Cardiac conditions: Angina, ACS, Heart failure, Hypertension

Question 1

Difference in pathology between normal angina and Prinzmetal angina

Answer 1

Normal angina = gradual permanent narrowing of coronary arteries by fatty plaque

Prinzmetal angina = coronary artery spasms

Question 2

What signs/ symptoms may make you suspect Prinzmetal angina over normal angina?

Answer 2

Prinzmetal tends to occur at night (vs normal)

Prinzmetal is not brought on by exercise or relieved by rest

Question 3

What are pathological Q waves?
ie what do they look like?
What do they signify?

Answer 3

A dip in the Q wave (>0.02s) before the QRS complex. (the significant dip changes according to which lead)

Signify previous MI (absence of electrical activity)

Question 4

Non-modifiable risk factors for Angina

Answer 4

• Diabetes
• Hypertension
• Anaemia
• Hypertrophic cardiomyopathy
• FH/ PMH of cardiovascular disease

Question 5

Treatment of acute angina

Answer 5

GTN spray
(repeat after 5min. If pain still present after 2nd dose, call 999)

Question 6

Long-term treatment of angina

Answer 6

1. B blocker OR CCB
2. B blocker + CCB
3. B blocker + CCB + 3rd drug

3rd drug =
Long acting nitrate OR 
Ivabrandine OR
Nicorandil OR
Ranolazine

Question 7

Medications for secondary prevention of CVD in angina

Answer 7

• Aspirin 75mg
• ACEi (if + diabetes)
  +/- Statins, BP meds

Question 8

Investigations to do for all ACS

Answer 8

FBC (anaemia can cause ACS)
BM (mortality indicator)

ECHO (check LV dysfunction)

Question 9

Possible ECG features in NSTEMI

Answer 9

ST depression
T wave inversion
Pathological Q waves

Question 10

Possible ECG features in STEMI

Answer 10

ST elevation
LBBB (new)
Pathological Q waves

Question 11

What is the optimal timeframe for PCI (aka stent) to be done in STEMI

Answer 11

90min

Question 12

Who should get PCI in STEMI

Answer 12

1. Presents within 12h + PCI can be delivered within 2h of time that fibrinolysis could have been given
2. Presents after 12h but evidence of continuing MI
3. Symptoms of cardiogenic shock (regardless of time of presentation)

Question 13

Follow up for pts who have been given thrombolysis/ fibrinolysis

• how to check if it worked
• what to do if it failed

Answer 13

Check if worked:
do ECG 60-90min later

If failed:
Send for PCI
Don’t repeat fibronolytic therapy

Question 14

Why should a CXR be done in all NSTEMI/STEMI patients

Answer 14

Check for pulmonary oedema

and exclude differentials

Question 15

Long term medications all patients should be on after NSTEMI/STEMI

Answer 15

1. Antiplatelets (dual for first 12 months then single therafter)
2. ACi
3. B blocker
4. Statin

+if LV ejection fraction 0.4 or less,
5. Eplenorone (aldosterone antagonist)

Question 16

Antiplatelet options after an MI

Answer 16

Dual antiplatelets for 12 months
Then single antiplatelet if needed thereafter

DUAL

1. Aspirin + clopidogrel OR
2. Aspirin + ticagrelor

SINGLE

1. Aspirin (most patients)
2. Clopidogrel (if vascular disease)

Question 17

ABCDE heart failure features on CXR

Answer 17

A: Alveolar oedema
B: Kerley B lines
C: Cardiomegaly
D: Dilated upper lobe vessels
E: Pleural effusion

Question 18

Difference in pathophysiology of normal vs reduced ejection fraction heart failure

Answer 18

Reduced ejection fraction:
Failure of heart to constrict properly, reduced cardiac output

Normal ejection fraction:
Failure of heart to relax properly, increased filling pressure

Question 19

Causes of reduced ejection fraction heart failure

Answer 19

Ischaemic heart disease
MI
Cardiomyopathy

Question 20

Causes of normal ejection fraction heart failure

Answer 20

Hypertension
Constrictive pericarditis
Cardiac tamponade
Restrictive cardiomyopathy

Question 21

Describe levels 1-4 of the NYHA score for heart failure

Answer 21

1. No limitation in physical activity
2. Mild SOB during ordinary activity
3. Breathless after walking short distances. Comfortable only at rest
4. Breathless even at rest

Question 22

Management of acute heart failure

Answer 22

Furosemide 80mg

Question 23

Management of reduced ejection fraction heart failure

Answer 23

1. ACEi + B blocker
2. • Spironolactone
3. • Ivabradine/ Digoxin/ Sacubitril valsartan

Question 24

What vaccines should be given to heart failure patients

Answer 24

1. Flu vaccine (annually)

2. Pneumococcal vaccine

Question 25

How to calculate mean arterial pressure (MAP)

Answer 25

Diastolic + 1/3 the difference between each reading

Eg with BP BP 105/60
MAP
= 60 + 1/3(45)
=75

Question 26

What is Dressler’s syndrome

Answer 26

Pericarditis

Immune response after damage to heart tissue eg post trauma, post surgery, after heart attack

Question 27

Drugs to manage Dressler’s syndrome

Answer 27

Aspirin
NSAIDs
Colchicine (anti inflammatory)

Question 28

Management (with doses) of acute pulmonary oedema

Answer 28

LMNOP

Loop: furosemide 80mg IV (repeat if needed, max 1.5g a day)
Morphine 2.5mg
Nitrate: GTN 2.5mg
Oxygen
Position: sit patient upright

Question 29

Blood pressure target in pt without diabetes
>80yo
<80yo

Answer 29

> 80yo: 140/90

<80yo: 150/90

Question 30

Blood pressure target in diabetes

• without end organ damage
• with end organ damage

Answer 30

without end organ damage: 140/80

with end organ damage: 130/80