OSCE3031 FINAL
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198 Terms
What is Heart Failure with Reduced EF (HFrEF)?
HFrEF is characterized by reduced left ventricular (LV) contraction and abnormal contractility/remodeling, with a Left Ventricular Ejection Fraction (LVEF) of
What is Heart Failure with Mildly Reduced EF (HFmrEF)?
HFmrEF is an intermediate stage of heart failure, characterized by an LVEF between 41-49%.
What is Heart Failure with Preserved EF (HFpEF)?
HFpEF is characterized by a normal LVEF (≥50%) but with reduced LV filling due to stiff, thickened walls. It was formerly known as Diastolic HF.
What is Heart Failure with Improved EF (HFimpEF)?
HFimpEF indicates a positive response to treatment, defined by a baseline LVEF ≤40%, a ≥10 point increase from baseline, and a second LVEF >40%.
What is Right Heart Failure (RHF)?
RHF is the inability of the right ventricle (RV) to adequately pump blood into the pulmonary circulation. It is often secondary to Left HF or caused by Pulmonary Hypertension.
What are the four pillars of treatment for HFrEF?
The four pillars for HFrEF are:
1. Renin-angiotensin Inhibitors
2. Heart Failure Specific Beta Blockers
3. Mineralocorticoid receptor antagonists
4. Sodium-glucose co-transporter 2 inhibitors
All four pillars are started at diagnosis.
How is Renin-angiotensin inhibitor therapy managed in HFrEF?
We typically use Sacubitril+valsartan 24+26mg twice daily, increasing the dose every 2-4 weeks. If hypotension is present, an ACE inhibitor can be used instead.
What is the mechanism of action of Sacubitril+valsartan?
Sacubitril inhibits Neprilysin, which increases vasodilation, while valsartan blocks Angiotensin II.
What are the side effects of Sacubitril+valsartan?
Side effects include hypotension, hyperkalemia, cough, dizziness, renal impairment, and angioedema.
What monitoring is required for patients on Sacubitril+valsartan?
Monitor blood pressure, potassium, and kidney function. Also, ask about dizziness and potassium supplement use.
What are some common beta-blocker options for HFrEF?
Options include Bisoprolol, Carvedilol, Metoprolol succinate, and Nebivolol.
What are some common mineralocorticoid receptor antagonist options for HFrEF?
Options include Spironolactone or Eplerenone 25mg daily, increasing to 50mg.
What are the side effects of mineralocorticoid receptor antagonists?
Side effects include hyperkalaemia, hyponatraemia, hypochloraemia (especially with thiazide diuretics), weakness, headache, nausea, and vomiting.
What monitoring is required for patients on mineralocorticoid receptor antagonists?
Monitor serum electrolytes, blood pressure, and renal function.
What are some common Sodium-glucose co-transporter 2 inhibitors (SGLT2 inhibitors) used in HFrEF?
Options include Dapagliflozin 10mg or Empagliflozin 10mg daily.
What is the mechanism of action of SGLT2 inhibitors?
SGLT2 inhibitors inhibit SGLT2, which reduces glucose reabsorption in the kidneys, leading to increased glucose excretion in urine. They also inhibit sodium absorption, leading to increased sodium and water excretion.
What are the side effects of SGLT2 inhibitors?
Side effects include allergic skin reactions, genital infections (like thrush), UTIs, dyslipidaemia, and constipation.
What counseling is important for patients on SGLT2 inhibitors?
Counsel patients that their urine will test positive for glucose, to drink enough water to control thirst, and to watch out for pain or discomfort due to an increased chance of genital infection.
What monitoring is required for patients on SGLT2 inhibitors?
Monitor renal function.
What are the four key parameters to monitor in HFrEF patients?
The four key parameters to monitor are hypotension, kidney function, hyperkalaemia, iron deficiency, and BNP levels.
How is Heart Failure with preserved Ejection Fraction (HFpEF) managed?
Management focuses on treating the underlying causes and comorbidities.
What is the role of SGLT2 inhibitors in HFpEF?
SGLT2 inhibitors are key agents that significantly reduce CV death and hospitalization risk (e.g., Dapagliflozin or Empagliflozin 10mg daily).
How are comorbidities managed in HFpEF?
Comorbidities such as hypertension, atrial fibrillation, CAD, and diabetes are treated.
How is symptom relief managed in HFpEF?
What is the role of BB/ARNI/ACEI/ARB & MRA in HFpEF?
These medications are used for comorbidity treatment, but not routinely for all HFpEF patients.
What are the key aspects of non-pharmacological management for Heart Failure?
Key aspects include:
1. Volume Management: Daily weighing, fluid restriction (≤1.5L/day if congested), and sodium restriction (≤2g/day).
2. MDT and Education: Vital for medication adherence, self-management (weight monitoring), and regular moderate physical activity.
3. Red Flags for Deterioration: Severe SOB (above baseline), worsening orthopnoea, severe oedema/fatigue, or treatment gaps.
4. Palliative Care: Integration is crucial due to HF's progressive, life-limiting nature, aiming for QoL and symptom management.
What is the definition of Sinus Rhythm (Normal)?
Sinus Rhythm means the heart is beating normally in both Pace (number of beats) and Timing (evenly spaced beats).
What is an Arrhythmia (Dysrhythmia)?
An arrhythmia is an abnormal heart rhythm.
What is a Tachyarrhythmia?
A tachyarrhythmia is an abnormal heart rhythm with a ventricular rate of ≥100 bpm.
What is a Bradyarrhythmia?
A bradyarrhythmia is an abnormal heart rhythm with a ventricular rate of ≤60 bpm.
What is Atrial Fibrillation (AF)?
AF is characterized by both abnormal automatic firing (ectopic beats from the pulmonary veins) and interacting re-entry circuits within the atria.
What are the common symptoms of Atrial Fibrillation due to reduced blood delivery to vital tissues?
Symptoms include palpitations, breathlessness/fatigue, angina, dizziness (presyncope), syncope, and an irregular + fast ventricular rate.
What are essential lifestyle modifications for Atrial Fibrillation?
Essential lifestyle modifications include weight management, alcohol reduction or cessation, and treatment of obstructive sleep apnoea.
Why are anticoagulants used in atrial fibrillation?
Anticoagulants are used in atrial fibrillation because it poses a significant risk of stroke.
How is the CHA2DS2VASc score used in AF management?
A CHA2DS2VASc score of 0 (males) and 1 (females) means anticoagulant therapy is not recommended. A score of 1 (males) and 2 (females) means the benefit of anticoagulants is less strong. A score of 2 or more (males) or 3 or more (females) means the evidence for anticoagulation is strong.
What is the first-line treatment for prevention of thromboembolic events (Stroke) in AF?
The first-line treatment is a Direct-acting oral anticoagulant (DOAC).
What are some common DOACs and their dosages?
Common DOACs include:
• Apixaban 5mg orally BD (2.5mg BD for renal impairment). If CrCl is
When should Warfarin be used instead of DOACs for stroke prevention in AF?
Warfarin should be used if the person has rheumatic mitral stenosis, a mechanical heart valve, or severe renal impairment.
What is the mechanism of action of Warfarin?
Warfarin is a Vitamin K antagonist, which stops clotting factors II, VII, IX, and X.
What are the side effects of Warfarin?
Side effects include bleeding, rash, fever, nausea, and vomiting.
What is the target INR range for Warfarin therapy?
The target INR is 2-3.
What are important counseling points for patients on Warfarin?
Important counseling points include:
• Take the same brand and stay with either coumadin or Marevan.
• Take the tablet at the same time each day and record it.
• Get regular blood tests (INR) to monitor blood clotting.
• Maintain a consistent intake of Vitamin K-rich foods.
• Avoid alcohol consumption and large volumes of cranberry juice.
• Inform the doctor about new supplements or herbal products.
• Report unexpected bruising, bleeding, or dark tarry stool immediately.
• Seek medical attention for cuts that bleed for >10 minutes.
• Wear a warning bracelet and inform all healthcare providers about Warfarin use.
What is the acute rhythm control strategy in AF for patients with LVEF >40% and no coronary artery disease?
Use Flecainide 2mg/kg IV infusion over 10 minutes.
What is the acute rhythm control strategy in AF for patients with LVEF
Use Amiodarone 300mg IV over 30-60 minutes, followed by 900mg IV infusion over 24 hours.
What is the long-term rhythm control strategy in AF for patients with coronary artery disease and normal LVEF?
Use Sotalol 40mg BD, increasing to 160mg BD.
What are the contraindications for Sotalol?
Sotalol is contraindicated in severe kidney impairment, prolonged QT interval, and asthma.
What are the side effects of Sotalol?
Side effects include palpitations, hypotension, bradycardia, drowsiness, and dizziness.
What is the long-term rhythm control strategy in AF for patients with LVEF
Use Flecainide 50mg BD, increasing up to 150mg BD. Do not increase the dose more than once every 4 days.
What are the contraindications for Flecainide?
Flecainide is contraindicated in a history of MI.
What are the side effects of Flecainide?
Side effects include nausea, vomiting, diarrhoea, constipation, dizziness.
What is the consideration when using Flecainide with a beta-blocker or diltiazem/verapamil?
Using it with a beta-blocker or diltiazem/verapamil helps as they block AV nodal.
What is the long-term rhythm control strategy in AF when both Sotalol and Flecainide are contraindicated?
Use Amiodarone 200mg TDS for 1 week, then BD for 1 week, then once daily.
What is the mechanism of action of Amiodarone?
Amiodarone slows atrioventricular and bypass conduction, prolonging the refractory period.
What are the contraindications for Amiodarone?
Amiodarone is contraindicated in second and third-degree heart block and can cause hyperthyroidism. Avoid use during pregnancy and 3 months before.
What are the side effects of Amiodarone?
Side effects include nausea, vomiting, constipation, anorexia, metallic taste, photosensitivity, and dizziness.
What monitoring is important for patients on Amiodarone?
Important monitoring includes regular blood tests, ECGs, and chest X-rays. It also has iodine, which can interfere with thyroid function tests.
What is the first-line treatment for Rate Control in AF?
The first line for rate control is Beta Blockers.
What are some common beta-blocker options for Rate Control in AF?
Options include Atenolol 25mg increasing to 100mg or Metoprolol tartrate 25mg BD. For LVEF <40%, use a heart failure-specific beta-blocker like carvedilol, bisoprolol, nebivolol, or metoprolol succinate.
What is the second-line treatment for Rate Control in AF (if beta-blockers are contraindicated)?
The second line is Nondihydropyridine CCBs.
What are some common Nondihydropyridine CCBs for Rate Control in AF?
Options include Diltiazem immediate release 60mg 2-3 times daily or Verapamil immediate release 40mg BD. Once the appropriate dose is found, switch to modified release.
What is an add-on option for Rate Control in AF?
What is the typical dosage for Digoxin in AF rate control?
How does Digoxin slow the heart rate?
Digoxin slows the heart rate by an increase in vagal tone and reduction of sympathetic activity.
What are the side effects of Digoxin?
Side effects include anorexia, nausea, vomiting, drowsiness, dizziness, and headache.
What monitoring is important for patients on Digoxin?
Monitor renal and electrolyte functions and check for toxicity, as small dosages can lead to toxicity. Resting heart rate is a good tracker.
What is the third-line treatment for Rate Control in AF?
The third line is Amiodarone 200mg TDS for 4 weeks, then 200mg once daily.
What is the mechanism of action of DOACs (Direct-acting oral anticoagulants) for stroke prevention?
DOACs (e.g., Apixaban, Rivaroxaban) selectively inhibit factor Xa, thereby blocking thrombin production and the conversion of fibrinogen to fibrin, which prevents thrombus development.
What are the side effects of DOACs?
Side effects include bleeding and nausea.
What are important counseling points for patients on DOACs?
Take DOACs at the same time each day, inform all healthcare providers (doctor, dentist, podiatrist, physio) about its use, and wear a medical alert bracelet. If a cut bleeds for 10 minutes, call an ambulance.
What is a Stroke?
A stroke is caused by a blood clot blocking blood flow within the brain, also known as cerebral infarction due to atherothromboembolism.
What are the risk factors for Stroke?
Risk factors include age, male gender, genetics, previous vascular history (e.g., MI), smoking, hypertension, dyslipidaemia, and diabetes.
What are the common symptoms of a Stroke (analogue F.A.S.T)?
Symptoms include:
• F-Face dropped
• A-Can't lift both arms
• S-Slurred speech
• T-Time to call 000
What is the urgent treatment for a Stroke?
Urgent treatment involves reperfusion via IV thrombolysis.
What is the prevention strategy for Stroke?
What are the key aspects of secondary prevention for Stroke?
Secondary prevention includes:
• Aspirin or Clopidogrel indefinitely
• Aim to lower BP to 120-130
• Lipid lowering
• Exercise
• Psychological support
What is Venous Thromboembolism (VTE)?
VTE is a blood clot that starts in a vein.
What are the two main presentations of VTE?
The two main presentations of VTE are Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).
What tests should be performed before VTE treatment?
Before treatment, perform:
• Activated partial thromboplastin time (APTT)
• INR
• Full blood count
• Kidney function
• Liver function
What is the DOAC treatment for VTE?
What is the Parenteral Anticoagulant treatment for VTE?
When is Warfarin used for VTE treatment?
Warfarin is used if there are severe renal impairments or if parenteral therapy is needed concurrently.
What is Post-thrombotic Syndrome?
Post-thrombotic syndrome occurs in 25-50% of people 3 to 6 months after DVT, causing chronic pain, discomfort, and skin discolouration.
What are the red flags for Post-thrombotic Syndrome?
Red flags include unilateral leg swelling, shortness of breath, chest pain, and bleeding risk.
What are the signs of Deep Vein Thrombosis (DVT)?
Signs of DVT include unilateral leg pain and warmth to touch.
What are the signs of Pulmonary Embolism (PE)?
Signs of PE include dyspnoea, chest pain, and cough.
What is the typical management for VTE Prophylaxis?
VTE prophylaxis is started within 24 hours of admission and reviewed after 7 days.
What are the parenteral anticoagulants used for VTE prophylaxis?
What are the side effects of parenteral anticoagulants?
Side effects include bleeding, bruising/pain, hyperkalaemia, and low platelet count.
What monitoring is important for patients on parenteral anticoagulants?
Monitor renal function, liver function, platelet count (days 0,3,5), and APTT. Consider monitoring antifactory Xa.
What is the DOAC used for VTE prophylaxis?
What is the recommended VTE prophylaxis for total hip/knee replacement?
What is the recommended mechanical VTE prophylaxis?
What are the criteria for initiating drug treatment for hypertension in a normal individual?
Drug treatment for hypertension is initiated if BP is above 160/100 mmHg.
What are the criteria for initiating drug treatment for hypertension in individuals with high ASCVD risk?
Drug treatment for hypertension is initiated if BP is above 140/90 mmHg.
What are the criteria for initiating drug treatment for hypertension in individuals with established ASCVD?
Drug treatment for hypertension is initiated if BP is above 135/85 mmHg.
What is the first pharmacological step in treating hypertension?
What is the second pharmacological step if monotherapy is insufficient for hypertension?
Add a low-dose second first-line agent.
What is the second pharmacological step if dual therapy is insufficient for hypertension?
Increase the dose of one or both agents until maximum.
What is the third pharmacological step if blood pressure remains high after previous steps?
Add a third low-dose first-line agent or second-line agent.
What are some examples of ACE Inhibitors (ACEIs) used in hypertension?
Examples include Perindopril Arginine (5-10 mg daily), Erbumine (4-8 mg daily), and Ramipril (1.25, 2.5, 5, 10 mg daily).