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MRCP Part 1 > Cardiology #3 > Flashcards

Cardiology #3 Flashcards

1
Q

A 54yo man with Angina has a percutaneous intervention with insertion of a drug-eluting stent. What is the single most important risk factor for stent thrombosis?

  • Patient’s age
  • Premature withdrawal of antiplatelet therapy
  • Failing to adhere to cardiac rehabilitation program
  • Duration of procedure
  • Hx of Diabetes Mellitus
A

Premature withdrawal of antiplatelet therapy.

  • Diabetes mellitus is a risk factor for restenosis rather than stent thrombosis.
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2
Q

What is ‘PCI’?

A

Percutaneous Coronary Intervention

  • a technique used to restore myocardial perfusion in patients with ischaemic heart disease (stable angina, acute coronary syndromes)
  • Stents are implanted in around 95% of patients.
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3
Q

Explain the physiology which occurs following the insertion of a stent following PCI.

A

Following stent insertion:

  • Migration and proliferation of smooth muscle cells and fibroblasts occur to the treated segment.
  • The stent struts eventually become covered by the endothelium
  • Until this happens, there is an increased risk of platelet aggregation leading to thrombosis.
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4
Q

What are the 2 main complications which may occur following PCI with stent insertion?

A

1) Stent thrombosis
- due to platelet aggregation
- Occurs in 1-2% of patients, most commonly in the first month
- Usually presents with an Acute MI

2) Restenosis
- due to excessive tissue proliferation around the stent
- Occurs in 5 - 20% of patients, most commonly in the first 3 - 6 months
- Usually presents with recurrence of Angina symptoms.
- RF: Diabetes, Renal impairment, and stents in venous bypass grafts

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5
Q

What are the 2 types of stent used for PCI?

A

1) Bare-metal stent (BMS)

2) Drug-eluting stents (DES):
- Stent coated with Paclitaxel or Rapamycin which inhibit local tissue growth
- Whilst this reduces restenosis rates, the stent thrombosis rates are increased as the process of stent endothelisation is slowed.

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6
Q

Following the insertion of a stent (for PCI), what is the most important factor in preventing stent thrombosis?

A

Antiplatelet therapy:

  • Aspirin should be continued indefinitely
  • The length of Clopidogrel treatment depends on the type of stent, reason for insertion and Consultant preference.
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7
Q

A 67yo woman presents to the Cardiology Clinic for urgent review. She is known to have Mitral Stenosis, but feels like her exercise tolerance has deteriorated rapidly over the past few months.
She is SOBOE and suffers from haemoptysis.
Meds: Bisoprolol 10mg, Isosorbide mononitrate 60mg, Furosemide 40mg OD.
BP 105/88, HR 62 (slow AF).
There are crackles at both lung bases on auscultation of the chest.
What is the most appropriate next step?

A

Percutaneous mitral valvotomy
-> the intervention of choice for severe Mitral Stenosis.

  • Narrow pulse pressure
  • Resistant cardiac failure
  • > appropriate to offer Percutaneous mitral valvotomy
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8
Q

A patient has severe Mitral Stenosis and is being considered for Percutaneous mitral valvotomy. List some contraindications to this procedure.

A
  • Mitral valve area > 1.5cm^2
  • Presence of left atrial thrombus on ECHO
  • Greater than mild mitral regurgitation
  • Severe valve calcification
  • Severe concomitant aortic valve disease
  • Severe combined mixed tricuspid valved disease
  • Concomitant coronary artery disease requiring bypass surgery.
  • In the event symptoms are not resolved by valvotomy, formal surgical valve replacement is indicated.
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9
Q

When might a surgical valve replacement be indicated in a patient with Mitral Stenosis?

A
  • Surgical valve replacement is only indicated where valvotomy is contraindicated or unsuccessful.
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10
Q

List 5 features of Mitral Stenosis.

A
  • Mid-late diastolic murmur (best heard in expiration)
  • Loud S1, opening snap
  • Low volume pulse
  • Malar flush
  • Atrial fibrillation
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11
Q

List 2 features of severe Mitral Stenosis.

A
  • Length of murmur increases

- Opening snap becomes closer to S2.

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12
Q

What might be seen on a CXR of someone with Mitral Stenosis?

A

Left atrial enlargement may be seen

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13
Q

What might be seen on Echocardiography if a patient has Mitral Stenosis?

A
  • The normal cross sectional area of the Mitral Valve is 4-6 sq cm.
  • A ‘tight’ mitral stenosis implies a cross sectional area of < 1 sq cm.
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14
Q

What are the causes of Mitral Stenosis?

A 
- Rheumatic fever (most common)
Rarer causes that may be seen in the exam:
- Mucopolysaccharidoses 
- Carcinoid
- Endocardial fibroelastosis
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15
Q

Which one of the following features would best indicate severe Aortic Stenosis?

  • Valvular gradient of 35mmHg
  • Quiet first heart sound
  • Loudness of ejection systolic murmur
  • Fourth heart sound
  • Development of an opening snap
A

Fourth heart sound

In Aortic Stenosis, S4 is a marker of severity.

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16
Q

A 72yo female is admitted for an elective AAA repair.
PMH: Asthma, undiagnosed peripheral neuropathy.
On day 4 post-op, she develops a net-like rash over her torso with fevers, myalgia and discolouration of her toes.
What is the most likely diagnosis?

A

Cholesterol emboli
-> Cholesterol emboli presents after a precipitating event such as angiography or AAA repair.

Clinical features include:

  • Livedo reticularis
  • Eosinophilia
  • Purpura
  • Renal failure
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17
Q

Describe the pathophysiology caused by a cholesterol emboli.

A

Cholesterol emboli may break off, causing renal disease.

  • The majority of cases are secondary to vascular surgery or angiography.
  • Other causes include severe atherosclerosis, particularly in large arteries such as the aorta.
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18
Q

List 4 features indicative of a cholesterol emboli.

A

‘PERL’

  • Purpura
  • Eosinophilia
  • Renal failure
  • Livedo reticularis
19
Q

What is the mechanism of action of a statin?

A

Statins inhibit the action fo HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.

20
Q

List some adverse effects of statins.

A

1) Myopathy: incl. myalgia, myositis, rhabdomyolysis and asymptomatic raised creatinine kinase.
Myopathy is more common in lipophilic statins (simvastatin, atorvastatin) than relatively hydrophilic statins (rosuvastatin, pravastatin, fluvastatin)

2) Liver impairment
- Check LFTs at baseline, 3 months and 6 months.
- Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.

3) Statins may increase the risk of intracerebral haemorrhage in patients who’ve previously had a stroke.

21
Q

List some contraindications to the prescription of Statins.

A
  • Macrolides (erythromycin, clarithromycin) are an important interaction. Statins should be stopped until patients have completed the course of antibiotics.
  • Pregnancy
22
Q

Who should receive a statin?

A
  • All people with established cardiovascular disease (Stroke, TIA, IHD, peripheral arterial disease)
  • Anyone with a 10-year Cardiovascular risk > 10%
  • Patients with T2DM should now be assessed using QRISK2, like other patients are, to determine whether they should be started on statins.
  • Patients with T1DM who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy.
23
Q

When should statins be taken and why?

A
  • Statins should be taken at night as this is when the majority of cholesterol synthesis takes place.
  • This is especially true for simvastatin which has a shorter half-life than other statins.
24
Q

What do NICE recommend for i) Primary; and ii) Secondary prevention of cardiovascular disease?

A

i) Primary Prevention:
Atorvastatin 20mg OD
-> increase dose if non-HDL has not reduced for >= 40%

ii) Secondary Prevention:
Atorvastatin 80mg OD

25
Q

A 70yo man with an existing diagnosis of a 5.0cm Abdominal Aortic Aneurysm and AF presents with acute onset abdominal pain radiating to his back.
His medications include Warfarin and Bisoprolol.
Last INR was taken 2 weeks ago and was 2.5.
BP 90 / 40
HR 140
The decision is made to proceed with emergency surgery within the next 30 minutes.
What is the appropriate management with regards to his Warfarin therapy?

A

Give four-factor prothrombin complex concentrate 25 - 50 units / kg

26
Q

What do the British Journal of Haematology guidelines say for patients on Warfarin having emergency surgery?

A
  1. If surgery can wait for 6-8 hours, give 5mg Vitamin K IV.
  2. If surgery can’t wait: 25-50units/kg of Four-factor Prothrombin complex.
  3. Stop Warfarin before elective or emergency surgery.
27
Q

What is Warfarin?

A
  • An oral anticoagulant
  • Inhibits Epoxide reductase, preventing the reduction of Vitamin K to its active hydroquinone form, which in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X and Protein C
28
Q

List some indications for Warfarin therapy.

A
  • Venous thromboembolism: Target INR = 2.5; if recurrent 3.5
  • AF: Target INR = 2.5
  • Mechanical heart valves. Target INR depends on the valve type and location.
    Mitral valves
29
Q

What does INR stand for, and what does it comprise?

A

International Normalised Ratio

It is the ratio of the Prothrombin time for the patient over the normal Prothrombin time.

30
Q

List some factors that may potentiate warfarin.

A
  • Liver disease
  • P450 enzyme inhibitors eg. Amiodarone, Ciprofloxacin
  • Cranberry juice
  • Drugs which displace Warfarin from plasma albumin eg. NSAIDs
  • Inhibit platelet function eg. NSAIDs.
31
Q

List some side effects of Warfarin.

A
  • Haemorrhage
  • Teratogenic (although can be used in breastfeeding mothers)
  • Skin necrosis
  • Purple toes
32
Q

A side effect of Warfarin in Skin Necrosis. Explain the pathophysiology of this.

A
  • When Warfarin is first started, biosynthesis of Protein C is reduced.
  • This results in a temporary pro-coagulant state after initially starting Warfarin (normally avoided by concurrent Heparin administration).
  • Thrombosis may occur in the venues, leading to skin necrosis.
33
Q

A 52yo female with a known history of Systemic Sclerosis presents for annual review to the Rheumatology clinic.
Which one of the following symptoms is most characteristic in patients who have developed Pulmonary Arterial Hypertension?
- Exertional dyspnoea
- Paroxysmal nocturnal dyspnoea
- Cough
- Early morning dyspnoea
- Orthopnoea

A

Exertional Dyspnoea

-> Acute vasodilator testing should be used in patients with pulmonary artery hypertension to determine which patients show a significant fall in pulmonary arterial pressure following vasodilators -> this should help to guide treatment.

34
Q

Define ‘Pulmonary Arterial Hypertension’.

A

PAH = a resting mean pulmonary artery pressure of >=25mmHg.

35
Q

Which vasoconstrictor peptide is thought to play a role in the pathogenesis of Pulmonary Arterial Hypertension?

A

Endothelin

36
Q

Who is usually affected by Pulmonary Artery Hypertension and when does it present?

A

PAH is more common in females and typically presents between the ages of 30 - 50 years.

37
Q

Approximately what percentage of cases of Pulmonary Artery Hypertension are inherited in an autosomal dominant fashion?

A

10%

38
Q

What factors increase the risk of Pulmonary Artery Hypertension?

A
  • HIV
  • Cocain
  • Anorexigens (eg. fenfluramine)
39
Q

List some features of Pulmonary Artery Hypertension.

A
  • Progressive exertional dyspnoea (classic presentation)
  • Exertional syncopa
  • Exertional chest pain
  • Peripheral oedema
  • Cyanosis
  • Right ventricular heave, loud P2, raised JVP with prominent ‘a’ waves, tricuspid regurgitation.
40
Q

Describe the management of a patient with Pulmonary Artery Hypertension.

A
  • Treat any underlying conditions (eg. with anticoagulants, oxygen).
  • Acute vasodilator testing should be conducted:
    The testing aims to decide which patients show a significant fall in Pulmonary Arterial pressure following the administration of vasodilators such as IV Epoprostenol or inhaled Nitric Oxide.
41
Q

A patient with Pulmonary Artery Hypertension has a positive response to Acute Vasodilator testing.* What should you treat them with?

*Note: a positive response is only seen in a minority of patients.

A

Oral Calcium Channel blockers

42
Q

A patient with Pulmonary Artery Hypertension has a negative response to Acute Vasodilator testing.* What should you treat them with?

*Note: this is the majority of patients

A
  • Prostacyclin analogues: Treprostinil, Iloprost
  • Endothelin receptor antagonists: Bosentan, Ambrisentan
  • Phosphodiesterase inhibitors: Sildenafil
43
Q

A patient with Pulmonary Artery Hypertension has progressive symptoms. What should you consider?

A

Patients with progressive symptoms should be considered for a heart-lung transplant.

MRCP Part 1 (16 decks)

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