cardio treatments

Question 1

aneurysm

Answer 1

Monitor unruptured aneurysms, consider elective surgical repair (endovascular or open) when >5.5cm (AAA) or rate of expansion >1cm/year. Followed up by regualr USS surveillance

ruptured - emergency surgical aneurysm repair - darcon or gore-tex graft, endovascular stent

Question 2

angina

Answer 2

Lifestyle changes: smoking cessation, exercise, dietary advice, GTN spray for symptom relief

Stable:
1. β-blocker (atenolol/bisoprolol)
2. +/ rate limiting calcium channel blocker (diltiazem/verapamil)
3. Trial other drugs: isosorbide mononitrate/GTN patch, nicorandil, ivabradine
4. Ranolazine
5. Revascularisation can be considered if medical therapy is inadequate
Percutaneous coronary intervention with stent
Coronary artery bypass graft

Variant: calcium channel blocker and long acting nitrate

Question 3

arterial dissection

Answer 3

initial management is BP control ▪ If the ascending aorta is involved – control the BP with IV labetolol then surgical management should be considered
▪ A descending aorta issue can be treated with medical management
● IV labetolol and bed rest

Question 4

aortic regurgitation

Answer 4

treat underlying cause and if not then valve replacement
treat hypertension e.g. ACEi
if symptomatic with LV dilatation and decreasing function – valve replacement

Question 5

asystole

Answer 5

NOT SHOCKABLE
iv adrenaline
iv should be given every 3-5 minutes

Question 6

atrial flutter

Answer 6

Rhythm control: ablation/DCCV
Rate control: β-blocker/ CCB,
2nd line =digoxin
3rd line = amiodarone, anticoagulation drugs

Question 7

atrial fibrillation

Answer 7

Rhythm control: ablation/DCCV

If cardioversion isn’t possible within the 24-48 hours of symptom onset, then you need to put the patient on anticoagulation (warfarin) for 6-8w and then bring back to cardiovert.

long term:
Rate control: β-blocker/ CCB,
2nd line =digoxin
3rd line = amiodarone, anticoagulation drugs

Paroxysmal: <48 hours, can spontaneously reverse, often recurrent
Persistent: >48 hours, needs DCCV
Permanent: no pharmacological or non-pharmacological methods

Question 8

cardiac tamponade

Answer 8

treat the underlying cause
Urgent drainage of pericardial effusion (pericardiocentesis)
send fluid for culture, Zn stain, TB culture and cytology

Question 9

dilated cardiomyopathy

Answer 9

Diuretics, β-blockers, ACEI, anticoagulation, ICD, LVADs, transplantation

Question 10

coarctation of the aorta

Answer 10

surgery or balloon dilatation and stenting

Question 11

heart failure

Answer 11

lifestyle
– exercise, fluid restriction, lower salt intake, stop smoking, stop alcohol

symptom relief
- furosemide (loop diuretic) / digoxin

treatment
- ACEI/ARB + β-blocker (carvedilol)
- spironolactone (mineralocorticoid antagonist)
- hydralazine + isosorbide dinitrate can be used if intolerant of ACEI/ARB or in African Caribbean patients.
- ivabradine can also be used.

annual flu vaccine and one-off pneumococcal vaccine

further
- cpap

Question 12

hypertension if < 55 and not afrocarribean or have type 2 diabetes

Answer 12

1st line - ACEi or ARB
2nd line - +CCB or thiazide diuretic
3rd line - +CCB or thiazide diuretic
4th line - blood potassium <= 4.5 mol/l then low dose spironolactone
if blood potassium > = 4.5mol/l then alpha blocker or beta blocker

Question 13

hypertension if > 55 or afrocarribean

Answer 13

1st line - CCB
2nd line - +ACEi or ARB or thiazide diuretic
3rd line - +ACEi or ARB or thiazide diuretic
4th line - blood potassium <= 4.5 mol/l then low dose spironolactone
if blood potassium > = 4.5mol/l then alpha blocker or beta blocker

Question 14

hypertrophic cardiomyopathy

Answer 14

treatment of symptoms and prevent sudden cardiac death

β-blockers/verapamil for symptoms, amiodarone for arrhythmias, anticoagulation, ICD

Question 15

infective endocarditis

Answer 15

staph aureus - flucloxacillin
IVDU - flucloxacillin
viridans - Benzyl penicillin + gentamicin
enterococcus - amoxicillin + gentamicin
staph epidermis - vancomycin + gentamicin
native valves - amoxicillin + gentamicin
prosthetic valves - vancomycin + gentamicin + rifampicin
native valves sepsis - IV flucloxacillin

Question 16

mitral regurgitation

Answer 16

Control any underlying/resultant conditions eg. AF
Surgery: repair if possible (eg. rupture/congenital problem) or replacement (eg. degenerative cause)
Diuretics improve symptoms particularly in functional mitral regurgitation

Question 17

myocarditis

Answer 17

Supportive, treat underlying cause

athletic activities should be avoided for 6 months

Question 18

pericarditis

Answer 18

NSAIDs or aspirin with gastric protection for 1-2 weeks, add colchicine for 3 months to reduce recurrence risk, steroids if due to autoimmune

if constrictive and chronic then complete removal of the pericardium

Question 19

shock

Answer 19

ABCDE
High flow oxygen
Treat underlying cause if possible
Volume replacement (except for cardiogenic shock)
Inotropes for cardiogenic shock
Vasopressors for septic shock
Adrenaline for anaphylactic shock

Question 20

stroke

Answer 20

Acute Management:
Thrombolysis (up to 4.5 hours from onset of symptoms)
Thrombectomy (up to 6.5 hours from onset of symptoms)

Prevention of another stroke:
If atheroembolic – aspirin, statins, diabetes management, hypertension management, lifestyle advice
If AF – anticoagulation drugs (warfarin, DOACs)

Question 21

MI

Answer 21

STEMI - PCI within 120 minutes or thrombolytic therapy if not
NSTEMI - MONAA
calculate GRACE score

Question 22

supraventricular tachycardia

Answer 22

acute
–valsalva/carotid massage
- IV adenosine or IV verapamil, if compromised (systolic BP<90mmHg) use DCCV

chronic – avoid stimulants, RFA, β-blockers

Question 23

varicose veins

Answer 23

Risk Factor Modification, Graduated Compression Stockings (not those with low ABPI/arterial disease), Endovascular treatment, Surgery

Question 24

wolf parkinson white syndrome

Answer 24

RFCA