Cardiology - Cardiovascular Disease

Question 1

What is atherosclerosis caused by?

Answer 1

Chronic inflammation and activation of the immune system

Causes deposition of lipids in the artery wall, then development of fibrous atheromatous plaques

Question 2

What does atheromatous plaque formation lead to?

Answer 2

Stiffening
Leads to hypertension and strain on the heart as it tries to pump against resistance

Stenosis
Reduced blood flow

Plaque rupture
Thrombus, can block distal vessel and cause ischaemia

Question 3

What are the risk factors of cardiovascular disease, modifiable and non-modifiable?

Answer 3

Modifiable
- Raised cholesterol
- Smoking
- Alcohol
- Diet
- Exercise
- Obesity
- Poor sleep
- Stress

Non-modifiable
- Age
- Family history
- Male

Question 4

What co-morbidities increase the risk of atherosclerosis?

Answer 4

Diabetes
Hypertension
CKD
Inflammatory conditions
Atypical antipsychotic medications

Question 5

What conditions can atherosclerosis result in?

Answer 5

Angina
MI
TIA
Strokes
Peripheral arterial disease
Chronic mesenteric ischaemia

Question 6

What does NICE recommend for cardiovascular disease?

Answer 6

Dietary changes
Aerobic activity - 150 minutes moderate or 75 intense
Strength training

Question 7

What is a QRISK3 score?

Answer 7

% Risk patient will have a stroke or MI in the 10 years

Question 8

What does NICE recommend for patients with a QRISK3 score over 10%?

Answer 8

20mg Atorvastatin at night

Question 9

What is the mechanism of action of statins?

Answer 9

HMG CoA reductase inhibitor

Reduces intracellular cholesterol

Increased cholesterol receptors on cell surface to remove cholesterol from blood

Question 10

What does NICE recommend after using statins?

Answer 10

Checking lipids 3 months after statins

Increase dose to aim for > 40% reduction in non-HDL cholesterol. Check adherence first

Checking LFTs within 3 months and again at 12 months

Causes mild rise in ALT and AST, doesn’t need to be stopped unless more than 3x baseline

Question 11

What are some rare side effects of statins?

Answer 11

Myopathy
Muscle weakness and pain

Rhabdomyolysis
Check CK in patients with muscle pain

Type 2 diabetes

Haemorrhagic strokes

Question 12

What medications interact with statins?

Answer 12

Macrolide antibiotics

Stop taking statins if patient is on clarithromycin or erythromycin

Question 13

What are the 4 As of secondary prevention for cardiovascular disease?

Answer 13

Antiplatelet medications (aspirin, clopidogrel, ticagrelor)

Atorvastatin 80mg

Atenolol (or other beta blocker e.g. bisoprolol)

ACEi, commonly ramipril to max tolerated dose

After MI patients offered dual antiplatelet, both aspirin 75mg and clopidogrel or ticagrelor

Question 14

What antiplatelet drug is preferred for peripheral arterial disease?

Answer 14

Clopidogrel

Question 15

What is familial hypercholesterolaemia?

Answer 15

Autosomal dominant condition causing high cholesterol

Can be both hetero and homozygous

Homozygous
Very rare, causes extremely high cholesterol (over 13mmol/L)

Question 16

What clinical criteria is used for diagnosing familial hypercholesterolaemia?

Answer 16

Simon Broome criteria
- Family history of premature CVD
- Very high cholesterol (over 7.5mmol/L in adults)
- Tendon xanthomata

Question 17

How is familial hypercholesterolaemia managed?

Answer 17

Specialist referral for genetic testing

Statins