal or at least above 40%.

Causes:
1. IHD
2. Cardiomyopathy
3. HTN
4. Mitral and aortic valve disease

Clinical features:
- Fatigue
- Dyspnoea
- Nocturnal cough with pink frothy sputum
- Weight loss

- Displaced apex beat
- Gallop rhythm ( 3rd heart sounds)
- Bibasal creps


Causes:
1. LVF
2. Cor pulmonale
3. Tricuspid and pulmonary valve disease

Clinical features:
- Anorexia
- Nausea

- Increase JVP
- Hepatomegaly
- Pitting oedema
- Ascites

22

Classification of Congestive cardiac failure

New York Classification of Heart Failure
I: Heart disease present but no undue dyspnoea from ordinary activities
II: Comfortable at rest; dyspnoea on ordinary activities
III: Less than ordinary activities cause dyspnoea that is limiting
IV: Dyspnoea present at rest; all activities cause discomfort

23

Discuss the relation between CCF and BNP

BNP: B-type natriuretic peptide
Secreted from the ventricles in response to
- Increase in pressure
- Tachycardia
- Glucocorticoids
- Thyroid hormones

Action
- Increase GFR and decrease renal NA reabsorption
- Reduced preload by reducing the smooth muscles

Marker of heart failure
BNP > 100 bad sign
Correlates with LV dysfunction

24

Signs of heat failure on CXR

1. Alveolar shadowing
2. Curly B wings
3. Cardiomegaly
4. Diversion to the upper lobes
5. Effusions

25

Medical management of chronic heart failure

1st line
- ACEi + BB+ loop diuretic
- with the BB start low go slow

2nd line
- Add in spiro
- Beaware of the increasing K=
- Vasodilators such as ISDN

3rd line
- Digoxin

Considerations
1. BP may be low
2. Renal function
3. Plasma K
4. Daily weight

26

Invasive therapies used in heart failure

1. Cardiac resynchronisation
2. Intra aortic ballon counterpulsation
3. LVAD

27

Risk factors for developing infective endocarditis

Prosthetic valves
VSD, PDS, CoA
Rheumatic fever
Dental caries
Post op wounds
IVDU ( tricuspid valve)
Immunocompromised

28

Causes of infective endocarditis

1. Strep viridans
2. Strep bovis
3. Staph aureus
4. Strep epideremis
5. Pseudomonas

-ve Cultures
1. Haemophilus
2. Actinobacillus

29

Features of infective endocarditis

1. Sepsis
2. Cardiac ( new changing murmur)
3. Embolic phenomena
4. Immune complex deposition

NOTE
- Roth spots: boat shaped retinal haemorrhages with pale centre
- Janeway lesions: painless palmer macules
-Oslers nodes: painful purple papules on the finger pulps

30

Outline the criteria used in the diagnosis of infective endocarditis

DUKES CRITERIA
Major
- +ve blood culture , 2 separate cultures
- Endocardium involved, +ve echo or new valvular regurgitation

Minor
- Predispostion
- Fever > 38
- Emboli
- Immune phenomenon
- +ve blood culture not meeting major criteria