Cardiovascular

Question 1

When should CVD risk be re-assessed (for differing risks)

Answer 1

Low risk = every 5 years
- or if risk factors worsen
- consider sooner if close to intermediate
- First nations every year
Intermediate = Every 2 years
High risk
- no formal reassessment
- manage as appropiate

Question 2

Age for CVD risk assessment (3)

Answer 2

45-79
DM - 35-79
First nations - 30-79

Question 3

Additional components on assessing CVD risk in diabetes (5)

Answer 3

HbA1c
Date from diagnosis
uACR + eGFR
BMI
Insulin within 6mo

Question 4

When to re-classify CVD risk in CKD

Answer 4

HIGH risk if:
- anyone with sustained eGFR <45
- men with persistent uACR >25mg/mmol
- women with persistent uACR >35mg/mmol

Question 5

Steps in CVD Risk Management (6/7)

Answer 5

SNAWAP
- Smoking cessation
- Nutrition
- Activity
- Weight
- Alcohol reduction
- Pharmacological -> BP lowering + Lipid Modification

Question 6

When BP + cholesterol treatment required regardless of risk

Answer 6

SBP >160
DMP >100
TC >7.5 mmol/L

Question 7

Calculated 45yo mans CVD risk 9% - multiple results showing eGFR 50, uACR 10 - ?any relevance

Answer 7

Mod CKD so could consider re-classifying to high risk.
- Sustained eGFR 45-59
- Persistent uACR 2.5-25mg/mmol (3.5-35 in women)
- lower eGFR or high ACR = severe = high risk

Question 8

Pre-existing HTN in patient. Now pregnant.
How to pharma manage? (3)

Answer 8

Methyldopa
Labetalol
Clonidine

Question 9

Lipid target for Very high risk
- CAD/Stroke/TIA/PAD
- Severe CKD (eGFR <30)
- FH + another risk factor
- DM with end organ damage

Answer 9

LDL - 50% reduction OR <1.4 (which is lower)
non-HDL - <2.2
Trigs - <1.7

Question 10

Lipid targets for high CVD risk

Answer 10

LDL - 50% reduction or 1.8

Question 11

seconadary causes of dyslipidaemia (7)

Answer 11

• CKD
• Nephrotic syndrome
• T2DM
• Hypothyroid
• Cholestasis
• Obesity
• Excessive ETOH

Question 12

Acute chest pain - likely ACS
Mx steps

Answer 12

• Call for help/Organise transfer
• 300mg aspirin
• GTN
• IV Morphine
• 02 if Sats <93%
• Repeat ECG
• +- IV Access

Question 13

Beta-blockers for heart failure with reduced LVEF (4)

Answer 13

Carvedilol
Bisoprolol
Nebivolol
Metoprolol succinate

Question 14

Presents with pain in the thigh. US shows 15cm thrombosis in right superficial femoral vein.
Treatment?

Answer 14

Treat as DVT - superficial femoral vein is a deep vein

Question 15

4 medications for HFrEF

Answer 15

ACE-i or ARB
B-Blocker
MRA (spiro)
SGLT2-inhibitor (empagliflozin)

Question 16

Rx for symptomatic complete heart block

Answer 16

Atropine 0.5mg IV stat
+ rpt in 15mins

Question 17

Presenting with new chest pain + new LBBB

Answer 17

Need to treat as ACS, assume MI until proven otherwise

Question 18

SVT Mx in ED (2) + O/P paroxysmal Mx

Answer 18

Vagal maneouvre
Rapid bolus 6m IV Adenosine
OP - beta-block

Question 19

Pt presents with acute onset palpitations and breathlessness. ECG shows VT, BP 120/60.
Rx?

Answer 19

VT:
Haemodynamically stable -> IV Amiodarone infusion
Unstable -> SHOCK

Question 20

Answer 20

Digoxin toxicity
- weakness, confusion, visual changes
- wide spread ST depression, with down sloping fashion

Question 21

ECG areas
- lateral
- inferior
- anterior

Answer 21

Question 22

Pre-op patient, asking about anti-platelet agents

Answer 22

Withold for 7 days prior to non cardiac surgery
- resume with oral intake
CVD surgery needs discussion with cardio

Question 23

85M pt on apixaban 5mg BD for AF. Stable weight 75kg, and recent mild worsening of renal failure - eGFR 45, Creat 110.
Would a dose change be needed

Answer 23

Apixaban for AF
- oral, 5mg BD
Reduce to 2.5mg BD for2+ risk factors for bleedings
- 80+ yo
- wt <60kg
- serum Creat >133

For this pt - leave dose unchanged
NB: above is NOT relevant in DVT/PE

Question 24

KFP question, person with calf pain + swelling, atraumatic, no recent surgery. Suspect DVT.
Aspects of hx to clarify cause?

Answer 24

Need diverse DDx in questions
DVT/PE
- Recent air travel/immobility OR/
- 1st degree FHx of DVT OR/
- SOB/chest pain
MSK injury
- recent excessive exercise
- onset of pain during exercise
Cellulitis
- fever

Question 25

KFP: 2 pharmacological managements steps for person with DVT

Answer 25

1. Anti-coagulation
   - Oral apixaban 10mg BD for 1wk, then decrease dose 5mg BD thereafter
   - Oral rivaroxaban 15mg BD for 3wks, then 20mg OD thereafter
2. Anagesia
   - oral paracetamol QID
   - oral ibuprofen TDS

Question 26

Duration of anti-coagulation therapy for DVT (4)

Answer 26

Question 27

Pt with known HTN, on meds, presents with poorly controlled HTN.
Possible causes (8)

Answer 27

• non compliance with meds
• OSA
• Excessive ETOH or caffeine
• Medications AE (eg. pred)
• Primary aldosteronism
• Renal artery stenosis
• phaeochromocytoma
• High salt diet

Question 28

Investigations for secondary HTN (6)

Answer 28

Renovascular
- UEC with eGFR
- Urinalysis
- uACR
Primary aldosteronism
- Aldosterone/renin ratio
Phaeochromocytoma
- plasma metanephrines
Cushings
- 1mg overnight dex supression test OR
- free cortisol in 24urine on 2 occasions

Question 29

Hypertriglyceridaemia mx (3)

Answer 29

Trigs <4 - standard statin
4-10 - add fish oil
10+ = statin + fish oil + fenofibrate

Question 30

Assessing stroke risk in patient with new AF?

Answer 30

CHA2DS2-VASc - 2+ males, 3+ females
C- CHF
H- HTN
A - Age >75 2points
D - DM
S - Stroke/TIA/VTE 2points
V - Vasc disease - IHD, PAD
A - Age 65-74
S - Sex female

Question 31

Pharmacological options for Rx of stable angina (3)

Answer 31

1. Beta-blocker: Atenolol OD
2. Dihydropyridine Ca-Channel blockers: Amlodipine OD
3. Long-acting nitrate: ISMN MR OD

Question 32

Diagnostic criteria for metabolic syndrome (5)

Answer 32

3 of 5 = Metabolic Syndrome
1. Large waist circumference - population specific
2. Elevated trigs >1.7
3. Reduced HDL <1 for men, <1.3 for women
4. Elevated BP >130/85
5. Elevated fasting glucose >5.5