Family Medicine

Max interval for measurement inr if on antucoags, anti vit k

4 weeks

Chronic disease follow up what to check

• disease control

• Development of complications

• Med adherence

• Lifestyle compliance

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is an opportunity to ensure vax, cancer screening, cv risk factors and lifestyle counseling

wellness visit

primary prevention

controlling risk factors

secondary prevention

reducing morbidity and mortality after event occurred

tertiary prevention

reduce impact of the disability

DALYS 

disability adjusted life years 

chemoprophylaxis

use med as prevention

RISE mnemonic

Risk factor identification

Immunization

Screening tests to consider

Education

risk factors

condition that is associated with increased likelihood of illness

types of risk factors

causal, association, behaviour

How to evaluate cv risk

SCORES02 and SCORE-op

first thing to do if patient complains of palpitations

hemodynamic studies (bp)

why would we need a holter (1-7d) or event monitor (7-30d) instead of ecg

to capture paroxysmal arrhythmia

what is necessary before initiating specific therapy in arrhythmia

identify and treat reversible causes of it

treatments arrhythmias

cardioversion, drugs (av nodal suppression), antiarrhythmic drugs, radiofrequency ablation

when is cardiology referral warranted in patient with arrhythmia

complex cardiac disease or confusing ecg, bad tolerance, need rhythm control, require albation/surgery/pacemaker/defib/antiarrhythmics

blood test arrhythmia

cbc, metabolic panel, mg, lipid panel, tsh

whaty test for vasovagal syncope + palpitations

table tilt test

what test for ischemia or coronary artery disease

nuclear perfusion imaging or cardiac catheterization

tests for investigation pheochromocytoma in patient with arrhythmia

urine vanilylmandelic acid, serum metanephrine

all patients presenting with palpitations should be evaluated for

ischemic cause

what tests on ecg in a patient with palpitations should prompt further evaluation for a cardiac disease

st segment and t wave changes

patients who have palpitations due to atrioventricular nodal reentrant tachycardia may find that their symptoms are triggered by

standing up after bending over

________ should raise concern for arrythmias

syncope

meds used to treat __________ and ___________ may cause palpitations

ADHD, inhalers for asthma

in a patient presenting cardiac symptoms (syncope, arrhythmia), what situations necessitate urgent transfer to ER

• syncope + high degree AV block or bradycardia

• wide complex sustained rhythms including VT

• unkown dg, ecg → concern dangerous arrhythmia

• history heart disease + have near/syncope ± ventricular arrhythmia

• sustained SVT

• AF or atrial flutter

  • arrhythmias + chest pain/dyspnea/HF

where to refer patients with wide QRS complex tachycardia of uncertain cause OR structural heart disease and ventricular arrhythmia

clinical electrophysiologist

some antiarrhythmic drugs are best initiated where

hospital, monitor early proarrhythmia

follow up of patient after starting antiarrhythmic

electrolytes, assess kidney and liver, periodic ecg

follow up of patients taking amiodarone

hepatic, thyroid and pul function, INR

diagnostic work-up for atrial fib

ecg

cbc, liver fxn, kidney fxn

electrolytes

echo

in patients with hypertension, what patients should be referred for expert eval

uncontrolled despite taking 3+ antihypertensives

suspected secondary causes - <40y, exam findings, sudden change bp, organ damage, intolerance meds, sympto hta/hypotension

_____________ hta’s origin depends on the interaction bw a genetic background, enviro factors and the ageing process

primary/essential

eye manifestations hta

microvasc remodelling, htensive retinopathy

heart manifestations hta

LVH, LA and LV dilatation, AF, CAD, MI, HF

kidney manifestations HTA

glomerular arteriolar hta, glomerulosclerosis, albumunuria/proteinuria, low GFR

brain manifestations HTA

white matter lesions, microinfarcts, microbleeds, brain atrophy, cognitive impairment, vascular dementia, stroke, hemorrhage

artery manifestations hta

atherosclerosis, calcification, stiffness

microcirc - endothelial dysfxn, increased vasoreactivity, vascular remodelling, fibrosis, inflammation, increased peripheral vasc resistance

cv and non cv outcomes of high bp

Stroke and cognitive impairment • Renal consequences • Heart failure • Atrial fibrillation • Valvular disease • Diabetes

inter-arm diff: there is a systolic BP diff of __________ when bp is measured sequentielly in each arm

up to 10mmHg

orthostatic hypotension

20+mmHg systolic BP ± 10+mmHg diastolic BP when measured standing at 1-3m after standing followed by 5m period sitting

masked hta

bp below hta dg in office but above at home

how long is ambulatory BP measurement used for

24h period

recommendations to measure BP at home

2+ in morning before meds, evening

4-7d

what 5 organs should be checked for damage from HTA

• eye - fundoscopy

• heart - echo

• kidney

• brain

• vasculature

high ___________ is associated w/ increased CV risk and more commmonly elevated in <50y

DBP

recommendations to measure BP

conditions - no smoking, coffee, food, exercise 30m before, seated 5m, no talking

posture - arm at heart level, back supported by chair

measurements - 2 readings at home, 3 readings (use average of last 2) in office; 1m interval bw measurements

ABPM - hta values

24h - >130/80

daytime - >135/85

night - >120/70

sex specific risk modifiers hta

gestational dm/hta, preeclampsia, preterm delivery, still births, recurrent miscarriage

shared risk modifiers hta

hiv, family history, poor, autoimmune diseases, mental illness

what to do if patient w/ office BP >120-139/70-89 and has CVD, HMOD, DM or FH

calculate SCORE2 DM if only DM and <60y

if not, consider risk modifiers, lifestyle measures

what to do if patient w/ office BP >120-139/70-89

calculate SCORE2/-OP → 10yr predicted CVD risk

• if <5% lifestyle measures, reassess 1y

• 5-10% - consider risk modifiers

• >10% - lifestyle measures, meds if post 3m bp is >130/80

during screening for hta by office BP = BP <120/70 and >40yr

bp screening every 3+ years

during screening for hta by office BP = 120-139/79-89 + high CVD risk/SCORE >10%/SCORE 5-10% + risk modifiers - YES or NO what to do

YES - confirm bp w/ home or ambulatory measurements

NO - bp screening every yr

during screening for hta by office BP = 160-179/100-109

confirm bp with home or ambulatory bp measurements

during screening for hta by office BP = >180/110

evaluate for hypertensive emergency

routine tests hta

fasting glucose, lipids, sodium, k+, hb, ca+, TSH, creat, egfr, ecg

how to assess HMOD in HTA patient

echo, CAC, large artery stiffness, fundoscopy

how to assess CVD in patient who’s HTA

ankle brachial index, abdo ultrasound

how to diagnose HMOD of kidney

eGFR <60ml/min/1.73m2 OR

albuminuria >30mg/g

how to dg HMOD of heart

ECG + echo - LVH, diastolic dysfxn

cardiac biomarkers ntproBNP

how to dg HMOD in arteries

carotid/femoral US - plaque (wall thickening >1.5mm)

pulse wave velocity

cardiac ct

what screening test to dg cause of secondary hta - primary aldosteronism

aldo - renin ratio

what screening test to dg cause of secondary hta - renovasc hta

renal doppler us

what screening test to dg cause of secondary hta - pheo

24h metanephrine

what screening test to dg cause of secondary hta - cushings

24h urinary cortisol, dexamethasone suppression test

what screening test to dg cause of secondary hta - hyperpth

pth hormone, calcium and phosphate

what screening test to dg cause of secondary hta - aorta coarctation

echo, aortic ct angiogram

types of BP profiles

• dipper - nocturnal bp falls 10-20%

• non-dipper

• extreme dipper - >20%

  • reverse dipper - bp increases at night

fibromuscular dysplasia

hta, miraine, tinnitus in women

dg - renal a duplex US

fibromuscular dysplasia ttt

angioplasty w/o stenting

cv phenotype - 24h ABPM in pheo

non-dipping

_______ should be prescribed to controlled hta patients with previous CV events + in patients w/ reduced renal fxn or high CV risk

antiplatelets

in hta patients w/ dm, a HbA1c target of ________ is recommended

<7%

review interval hta on treatment

revierw 2-4w after - if controlled, review 3m then every 6m

if not controlled - patient repeats bp monitoring - if high bp → >1 drug

check bp → ________________ → meds → ____________ → reinforce non drug tt

look signs HMOD

treat modifiable risk factors

when to stop bp med in hta

never

morisky med adherence scale - score results

8 - good adherence

how to prevent hta and preeclampsia in pregnancy

exercise

factors indicating high risk pre-eclampsia

• hta, chronic or at past pregnancy

• ckd

• auto-immune disease

• dm

chronic coronary sd symptoms

angina - constricting, retrosternal → left arm, short duration, triggered by cold, emotional distress

exertional dyspnea - on effort

how to confirm dg CAD the best

• CCTA - low pre-test likelihood

• stress echo - mod pre-test likelihood

  • invasive coronary angio - very high pre-test likelihood

meds for obstructive CAD

dihydropyridine CCB, diltiazem, verapamil, b blockers, nitrates

meds for hta

dihydropyridine CCB

follow-up of hta: patients should have ongoing evauation every

4-12m

risk factors conduction abnormalities

old men, cv risk factors

what to investigate if arrythmia

cv symptoms, sleep apnea, new meds/supplements, thyroid disease, recent illnness, alcohol, pheochromocytoma + endocrine disorders

paraclinicals for arrhythmia

ecg, transthoracic US

timings of types of ecgs

12 lead → holter (24h - 7d), (7-30d) ext loop recorder → implantable loop recorder/insertable cardiac monitor (<3y) → permanent ECG

ttt arhhythmia

cardioversion, drugs w/ AV nodal suppression, antiarrhythmic drugs, radiofrequency ablation, pacemakers, defib, surgery

prior to initiating a specific therapy for arrhythmia, it’s essential to identify and treat

reversible causes of it

when is referral to cardiologist warranted if patient w/ arrhythmia

complex cardiac disease, can’t tolerate it, need rhythm control, require ablation therapy/surgery/pacemaker/defib/antiarrhythmics

uncertain dg, prognosis or management strategy

wide QRS complex tachy of uncertain cause

structural heart disease, ventricular arrhythmia

initial blood tests for patient w/ arrhythmia

cbc, metabolic panel, mg, lipid panel, tsh

in patient w/ arrhythmia, what exam to do if ischemia or coronary a disease

nuclear perfusion imaging or cardiac catheterization

in patient w/ arrhythmia, what exam to do if vasovagal syncope

table tilt test

in patient w/ arrhythmia, what exam to do if supsicion pheochromocytoma suspicion

urine vanillylmandelic acid, serum metanephrine

when should patient w/ arrhythmia undergo a transthoracic echo

palpitations + elevatd JVP, rales, lower extremity edema

in arhrythmia : patients w/ _____________ may find their symptoms are triggered by standing up after bending over

palpitations from av nodal reentrant tachycardia

what medications can cause palpitations

ADHD meds, rescue inhalers for asthma

nasal decongestants