Cardiology

Question 1

Diagnostic classification HTN

Answer 1

1: clinic BP 140/90 - 159/99 and home BP >135/85
2: clinic BP 160/90 - 180/120 and home BP 150/95
3. Clinic BP 180+ systolic, or clinic diastolic120+

Question 2

Target clinic BPs

Answer 2

age <80: <140/90, home < 135/85
in >80s: <150/90, home below 145/85
If postural hypotension, then target should be based on standing BP
frailty & multimorbidity: make clinical judgement

Question 3

investigations for HTN

Answer 3

If clinic BP high, ofer ABPM or home BP monitoring
Assess for target organ damage: urine dip (haematuria), urine albumin: creatinine, HbA1x, U&Es, retinal fundi, 12 lead ECG
Assess cardiovascular risk: blood lipids, calculate QRisk
If BP > 180/120 + ANY of:
- retinal haemorrhage/papilloedema
- life threatening symptoms
- suspected phaeochromocytoma
–» refer for same day specialist review

Question 4

HTN management

Answer 4

Do not forget conservative
If <55 not black African/afro-caribbean OR anyone w diabetes-> ACEi or ARB
Otherwise CCB
+other one
+ thiazide diuretic
+ consider starting spiro or alpha or beta blocker

Question 5

Mx stable angina

Answer 5

Beta blocker or CCB first line
Consider antiplatelet treatment eg low dose aspirin
consider ACEi if also diabetes
Review 6mo-1 year

Question 6

Pump failure causes of heart failure

Answer 6

1. Impaired systolic function
   - following ischaemia/MI
   - dilated cardiomyopathy
   - hypertension
   - myocarditis
2. Impaired diastolic function (impaired filling)
   - pericardial effusion or tamponade
   - cardiomyopathy restricted or hypertrophic
   3, arrhythmias
   - bradycardiac or heart block
   -tachycardias
   -anti-arrhythmics eg beta block/verapamil

Question 7

Excess pre load causes of heart fialure

Answer 7

Aortic regurg/mitral regurg
Fluid overload

Question 8

Excess afterload causes of heart failure

Answer 8

Aortic stenosis
Hypertension
HOCM

Question 9

high output causes of heart failure

Answer 9

Anaemia
Thyrotoxicosis
Pregnancy

Question 10

Pathophys of heart failure

Answer 10

Reduced output then heart dilates to increase contractility
Remodelling leads to hypertrophy
RAS and ANP/BNP release
Sympathetic activation
= compensated phase
THEN…
dilation increases, so contractility impaired and functional valve regurgitation
hypertrophy -> relative myocardial ischaemia
RAS activation -> sodium and fluid retention, increased venous pressure
Sympathetic excess incr afterload -> reduced cardiac output
= progressive decrease in CO and decompensation

Question 11

Symptoms and signs of R heart failure

Answer 11

Anorexia
Nausea
Incr JVP
Jugular venous distension
Tender smooth hepatomegaly
Pitting oedema
Ascites

Question 12

Symptoms and signs of left heart failure

Answer 12

Fatigue
Exertional dyspnoea
Orthopnoea ad paroxysmal nocturnal dyspnoea
Nocturnal cough
Weight loss and muscle wasting

Question 13

CXR changes in heart failure

Answer 13

Alveolar shadowing
Kerley B lines
Cardiomegaly
upper lobe Diversion
Effusion
Fluid in the fissures

Question 14

Mx heart failure

Answer 14

Prescribe ACE
Then beta blocker
2nd line therapy: aldosterone antagonist eg spironolactone and eplenerone (monitor K as both this and ACEi both potential hyperkalaemia)
incr role for SGLT-2 inhibitors if reduced ejection fraction
3rd line: specialist treatment eg ivabradine, sacubitril-valsartan and digoxin

Question 15

Adverse signs indicating need for shock

Answer 15

Hypotension <90
pallor, sweating, cold, clammy extremities, confusion, impaired consciousness
syncope
myocardial ischaemia
heart failure

Question 16

What to do if irregular broad complex tachycardia?

Answer 16

seek help!
Possibly AF with bundle branch block, or AF with ventricular pre-excitation or torsade de pointes

Question 17

Mx regular narrow complex tachycardia

Answer 17

Vagal manoeuvres
IV adenosine
If unsuccessful consider dx atrial flutter and control rate eg w beta block

Question 18

Mx regular broad complex tachycardias

Answer 18

Assume VT
Loading dose of amiodarone, followed by 24h infusion

Question 19

Mx irregular narrow complex tachycardia

Answer 19

Probably atrial fibrilaiton
If onset <48h consider electrical or chemical cardioversion
Otherwise rate control, beta block first line unless contraindication

Question 20

ECG features of hypokalaemia

Answer 20

Small/absent T waves (occasionally inversion)
Prolonged PR interval
ST depression
Long QT

Question 21

Secondary prevention drugs post MI

Answer 21

Dual antiplatelets eg aspirin + ticagrelor
ACE inhibitor
Beta blocker
Statin

Question 22

Amiodarone action

Answer 22

Potassium channel blocker
So inhibits repolarisation and prolongs action potential
Also blocks Na channels
USed in treatment of atrial, nodal and ventricular tachycardias

Question 23

Problems with amiodarone

Answer 23

Very long half life (20-100 days), so loading doses freq give
Causes thrombophlebitis so ideally should be given central veins
Lengthens QT interval
p450 inhibitor, so interacts w many drugs, eg decr metabolism of warfarin
Many adverse effects

Question 24

Adverse effects of amiodarone

Answer 24

Thyroid function (both hypo and hyper)
Corneal deposits
Pulmonary fibrosis/pneumonitis
Liver fibrosis/hepatitis
Peripheral neuropathy, myopathy
Photosensitivity
Slate-grey appearance
Thrombophlebitis
Bradycardia
Long QT interval

Question 25

Side effects if ACE inhibitors

Answer 25

Cough (15% of patients and may be up to a year after starting)
Angioedema
Hyperkalaemia
Signif risk of hypotension if als taking diuretics

Question 26

Contraindic for ACE inhibitors

Answer 26

Pregnancy and breastfeeding
May result in renal impairment
Aortic stenosis - may result in hypoetnsis
Hereditary idiopathic angiodoema
If pre existing hyperkalaemia