Cardiovascular

Question 1

Aortic stenosis - replacement strategies

1) Over 65
2) Under 65
3) Not fit enough for surgery - temporary measures & monitoring

Answer 1

In symptomatic patients that are fit enough for surgery:

Biprosthetic aortic valve replacement - offered to those > 65 yrs OR younger patients NOT wishing to take lifelong anticoagulation. Biprosthetic valves advantage of NOT requiring lifelong anticoagulation.

Mechanical aortic valve replacement is typically offered to YOUNGER patients ( under 65 with longer life expectancy therefore more at risk of degeneration of biprosthetic valve). Requires LIFELONG anticoagulation.

Balloon valvuloplasty - reserved for patient too high risk for surgical intervention now replaced by transcatheter methods.

Watch & wait - Annual ECHO, intervention when gradient > 75 mmHg. In ASYMPTOMATIC patients or unfit for surgery

Question 2

Two most common valves needing replacement?

Outline adv/ disadvantages of two main options for valve replacement

Answer 2

1) mitral and aortic valves

Question 3

Outline the stages of hypertension

Answer 3

Stage 1 HTN CLINIC 140/90 , ABPM 135/85

Stage 2 CLINIC >=160/100, ABPM >= 150/95

Stage 3. (SEVERE) CLINIC systolic > =180 OR diastolic >= 120

Question 4

Thresholds for treatment of hypertension

Answer 4

Stage 1 HTN ( > 140/90/ 135/85) treated if:
- Evidence of target organ damage
-Established CV disease
-Renal disease
-Diabetes
- QRISK score > 10%

Stage 2 HTN ( > 160/11, 150/95) - Treat ALL patients, regardless of age

Question 5

Lifestyle advice for HTN mx

Answer 5

1) low salt diet aiming less than 6g/ day ( ideally 3g/day)
2) Reduce caffeine intake
3) Smoking cessation
4) Reduce EtoH
5) Increase exercise & Weight loss
6) Healthy balanced diet

Question 6

Patients diagnosed with essential HTN under 40 what should occur?

Answer 6

Referral to specialist to exclude secondary causes of HTN

Question 7

Outline the stages of treatment for HTN

Answer 7

Step 1: Under 55 yrs OR T2DM 1st line ACEi/ ARB ( ARB if ACE i not tolerated e.g cough). Over 55 yrs OR black african/ african carribean patients 1st line CCB ( ACEi reduced efficacy in african origin).

Step 2: If already taking ACEi/ ARB then add CCB or thiazide like diuretic. If already on CCB then add ACEi/ARB or thiazide like diuretic.
*Note for black african patients taking a CCB consider an ARB as second line agent over ACEi. *

Step 3: Add 3rd drug e.g. ACEi + CCB then add Thiazide etc

Step 4: Resistant HTN - add 4th drug. 1st check for 1) confirm elevated BP in clinic or with ABPM 2) Assess for postural hypotension 3) Discuss drug adherence. Then add 4th based of K levels:
If K < 4.5 add low dose spironolactone
If K > 4.5 add alpha or beta blocker

If BP remains uncontrolled on 4 drugs then referral to specialist.

Question 8

What are the BP targets in treating HTN

Answer 8

Under 80 yrs - aiming for clinic under 140/ 90and ABPM under 135 /85

Over 80 yrs - aiming under 150/90 and ABPM under 145 /85

Question 9

ECG features of hypokalaemia

Answer 9

In hypokalaemia U have not Pot and no T but a long PR and long QT

U waves
Absent or small T waves
Long PR
Long QT
ST depression

Question 10

Aortic dissection: 2 Classifications / Percentages of presentation

Answer 10

Stanford:
Type A - ascending aorta 2/3rds cases
Type B - descending aorta 1/3rd cases

DeBakey classification

Type 1 - originates in ascending aorta, involves at least the arch if not the whole aorta
Type 2 - isolated to ascending aorta
Type 3 a- originates descending aorta involving only section above diaphragm
Type 3b - originates in descending aorta involving section below diaphragm

Question 11

Define aortic dissection

Answer 11

Tear forms in the inner layer of the aorta, blood enters between the intima and media layers of the aorta creating a false lumen. Most commonly affects ascending aorta and aortic arch. Right lateral ascending aorta most common as highest site of stress as blood exits the heart.

Question 12

Risk factors for aortic dissection

Answer 12

Same RF as Peripheral arterial disease:
Age
Male
HTN
Smoking
Poor diet
Hypercholesterolaemia
Connective tissue diseases - Ehlers Danlos/ Marfans
Cocaine use / heavy weight lifting
Cardiac surgery - Aortic valve replacement, CABG
Cardiac malformation - Bicuspid aortic valve, coarctation of aorta

Question 13

Presentation of aortic dissection

Answer 13

Sudden onset severe “ ripping/ tearing” chest pain
Radiates to back
May be in anterior chest when ascending is affected, or in back if descending is affected. Pain may migrate.

Other features:
HTN
Difference in BP between the arms ( more than 20 mmHg is significant)
Radial pulse deficit ( radial pulse in one arm decreased/absent/ does not match apex beat)
Diastolic murmur
Focal neurological deficit - Limb weakness or paraesthesia
Chest AND abdominal pain
Collapse
Hypotension as dissection progresses

Question 14

Diagnosis/ investigations of aortic dissection

Answer 14

ECG and CXR - common initial investigations to rule out MI ( although acute MI can occur in conjunction with aortic dissection, treatment of which can lead to progression of aortic dissection).
CXR - widened mediastinum
CT angiography of the chest abdomen and pelvis is IX of choice. Suitable for STABLE patients, false lumen key finding.
TOE - Suitable for unstable patients too risky to take to CT scanner.

Question 15

Management of aortic dissection

Answer 15

Type A - surgical management but BP should be controlled to target systolic 100-120 whilst awaiting intervention. Midline sternotomy to remove defect in aortic wall and replace with synthetic graft.
Type B - conservative management, bed rest, reduced BP with IV labetalol to prevent progression. Endovascular has more of a role to play now - TEVAR. (Thoracic endovascular repair).

Question 16

Complications of aortic dissection

Answer 16

1) MI ( normally inferior)
2) Aortic valve incompetence/regurgitation & risk of tamponade
3) Stroke
4) Paraplegia - motor or sensory impairment in legs
5) Renal failure
6) Death

Question 17

Diagnosis of HTN: Steps as a GP to take

Answer 17

Offer ABPM / HBPM to any patient with BP > 140/90. NICE recommend taking second reading and using lowest of second reading to determine management. Measure BP in both arms, recording should be made from arm with higher reading.

If BP > 180 / 120 –> admit for specialist ax if signs of retinal haemorrhage/ papilloedema, new onset confusion, chest pain, signs of HF, AKI.
Referral if any evidence of phaeochromocytoma - labile or postural hypotension, headache, palpitations, pallor, sweating.
If none of the above arrange for urgent investigations for end organ damage - ECG, Bloods, Urine ACR. If target organ damage identified then consider starting antihypertensive treatment immediately without waiting for ABPM.

Question 18

Management of Angina pectoris (Stable angina)

Answer 18

1) all patients should receive aspirin and statin ( in abscence of contraindications)
2) Sublingual GTN to abort angina attacks
3) Beta blocker or CCV 1st line
4 )If CCB 1st line then rate limiting e.g. verapamil or diltiazem should be used
5) If used in combo with BB then longer acting such as amlodipine or MR nifedipine should be used
6 ) remember NO verapamil with BB - risk of heart block and HF
7) If poor response to first medication then increase to max tolerated dose
8) If patient still symptomatic after monotherapy then add other drug
9) if patient on monotherapy but cannot tolerate CCB/BB then consider one of:
- long acting nitrate
- ivabradine
- nicorandil
-Ranolazine

Question 19

Anticoagulant treatment post ischaemic stroke

Answer 19

Aspirin 300 mg daily for 2 weeks immediately following by Clopidogrel 75 mg lifelong ( if tolerated and not contraindicated)

Question 20

clinical features of symptomatic aortic stenosis

Answer 20

SAD
Syncope, angina, dyspnoea on exertion
Murmur - Ejection systolic murmur, classically radiates to the carotids, decreased after valsalva manouvre, loudest R 2nd IC space, crescendo - decrescendo

Other features of severe aortic stenosis:
Narrow pulse pressure
Slow rising pulse
Delayed ESM
Soft/ absent S2
S4
Thrill
LV hypertrophy/ L sided HF

Question 21

Causes of aortic stenosis

Answer 21

Degenerative - calcification most common cause in older patients
Bicuspid aortic valve - commonest cause in younger patients
Post rheumatic disease
Subvalvular HOCM

Question 22

Management of aortic stenosis

Answer 22

If asymptomatic generally observation as general rule.
Symptomatic then valve replacement. If asymptomatic but valvular gradient > 40 mmHg / LVSF then consider surgery. Surgical options:
AVR choice for young , low-medium risk operative patients. CV disease can coexist therefore angiogram often done prior to surgery so procedures can be combined.
Transcatheter AVR ( TAVR) is used for patients with high operative risk
Balloon valvuloplasty - may be used in children with no aortic valve calcification or in adults with critical aortic stenosis but not fit enough for valve replacement.

Question 23

SE of ACEi

Answer 23

Cough - due to increased bradykinin levels
Angioedema - can occur up to a year after starting tx
Hyperkalaemia
1st dose hypotension ( more common if taking diuretics)

Question 24

Cautions of ACEi / Contraindications

Answer 24

Pregnancy and breastfeeding - avoid
renovascular disease - may result in renal impairment
aortic stenosis - can result in hypotension
specialist advice if K > 5.5

Question 25

Monitoring of ACEi therapy

Answer 25

U&Es pre and post treatment / dose adjustments
Note rise in creatinine and potassium expected, acceptable changes up to 30% from baseline and up to 5.5 K.
Significant renal impairment can occur in undiagnosed BL renal artery stenosis

Question 26

Outline the coronary arteries affected in the following ECG changes:

V1-V4

Leads 2/3/AVF

Leads V1-V6, lead 1, avL

leads 1, aVL +/- V5/V6

Answer 26

Question 27

Key point about the management of acute AF ( first presentation)

Exceptions to rate control

Answer 27

< 48 hours then may be suitable for rhythm control strategy - cardioversion
> 48 hours ( or uncertain onset) then rate control is first line.

Exceptions to rate control being first line:
1) reversible cause of AF
2) presenting with AF duration < 48 hrs
3) patient who have HF caused by their AF
4) Patient with atrial flutter who could be managed with ablation
5) Rhythm control considered better on clinical judgement

Question 28

Management of haemodynamically unstable AF?

Haemodynamic instability/ worrying signs with AF?

Answer 28

DC electrocardioversion under sedation

Shock
Heart Failure
Ischaemia ( angina / chest pain)
Syncope / SOB

Question 29

How is electrocardioversion performed?

Answer 29

DC cardioversion is performed under adequate short-acting general anaesthesia and involves delivery of an electrical shock synchronised with the intrinsic activity of the heart by sensing the R wave of the ECG (i.e., synchronised)

Question 30

Atrial fibrillation management:

What is the HR aim in rate control strategy?

Drugs used in rate control?

Answer 30

Aiming generally for 60-80 bpm and under 115 Bpm during exercise. However individualised approach ( ok for faster if LV systolic function is preserved & pt asymptomatic).

Rate control BCD

Beta blockers ( bisoprolol, metoprolol, propanolol, atenolol) * caution in asthma*
CCB - ( Diltiazem or verapamil) * caution in cancer pts*
Digoxin

Question 31

AF management -

Drugs used in Rhythm control strategy?

Answer 31

Using class 1c or class 3 antiarrhythmic drugs:

Beta blockers ( sotalol)
Dronedarone / propafenone
Flecainide
Amiodarone - older patients with concomitant HF

Question 32

When is catheter ablation recommneded in AF management?

What are the recommendations for anticoagulation with catheter ablation?

Answer 32

Catheter ablation is recommended in patients who have not responded or wish to avoid antiarrhythmic medications.

Anticoagulation
should be used 4 weeks before and during the procedure.
Remember catheter ablation controls the rhythm but does not reduce the stroke risk, even if patients remain in sinus rhythm. Therefore, patients still require anticoagulation as per their CHA2DS2-VASc score
if score = 0: 2 months anticoagulation recommended
if score > 1: longterm anticoagulation recommended

Question 33

Anticoagulation in AF - when should it be considered and what scoring system is used?

Answer 33

Should be considered in all types of AF and flutter, and in those who have undergone ablation therapy.

Congestive HF ( 1)
Hypertension
Age - > 75 (2), 65 > (1)
Diabetes
Stroke/TIA/Thromboembolism (2)
Vascular disease ( PVD/IHD)
a
Sex - female ( 1)

Scores > 2 for female - offer anticoagulation
Scores > 1 for males - offer anticoagulation

Question 34

How do we assess bleeding risk for anticoagulation with AF?

Answer 34

ORBIT score

Question 35

Pharmacological management of Heart failure

Answer 35

1st line - ACE i and Beta blocker.
One drug should be started at a time. Clinical judgement used when determining which one to start first. ACEi/ BB have no effect on mortality in HFwPEF.

2nd line therapy - aldosterone antagonist.
Spironolactone / Epleronone.
SGLT2 inhibitors ( dapagliflozin and empagliflozin). EVidence that they reduced hospitalisation and CV death associated with HF.

3rd line - started by a specialist.
1) Ivabradine - for sinus but reduced EF <35%
2) Entresto/ Sacubitril valsartan - reduced EF < 35% & still symptomatic on ACEi. ( needs washout of prev ACEi)
3) Digoxin - strongly indicated in coexistent AF
4) Hydralazine + nitrate - Afrocarribean ots
5) Cardiac resychronisation therapy

Question 36

Vaccinations offered to those with HF

Answer 36

Annual influenza
One off pneumococcal vaccine.

Question 37

What are the NYHA classifications of HF?

Answer 37

NYHA Class 0 - no signs/ symptoms HF
NYHA class 1 - No symptoms & no limitation
NYHA class 2 - Mild symptoms. Comfortable at rest but slight limitation in regular physical activities.
NYHA class 3 - Moderate symptoms . Marked limitation in ability to carry out normal physical activities. Significant symptoms with less than ordinary exertion.
NYHA class 4 - severe symptoms both at rest and worsened w activity.

Question 38

What drug is given before fibrinolytic therapy in STEMI mx?

How does this drug work?

Answer 38

Fondaparinux is given to patients undergoing fibrinolysis with a STEMI ( PCI unavailable within 2 hours of presention)

Fondaparinux activates antithrombin 3 which binds to Factor Xa. This prevents the clot from enlarging whilst awaiting fibrinolysis.

Question 39

Management of INR in patients taking Warfarin?

Answer 39

Major bleeding ( variceal/ intracranial H) - Stop warfarin, Give IV Vit K 5mg, plus Prothrombin complex concentrate ( if not available then FFP)

INR > 8.0 & minor bleeding - stop warfarin, give IV Vit K 1-3 mg. Repeat dose Vit K if INR still too high after 24 hrs. Restart warfarin when INR < 5.0

INR > 8.0 No bleeding - Stop warfarin. Give Vitamin K 1-5 mg orally. Repeat dose of Vit K if INR still too high after 24 hours. Restart when INR < 5.0

INR 5- 8 & Minor Bleeding - Stop warfarin. Give IV vit K 1-3 mg . Restart when INR < 5.0

INR 5-8 and no bleeding - withold 1 - 2 doses of warfarin. Reduce subsequent maitenance dose.