Cardiology

Question 1

Which conditions and pathologies can occur as a result of atherosclerosis?

Answer 1

Angina, Myocardial infarction, TIA, Strokes, Peripheral vascular disease, chronic mesenteric ischaemia.

Question 2

Explain the difference between primary and secondary prevention of cardiovascular disease?

Answer 2

Primary Prevention - for patients who have not had CVD in the past.
Secondary Prevention is for patients who have developed angina, MI, TIA, Strokes or peripheral vascular diseases already.

Question 3

What primary prevention of cardiovascular disease entail?

Answer 3

You must complete a QRISK 3 Score. This score calculates your patient’s risk of developing a heart attack or stroke within 10 years. If there is more than a 10% risk of one of these pathologies, the patient must immediately be started on a statin (NICE guidelines suggest 20mg of atorvastatin)

Question 4

What should be prescribed to patients with CKD or TD1 for Primary prevention of cardiovascular disease?

Answer 4

Atorvastatin 20mg.

Question 5

What are the 4 As involved in secondary prevention of cardiovascular disease?

Answer 5

Aspirin (alongside second anti platelet e.g. clopidogrel)
Atorvastatin (80mg)
Atenolol (or another beta blocker most commonly bisoprolol)
Ace inhibitor (commonly ramipril)

Question 6

What are side effects of statins?

Answer 6

• Myopathy (check the creatine kinase of patients with muscles pain/weakness)
• Type 2 diabetes
• Haemorrhagic strokes (rare)

Question 7

What is angina?

Answer 7

Angina is the narrowing of coronary arteries resulting in reduced blood flow to the heart muscle. This may result in chest pain upon exertion (stable angina) or at rest.

Question 8

Explain the two types of angina? (Stable vs unstable)

Answer 8

Stable angina occurs upon exertion and can be relieved using glyceryl trinitrate (GTN) or by resting. Unstable angina can come randomly whilst at rest, it is therefore a type of acute coronary syndrome.

Question 9

What is the gold standard investigation for angina?

Answer 9

A CT coronary angiography. This is the gold standard diagnostic investigation which involves injecting contrast and taking CT images in time with the heartbeat to provide a view of the coronary arteries allowing any narrowed vessels to be seen.

Question 10

What medical management can be offered to patients with angina?

Answer 10

Immediate symptomatic relief = GTN spray as required, use the spray as symptoms start. Repeat after 5 minutes, if symptoms persist call ambulance.

Long term symptomatic relief = Betablocker (bisoprolol 5mg/day) and a calcium channel blocker (amlodipine 5mg/day)

Long acting nitrates may be considered by specialists; isosorbide mononitrate, ivabradine, nicorandil and ranolazine.

Don’t forget the 4 As of secondary prevention; Aspirin, Atorvastatin (80mg), Atnolol (beta blocker) and Ace-inhibitor…

Question 11

Following a CT Coronary angiography what surgical/procedural interventions can be offered to patients?

Answer 11

Percutaneous Coronary Intervention (PCI) - This is for patients with more proximal disease. A catheter is inserted into the patient’s brachial or femoral artery and with X-ray and contrast guidance is fed to the coronary arteries where a stent can be inserted.

Coronary Artery Bypass Graft (CABG) - This is for patients with severe stenosis and is a surgery in which the patient’s chest is open (midline sternotomy) and a vein is removed from elsewhere (usually the great saphenous vein) and is sewn to their heart to bypass the stenosed vessel. Record for this procedure is slower and complications higher than the PCI.

Question 12

What is the difference between acute coronary syndrome and angina?

Answer 12

Acute coronary syndromes usually occur as a result of a thrombus (clot) where are angina is more due to narrowing from atherosclerotic plaques.

Question 13

Which parts of the heart does the right coronary artery supply?

Answer 13

The Right coronary artery (RCA) curves around the right side of the heart and under the heart. It supplies the right atrium, right ventricle, inferior aspect of the left ventricle and the posterior septal area.

Question 14

Which parts of the heart does the circumflex artery supply?

Answer 14

The circumflex artery curves around the top, left and back of the heart and supplies the left atrium and posterior aspect of the left ventricle

Question 15

Which parts of the heart does the left anterior descending artery supply?

Answer 15

The Left anterior descending artery (LAD) travels down the middle of the heart and supplies the anterior aspect of the left ventricle and the anterior aspect of the septum.

Question 16

What are the three types of acute coronary syndromes?

Answer 16

• Unstable angina
• ST elevation MI (STEMI)
• Non-ST elevation MI (Non-STEMI)

Question 17

When a patient presents with acute coronary syndrome symptoms (i.e. chest pain) and an ECG is performed how can that help with your diagnosis?

Answer 17

1) If there is ST elevation or a new left bundle brand block, the diagnosis is STEMI
2) If there is no ST elevation, preform a troponin. Raised troponin levels with other ECG changes such as ST depression, T wave inversion or pathological Q waves will suggest an NSTEMI.
3) If troponin levels are normal and there are no pathological changes in the ECG, the diagnosis is either angina or the chest pain might be caused by MSK issues.

Question 18

Aside from chest pain what are the symptoms associated with acute coronary syndrome?

Answer 18

• Nausea and vomiting
• Sweating and clamminess
• Feelings of impending doom
• Shortness of breath
• Palpitations
• Pain radiating to jaw or arms

These symptoms should continues at rest for more than 20 minutes. If they settle at rest think of angina.

Question 19

What is a silent MI and why does this happen?

Answer 19

A silent Myocardial infarction can happen to patients who have diabetes. This is because diabetes can cause neuropathy which means damaged nerves that mask the chest pain a heart attack usually causes. Diabetics might present with a squeezed chest, tiredness or indigestion that won’t go away.

Question 20

Why should you be careful when testing for troponin?

Answer 20

Troponin tests are non-specific. There are many alternatives causes for raised troponin. Those include;

• chronic renal failure
• sepsis
• myocarditis
• aortic dissection
• pulmonary embolism

Question 21

Why should you perform an ECG, chest xray and CT coronary angiogram on patients with chest complaints?

Answer 21

• ECG assists with assessing the functional damage to the heart
• Chest xray investigates the presence of a pulmonary oedema and other causes of chest pain.
• CT coronary angiogram assesses for coronary artery disease.

Question 22

What is thrombolysis?

Answer 22

This is the process of injecting a fibrinolytic. medication to break down fibrin in order to dissolve clots in vessels. (It’s important to remember that this therapy results in increased risk of bleeding in patients.)