Cardiology

Question 1

Describe the investigations for acute coronary syndromes

Answer 1

Troponin – begin to rise 3 to 4 hours after myocardial damage
CK – measured in STEMI patients
Recommended hs-TnI taken on admission & again at 1 hour (only one hs-TnI level is required if the onset of symptoms was 3 or more hours previously)
ECG

Question 2

Describe the management of a STEMI

Answer 2

Pain relief – morphine & anti-emetic
Oxygenation
Aspirin (300mg loading followed by 75mg od for life)
Prasugrel/clopidogrel/ticagrelor
PPCI
Biochemical screen
Medications post MI: bisoprolol, ACEi, statin
Control of diabetes & hypertension

Question 3

Describe the management of NSTEMI/unstable angina

Answer 3

Morphine & anti-emetic
Aspirin 300mg loading and 75mg od
LMWH (enoxaparin) for 48 hours
Repeat ECG
Risk assessment of patient with elevated hs-TnI (grace score)
Consider anti-anginals

Question 4

Describe the investigations for stable angina

Answer 4

FBC & biochemical screen including glucose/HbA1c
Full lipid profile
Resting 12-lead ECG

Question 5

Describe the management of stable angina

Answer 5

Treated with aspirin 75mg OD, for those allergic, clopidogrel 75mg OD should be used
Sublingual GTN & instructed on its use
Symptom control – B-blockers
Rate control – B-blockers & CCBs (diltiazem or verapamil)
Statin

Question 6

Describe investigations for hypertension

Answer 6

Urine sample – test for presence of protein in the urine & for estimation of the albumin:creatinine ratio & haematuria
Bloods – glucose, electrolytes, creatinine, eGFR, total cholesterol & HDL cholesterol
Examine the fundi – hypertensive retinopathy
ECG
Echo – if suggestive of LVH, valve disease or LVSD or diastolic dysfunction

Question 7

List non-pharmacological management of hypertension

Answer 7

Weight reduction if BMI > 25
Moderate salt intake
Minimise alcohol intake
Aerobic exercise
Smoking cessation

Question 8

List the management of a hypertensive emergency

Answer 8

Aim is to reduce the diastolic BP to 110mmHg in 3-12 hours (emergency) or 24 hours (urgency)
1) Sodium nitroprusside
2) Labetalol
3) GTN
4) Esmolol (acts within 60 seconds, with a duration of action of 10-20 mins)

Question 9

Describe the investigations done for suspected heart failure

Answer 9

Bloods – U&Es, FBC, LFTs, TFTs, ferritin & transferrin, NT-proBNP
CXR
Echo (confirms diagnosis)
Cardiac MRI – may elaborate cause for HF as echo may miss right ventricle

Question 10

List potential findings in a CXR & echo for heart failure

Answer 10

CXR – cardiomegaly, pleural effusions, perihilar shadowing/consolidations, alveolar oedema, air bronchograms, increased width of vascular pedicle
Echo – dilated poorly contracting left ventricle (systolic dysfunction), stiff, poorly relaxing, small diameter left ventricle (diastolic dysfunction), valvular heart disease, atrial myxoma, pericardial disease

Question 11

Describe the management of heart failure

Answer 11

Lifestyle – smoking cessation, restriction of alcohol consumption, salt restriction, fluid restriction (especially in hyponatraemia)
Medications – diuretics, ACEi, ARB, ARNI, B-blocker, hydralazine, isosorbide mononitrate, ivabradine, nitrates
Complex device therapy – when medical therapy fails, then pacemakers can be used when there is LBBB

Question 12

Describe the difference between CRT & ICD

Answer 12

CRT (cardiac resynchronisation pacemaker) – paces from the septum to the lateral wall -> alters the QRS duration to becoming narrow again -> heart muscle can pump properly
ICD – deliver an electric shock: don’t improve symptoms, their purpose is to prevent sudden cardiac death associated with HF by detecting & cardioverting VT/VF

Question 13

Describe the symptoms of aortic stenosis

Answer 13

Three classical symptoms: angina, heart failure & syncope
Most common initial symptom = dyspnoea on exertion
Ejection systolic murmur best heard at the aortic area, radiating to the carotid/neck

Question 14

Describe the investigations and management for aortic stenosis

Answer 14

Echo – allows quantification of the severity of the stenosis and assessment of the rest of the heart
Indications for surgery – symptomatic, asymptomatic severe AS with LVSD/abnormal exercise test/at time of other cardiac surgery
In older patients, TAVI is considered (implanted via the femoral artery)

Question 15

Describe the symptoms of aortic regurgitation

Answer 15

May remain asymptomatic for many years -> increased volume load on the left ventricle eventually leads to heart failure
Exertional dyspnoea/reduction in exercise tolerance
Murmur best heard at the left sternal edge & is an early diastolic murmur
Associated with a collapsing pulse & De Musset’s sign (head bobbing)

Question 16

Describe the investigations and management for aortic regurgitation

Answer 16

Echo – quantification of the severity of the regurgitation and assessment of the rest of the heart
Indications for surgery: symptomatic severe AR, asymptomatic with evidence of early LVSD, asymptomatic with aortic root dilatation > 5.5 cm

Question 17

Describe the symptoms of mitral regurgitation

Answer 17

May remain asymptomatic for many years
Classified by a pan-systolic blowing murmur best hear over the mitral area and radiates to the axilla

Question 18

Describe the investigations and management of mitral regurgitation

Answer 18

Echo – important to assess LV function and size together with the severity of the jet of blood coming through the valve
Surgical options include mitral valve replacement or mitral valve repair
Surgical intervention is indicated in severe MR: symptomatic patients & asymptomatic patients with mild-moderate LV dysfunction
Medical therapy – diuretics, ACEi, beta blockers

Question 19

List common organisms in infective endocarditis

Answer 19

Strep viridans
Staph aureus
Pseudomonas aeruginosa

Question 20

List investigations to do for suspected infective endocarditis

Answer 20

FBC, ESR, CRP, U&Es, LFTs
Urine dipstick & MSU
CXR
ECG
Key diagnostic investigations: blood cultures & echo (TOE will detect 95% of vegetations)

Question 21

Describe how blood cultures are taken from a patient who has suspected infective endocarditis

Answer 21

At least three (preferably 6) sets of blood cultures should be taken from different sites over several hours
Reasonable to delay abx treatment to allow for comprehensive sampling

Question 22

Describe the diagnostic criteria for infective endocarditis

Answer 22

Modified Duke’s criteria – diagnosis on basis of two major criteria/one major and three minor/five minor criteria
Major criteria:
1) Positive blood cultures
2) Endocardial involvement
3) Positive echo findings
4) New valvular regurgitation
5) Dehiscence of prosthesis
Minor criteria:
1) Predisposing valvular/cardiac abnormality
2) IV drug abuser
3) Pyrexia > 38
4) Embolic phenomenon
5) Vasculitic phenomenon
6) Blood cultures suggestive
7) Suggestive echo findings

Question 23

Describe the management of infective endocarditis

Answer 23

Antibiotic therapy
1) Caused by strep: benzylpenicillin IV & low dose gentamicin
2) Caused by enterococci: amoxicillin IV & low dose gentamicin
3) Caused by staph: flucloxacillin & gentamicin

Question 24

How should you monitor treatment response in IE?

Answer 24

Once weekly echo – assess vegetation size & look for complications
Twice weekly ECG – detect conduction disturbances
Twice weekly bloods

Question 25

List indications for surgery in IE

Answer 25

Moderate to sever cardiac failure due to valve compromise
Valve dehiscence
Threatened or actual systemic embolism
Uncontrolled infection despite appropriate antimicrobial therapy

Question 26

List the clinical features of mitral stenosis

Answer 26

Mid-diastolic, low pitched ‘rumbling’ murmur
Malar flush
Atrial fibrillation

Question 27

Describe the management of mitral stenosis

Answer 27

If in AF, rate control is crucial
Anti-coagulate with warfarin
Diuretics
If this fails -> balloon valvuloplasty, open mitral valvotomy or valve replacement

Question 28

Describe the management of cardiac tamponade

Answer 28

Oxygen
Diamorphine IV for pain and anxiety
Drainage: needle pericardiocentesis & surgical drainage

Question 29

Describe the management of hyperlipidaemia

Answer 29

Lifestyle advice – exercise, Mediterranean diet
1st line therapy – atorvastatin 20mg PO at night for primary prevention, atorvastatin 80mg PO for secondary prevention (simvastatin 40mg)
2nd line therapy – ezetimibe
3rd line therapy – alirocumab: monoclonal antibody

Question 30

List investigations for peripheral arterial disease

Answer 30

Bloods – ESR, CRP, FBC, U&E, lipids, ECG
Ankle brachial pressure
Colour duplex US 1st line

Question 31

Describe the management of peripheral arterial disease

Answer 31

Risk factor modification – quit smoking, treat hypertension & high cholesterol, clopidogrel
Management of claudication – supervised exercise programme & vasoactive drugs
If conservative measures, intervention is required:
1) Percutaneous transluminal angioplasty
2) Surgical reconstruction
3) Amputation

Question 32

Describe the pathophysiology of varicose veins

Answer 32

Long, tortuous & dilated veins of the superficial venous system
Blood from superficial veins of the leg passes into deep veins via perforator veins & at the saphenofemoral and saphenopopliteal junctions
Valves prevent blood from passing from deep to superficial veins -> if they become incompetent there is venous hypertension & dilation of the superficial vein occurs

Question 33

Describe the management of varicose veins

Answer 33

Treat underlying cause
Education – avoid prolonged standing and elevate legs whenever possible
Endovascular treatment:
1) Radiofrequency ablation
2) Endovenous laser ablation
3) Injection sclerotherapy
4) Surgery