Cardio

Question 1

General investigations for diagnosing heart failure?

Answer 1

• ECG
• CXR
• BNP -> if uncertain dx
• TT

Question 2

General managment for acute heart failure?

Answer 2

• O2 if SpO2 <94%
• NIV if acute HF with assocaited pulm congestion + hypoxic despite O2
• IV loop diuretics if consolidation
• IV vasodilators i.e. GTN (if SBP >90)
• IV inotropes if periph hypoperfusion
• Ix/Mx the precipitating factor/cause i.e. -> ACS, hypertensive crises, arrhythmia, mechanical catastrophe (ruptured interventricular septum, mitral papillary muscles or LV free wall, acute valvular regurgitation) & pulmonary embolism

Question 3

Diagnostic criteria for HFrEF?

Answer 3

• Symptoms +/- signs of heart failure, AND
• LVEF <50%

Question 4

Diagnostic criteria for HFpEF?

Answer 4

Question 5

Symptoms of heart failure?

Answer 5

• Typical
  
  • Dyspnoea (esp exertional)
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Fatigue
• Less typical
  
  • Nocturnal cough
  • Wheeze
  • Abdo bloating
  • Anorexia
  • Confusion (elderly)
  • Depression
  • Palpitations
  • Dizziness
  • Syncope
  • Bendopnoea

Question 6

Signs of heart failure?

Answer 6

• Specific
  
  • Elevated JVP
  • Hepatojuglar reflux
  • 3rd heart sound
  • Laterally displaced apex beat
• Less specific
  
  • Weight gain (>2kg/week)
  • Weight loss (advanced HF)
  • Perpheral oedema (ankles, sacrum)
  • Pleural effusions
  • Cardiac murmur
  • Tachycardia
  • Tachypnoea
  • Cheye-stokes respiration
  • Ascites

Question 7

Describe the 4 classes of NYHA functional classification of heart failure

Answer 7

• Class I
  
  • No limitation of ordinary physical activity
• Class II
  
  • Slight limitation of physical activity
  • No symptoms at rest
• Class III
  
  • Marked limitation of physical activity
  • No symptoms at rest
• Class IV
  
  • Symptoms on any physical activity or rest

Question 8

General work up of patient with suspected heart failure?

Answer 8

Question 9

General management of patient with HFrEF?

Answer 9

Question 10

When to use ACEI in chronic heart failure?

Answer 10

• ACEI
  
  • Recommended in ALL pts w/ HFrEF + mod-severe LVEF reduction (≤40%)
    
    • Decrease mortality + hospitalisation
  • Consider if HFrEF + mild LVEF reduction (41-49%), unless not tolerated

Question 11

When to use beta blockers in heart failure? Also which ones?

Answer 11

• Beta Blockers
  
  • ALL pts w/ HFrEF + mod-severe LVEF reduction (≤40%)
    
    • Once stabilised w/ no/minimal congestion on physical exam
    • Bisoprolol, carvedilol, metoprolol(CR, ER) or nebivolol
  • Consider if HFrEF + mild reduction LVEF (41-49%), also once stabilised

Question 12

When to use MRAs in CHF?

Answer 12

• Mineralocorticoid receptor antagonists (MRAs) i.e. spironolactone
  
  • ALL pts HFrEF + mod-severe LVEF (≤40%)
  • Consider in HFrEF + mild reduction (41-49%),

Question 13

When to use diuretics in CHF?

Answer 13

• Consider in pts with HF + clinical signs/symptoms of congestion ->improves symptoms but no change in mortality

Question 14

When to use ARBs in CHF?

Answer 14

• Angiotensin receptor blockers (ARBs)
  
  • Recommended if HFrEF + LVEF mod reduced ≤40% + cant have ACEI
  • Consider if HFrEF + mild LVEF reduction (41-40%) + not tolerating ACEI (or CI’d)

Question 15

Other less common drugs for CHF?

Answer 15

• Angiotensin receptor neprilysin inhibitor (ARNI) i.e. valsartan/sacubitril (entresto)
  
  • Replacement of ACEI or ARB in pts w/ HFrEF + LVEF ≤40% despite maximal ACEI/ARB therapy AND beta blocker, with or w/o MRA
    
    • Concomitant use of ACEI + ARNIs CONTRAINDICATED -> should not be administered within 36hrs -> increased risk of angioedema
• Ivabradine
  
  • Consider in pts w/ HFrEF + LVEF ≤35% AND SR 70 BPM or higher, despite max tolerated ACEI/ARB AND a beta blocker, with or w/o MRA
    
    • Decrease CV mortality and heart failure
    • Direct sinus node inhibitor
• Hydralazine plus nitrates
  
  • Consider if pts w/ HFrEF if ACEI/ARB not tolerated or CI’d
  • Also consider in black pts of African descent with HFrEF despite receiving max ACEI/ARB + beta blocker with or w/o MRA
• Digoxin
  
  • Consider in pts w/ HFrEF + sinus rhythm + mod-severe symptoms (NYHA Class 3-4) despite max ACEI/ARB
    
    • Weak evidence
  • Increases cardiac contractility

Question 16

Indications for implatable cardioverter difibrillators in CHF?

Answer 16

• Secondary prevention following resuscitated cardiac arrest, sustained VT with HD compromise, VT associated w/ syncope and LVEF <40%
• Primary prevention in pts w/ HFrEF at least 1 mth post MI associated w/ LVEF ≤30%
• Primary prevention in pts w/ HFrEF associated with IHD + LVEF ≤35%
• Consider as primary prevention in pts w/ HFrEF with dilated cardiomyopathy

Question 17

Antihypertensives to avoid in patients with HFrEF?

Answer 17

• Diltiazem
• verapamil
• moxonidine

Question 18

Causes of heart failure? (general categories then sub groups)

Answer 18

Question 19

Red flags for early referral of Heart Failure? (symptoms, signs, investigation results)

Answer 19

Question 20

Definition of grade 1 (mild) HTN?

Answer 20

SBP 140-159 AND/OR DBP 90-99

Question 21

Definition of Grade 2 (moderate) HTN?

Answer 21

SBP 160-179 AND/OR DBP 100-109

Question 22

Definition of grade 3 (severe) HTN?

Answer 22

SBP >180 AND/OR DBP >110

Question 23

Definition of isolated systolic HTN?

Answer 23

SBP >140 AND DBP <90

Question 24

What is the definition & treatment of Hypertensive Urgency?

Answer 24

• BP >180/110 that is not immediately life threatening BUT is associated with EITHER symptoms (i.e. headache, vision disturbance) OR moderate target organ damage
• Treatment with oral drugs and F/U within 24-72 hrs recommended

Question 25

What is the definition & treatment of Hypertesnive Emergency/crisis?

Answer 25

* BP \>220/140 and acute target organ damage/dysfunction present (heart failure, APO, AMI, aortic aneurysm, acute renal failure, major neurological changes, hypertensive encephalopathy, papilloedema, cerebral infarction, haemorrhagic stroke) * Need hospitalisation (ICU), close BP monitoring and parenteral drug therapy

Question 26

Symptoms of possible causes of secondary hypertension?

Answer 26

* Phaeochromocytoma: frequent headaches, sweating, palpitations * Sleep apnoea: obesity, snoring, daytime sleepiness * Complementary and/or recreational drug intake * Hypokalaemia: muscle weakness, hypotonia, muscle tetany, cramps, arrhythmias * Symptoms of thyroid disease

Question 27

Initial investigations for ALL patients with newly diagnosed hypertension?

Answer 27

* Urine dip for blood -\> if abnormal send for microscopy * Albuminuria & proteinuria status * Recommended for ALL pts, MANDATORY for those w/ diabetes * First void spot urine preferable, but random okay * If in the maroalbuminuria range -\> recommend 24 hr protein level * Proteinuria = \>500mg/day excretion rate * Blood tests * Fasting glucose * Fasting serum total chol, LDL, HDL, triglycerides * Serum urea, EUC w/ eGFR * Hb + HCt * 12 Lead ECG * Detect AF, LVH, prev evidence of IHD

Question 28

If you have a patient with newly diagnosed hypertension, other than the standard (bloods/ECG/urine dip) what are some specific Ix for patients with other co-morbidities?

Answer 28

* CVD * Echocardiography (TTE) -\> To dx LVH, or where left atrial dilatation & concomitant heart disease is suspected * Carotid US -\> of arteries ?asymptomatic atherosclerosis esp in older adults * CKD * Renal artery imaging * Renal artery duplex US, renal nuclear med +/- CT angiography * For Ix of renovascular causes of HTN (e.g. fibromuscular dysplasia in young females with HTN, older pts who may have atherosclerotic renal artery disease & pts with a renal and/or femoral bruit * Peripheral arterial disease * ABI (Ankle Brachial Index) -\> in ALL w RFs for PAD; inc hypertensive pts w/ DM, vascular bruit, older age and/or smokers * Index \<0.9 diagnostic for PAD * Other * Plasma aldosterone/renin ration * Primary aldosteronism occurs 5-10% of pts w/ HTN and is NOT excluded by normal serum K * Consider in pts w/ HTN, esp those with mod-severe OR treatment resistant HTN, and those with hypokalaemia * Referral to specialist for Ix recommended when primary aldosteronism suspected as interpretation is difficult in treated pts * Refer to clinical practice guideline: case detection, diagnosis and treatment of patients with primary aldosteronism (ref 42) * Metanephrine & normetanephrine excretion (with creatinine) and/or plasma catecholamine, metanephrine and normetanephrine concentration, 24 hr urinary catecholamine * Indicated when symptoms of episodic catecholamine excess and/or episodic HTN (suggestive of phaeochromocytoma)

Question 29

General lifestyle advice and recommendations for patients with hypertension?

Answer 29

Question 30

First line anti-hypertensive classes? (bonus marks for an example and dose range)

Answer 30

1. ACEI -\> i.e. perindopril arginine 5-10mg daily 2. ARB -\> candesartan 8-32mg daily 3. CCB -\> amlodipine 2.5-10mg daily 4. Thiazides -\> Hydrochlorothiazide 12-25mg daily

Question 31

Antihypertensive combos to avoid/use with caution?

Answer 31

Question 32

Effective antihypertensive drug combos?

Answer 32

Question 33

How to decide when to initiate treatment of antihypertensives? \*assuming accurate readings and persistently elevated BP

Answer 33

1. **Absolute CVD Risk** * High risk \>15% -\> start immediately * Medium risk 10-15% * _Immediately_ if BP \>160/100, FHx of premature CAD OR ATSI * Otherwise review BP next visit * Low risk \<10% * Start immediately if SBP \>160/100 * Otherwise review in 2/12 2. **Not eligible for CVD Risk** (i.e. \<45y.o. etc) * Assess for * target organ damage * Relevant co-morbidities * Any know vascular disease * Decision to treat depends on this + BP readings

Question 34

What is eligibility criteria for absolute CVD risk assessment?

Answer 34

* Eligible * Adults \>45 (\>35 ATSI) * WITHOUT known pmhx of CVD or other co-morbidities * Ineligible * Adults \<45 (ATSI \< 35) * Existing CVD * Prior MI, stroke/TIA, PAD, heart failure, AF, Aortic disease * End-stage kidney disease on dialysis

Question 35

Physical exam findings of secondary HTN or end organ damage?

Answer 35

Question 36

Contraindications to ACEI/ARBs?

Answer 36

* Compelling * Pregnancy * Angioedema * Hyperkalaemia * Bilateral renal artery stenosis * Possible * Women with child bearing potential

Question 37

Contraindications to CCBs (dihydropyridines)?

Answer 37

* No compelling * Possible * Heart Failure

Question 38

Contraindication to thiazide diuretics?

Answer 38

* Compelling * Gout * Age (risk of DM onset) * Possible * Glucose intolerance * Metabolic syndrome * Hypercalcaemia * Hypokalaem*a*

Question 39

Contraindication to beta blockers?

Answer 39

* Compelling * Asthma * Bradycardia * AV block (2 or 3) * Uncontrolled heart failure * Possible * T1DM or T2DM * Metabolic syndrome * Glucose intolerance * Athletes or active patients * COPD * Depression * Also have an increased risk of developing DM

Question 40

Review frequency and drug treatment strategy to reach BP target in a newly diagnosed hypertensive patient?

Answer 40

1. Start drug treatment with: * low-mod dose of 1st line drug * If doesn't tolerate change to other 1st line 2. If target not reached after 3 months * Add 2nd drug from different class at low-mod dose BEFORE increasing dose of 1st drug 3. If target not reached after further 3 months: * increase dose of one drug incrementally to max dose BEFORE increasing dose of other drug 4. Target not reached after further 3 months * 3rd drug class at low-moderate dose * Re-assess for non-adherence, secondary HTN and hypertensive effectos of other drugs * Consider OSA, EtOH, recreational drugs, high salt intake 5. If remains elevated -\> referral to cardiologist Note: Review every 4-6 weeks NOT 3 monthly (this is when to consider dose increases) -\> more frequently if sig elevated BPs. Max drug effect likely to be seen in 4-6 weeks Life style advice for ALL patients