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CCC - Cardiovascular Conditions - Coggle Diagram
CCC - Cardiovascular Conditions
Ischaemic Heart Disease
Angina
Definition
Central chest tightness / heaviness brought on by exertion and relieved by rest +/- radiation
Pathogenesis
Transient myocardial ischaemia
Causes
Atheroma
Anaemia
Aortic stenosis
Tachyarrhythmias
HOCM - Hypertrophic cardiomyopathy
Thyrotoxicosis
Prevelance
2% of UK population
15% of those with unstable angina with have an MI in 1 month
Unstable Angina
Angina that occurs with increasing frequency / severity especially if on minimal exertion or at rest
Management
Lifestyle
Risk factor modification
Occupational advice
Pharmacological
Secondary Prevention
Conside while arranging investigations
Aspirin 75 mg
ACE inhibitor (in + diabetes)
Statin
Optimise HTN management
Symptom control
GTN spray: 1-2 puffs PRN
β Blockers 1️⃣line
Check adequately blocking (resting <60 bpm, post-exercise <90 bpm)
C/i Left ventricular failure, asthma
Ca2+ Channel Blockers
Alternative 1st line
Verapamil
Alternatives
Nitrates - Isosorbide mononitrate
Nicorandil, Ranozaline, Ivabradine
Cardiology Referral
Anyone fit enough for angiography +/- stenting
Elderly pts with Aortic Stenosis
PCI / CABG
Prognosis
0.5%-4% mortality per yr
Doubled if left ventricular dysfunction
Myocardial infarction
Presentation
Sustained severe, central chest pain
Not relieved by GTN
+/- Collapse, sweating, SOB, nausea, referred pain
Emergency Mangament
Call Ambulance
ABCs if collapse
Give O2
Aspirin 300mg - chew
IV access
IV analgesia: 2.5-5mg morphine repeated PRN
IV antiemetic: metaclopramise 10mg
GTN spray is SBP> 90mmHg and pulse <100 bpm
If bradycardia: Atropine 300mcg IV
ECG if stable - ST elevation, T wave inversion / new LBBB
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Post-MI Medication
Statin and Aspirin for all unless c/i
β blocker for all unless c/i
ACE inhibitor for all
Effects greater if heart failure at presentation
Clopidogrel (Plavix) 75mg x 1 yr
Dual antiplatelet therapy with the aspirin
GP Management
Ongoing follow up and monitoring of risk factors
Gradual increase in activity 2 weeks post MI
Sexual activity can resume from 6 wks
Depression 50% at one year
Sedentary work at 4-6 wks
Light manual work at 6-8 wks
Heavy manual work t 3 months
No driving for a month
No flying for 2 wks
ECS guidelines 💓
Atrial Fibrillation
Definition
Irregulary irregular cardiac rhythm - absent p waves
If symptomatic, may relate to degreee of tachycardia
Prevalence
Increases with age
10% >75
Causes
Idiopathic
Ischaemic heart disease
Hyperthyroidism
Valvular heart disease - mitral stenosis
Investigations
Bloods
FBC
U&E
TFTs
Imaging
ECG / holter
Echo if suspected HF or structural HD
Managament
Rate Control
Target 90/min depending on symptoms
Do not use amiodarone long term
Consider restoration of sinus rhythm - cardiology referral
Beta blockers : Bisoprolol
Rate limiting CCB - Diltiazem or Verapamil
Digoxin - if sedentary
Stroke Prevention
Everyone with Afib secondary to valvular heart disease
CHA2DS2-VASc Score
Consider bleeding risk - HAS-BLED or Orbit Tool
Apixiban
CHA2DS2-VASc
https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/001/650//content/cha2ds2-vasc_scoring_system.jpg
(DOAC) in all patients with a score ≥ 2
Heart Failure
Underdiagnosed in primary care
Differential : COPD
Main issue is to recognise it, do BNP and refer
Presentation
BEAT-HF
Breathless
Exhausted
Ankle swelling
Time to get a HF test
Investigations
Bloods
BNP
(NICE threshold 400)
FBC
Renal profile
Lipids
LFTs
TFTs
HbA1c
Iron studies
Imaging
CXR
ECHO
https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/001/669//content/diagnosis_of_heart_failure.jpg
Management
Referral depnding on symptoms and BNP
Specialist nurses
Fluid restriction
Weight management
Consider iron deficiency
BNP not used for monitoring
Drug Management
Diuretics for symptom control
ACE / ARB + Beta blocker
(Ramipril / candesartan + bisoprolol)
Titrate every 2 wks
Monitor BP
Monitor renal fx
Symptomatic at max dose - Add Spironolactone
Add SGLT2 inhibitors
4 drugs for HFrEF → ABMS
Cardiovascular risk
Q risk Score
Guides decision making
Aspirin 75mg OC
No longer indicated in Primary prevention unless ++ risk factors
All pts in Secondary prevention
Statins
Primary prevention
QRISK score of >10%
Treat CVD risk not cholesterol levels
Secondary Prevention
Atorvastation 10mg OD
Smoking Cessation
Hypertension
Definition
Level of BP above which there is a benedit from investigation and treatment
Prevalence
Underestimated
Over 40% underestimated
50% in 65-74 yr
Why Treat
Risk of CVS disease (MI, stroke, retinal, renal, PVD)
Evidence that controlling BP reduces risk
HOPE study (ramipril)
ALLHAT
Blood Pressure Lowering Treatment Trialists' Collaboration
Screening
Usually opportunistic
All adults - Check routinely every 5 years until 80 yrs
Annual check if "high normal" or hx of abnormal BP
Classification
Essential Hypertension 95%
95%
Unknown cause
Isolated systolic HTN
Elderly pts - 5% at 60yo
Secondary Hypertension 5%
Renal Disease
75% intrinsic renal disease
GN
Polycytic kidney disease
Chronic pyelonephritis
25% renovascular disease
Endocrine Disease
Cushing's
Conn's syndrome
Phaechromocytoma
Acromegaly
Hyperparathyroidism
Other
Coartation
Pregnancy
Steroids
COCP
Alcohol
Consider in younger pts under 45 / drug resistant HTN
https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/001/598//content/stages_of_htn.jpg
Diagnosis
ABPM - Ambulatory Blood Pressure Monitor
Home BP reading
Managment
Asses absoloute 10 yr risk of CVS disease - Qrisk 3
Lifestyle Interventions
For:
All pts with HTN/ high normal BP
Grade 1 HTN and no complications
DASH diet
Dietary Approaches to Stop Hypertension
Maintain normal BMI
Reduce salt intake to <100mmol/day
Limit daily alcohol consumption
<= 3 units - Men
<= 2 units - Women
Regular aerobic exercise > 30 mins most days
Eat five portions fresh fruit and vegetables per day
Smoking cessation
Reduced intake of total / saturated fats, replacing with monosaturates
Increase consumption of oily fish - 3 portions per week
Pharmacological
Under 55 White /
With Diabetes
ACE / ARB
ACE / ARB + CBB / Thiazide- like diuretic
ACE / ARB + CBB + Thiazide like diuretic
Confirm resistent hypertension
Check for postural hypotension
Discuss adherence
Seek expert advice / add:
Low dose spironolactone
Alpha blocker
Beta blocker
Seek expert advice if BP uncontrolled on 4 drugs
Without Diabetes
Over 55
Black
CCB
CBB + ACE/ARB or Thiazide - like diuretic
same as above
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Drug therapy should be initiated in the setting of
grade 1 hypertension with complications
, or
grade 2
hypertension
or higher
.
Complications include end-organ damage, diabetes, QRISK >10%??? over 10 years
Initial Assessment
Consider End Organ Damage
History / Symptoms
Asymptomatic
Headache / visual disturbance
Contributory factors
Obesity
Excess alcohol
Excess salt
Lack exercise
Environemental stress
Medications
Illicit drugs
Cardiovascular Risk Factors
Smoking
DM
Hypercholesterolaemia (esp total chol:HDL ration)
FHX
Examination
General
BMI
Waist circumference
CVS
BP
Pulse
Heart size
Heart sounds
Heart failure
Renal
Bruit
Palpable kidneys
Fundoscopy
Hypertensive retinopathy
Investigations
Bloods
U&E
Low K+
Consider secondary cause
Aldosteronism
LFTs
If likely to start statin
Excess alcohol
Fasting Blood glucose
Screen for DM
Fasting lipid profile
Bedsides
Dipstick Urine
Send for Microalbuminuria
30% of pts with HTN have microalbuminuria - strong marker for complications
ECG
Cardiomegaly
Previous Cardiac events
ABI - Ankle-branchial index
COnsider
Indicates advanced atherosclerosis - strong marker for complications
Imaging
CXR
In suspected cardiomegaly
NNT
Death: treat 125 pt
Stroke: treat 67
Heart Attack: treat 100
NNH
1/10 had ide effects / stopped the drug
Stroke / TIA
CVA - Cerebral Vacular Accident
Sudden onset global or focal neurological deterioration >24 hrs
Infarction secondary to embolism or haemorrhage
Risk Factors
Age
Previous TIA / CVA
HTN
Afib
Smoking
DM
Artificial heart valves
Obesity
Needs urgent admission for thrombolysis - NO ASPIRIN
FAST Test
Face
Arms
Speech
Time to call 999
Management
Exclude hypoglycaemia
Thrombolysis within 4 hrs once haemorrhage excluded
TIA
Similar hx <24 hrs
20% risk in subsequent month
Refer immediately
30-50% of people referred won't have TIA
Dual Antiplatelet Therapy (DAPT)
Clopidogrel + Aspirin with 24hr of high rsk TIA / acute minor stroke
Reduces subsequent stroke risk by 20/1000
Increase in severe bleeding in 2/1000 compared to aspirin alone
Chronic Disease Managment
