Cardiovascular

Question 1

What is the most appropriate treatment of hypertension during pregnancy?

Answer 1

1st Line: Labetolol - if starting treatment or if changing (pt already on ACE/ARB etc for prev htn )
- Nifedipine (CC) if labetolol not suitable ie patient is asthmatic (unlicensed use)
- Consider methyldopa 3rd line

ACE/ARBs/thiazide like diuretics not recommended during pregnancy

Question 2

Clinical features of mitral stenosis

Answer 2

SOB, fatigue, malar flush
Mid-late diastolic murmur
ECG changes: bifid P waves (P mitrale) - sign of atrial enlargement

Question 3

Side Effects of statins

Answer 3

• myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase
• Liver impairment- check LFTs at baseline, 3 months and 12 months. Stop if 3x upper limit normal
• some evidence that statins may increase the risk of intracerebral haemorrhage in patients who’ve previously had a haemorrhagic stroke- avoid in these pts

Question 4

Statin Dosing primary vs secondary?

Answer 4

atorvastatin 20mg for primary prevention
- (increase the dose if non-HDL has not reduced for >= 40)
atorvastatin 80mg for secondary prevention

Question 5

Contraidications for statins

Answer 5

• macrolides (erythromycin/clarithromycin)
• pregnancy

Question 6

What drugs should be given on discharge post PCI?

Answer 6

a statin, an ACE inhibitor, a beta-blocker and dual antiplatelet therapy after PCI to reduce the likelihood of future coronary events

Question 7

What is the acceptable rise in creatinine and potassium from baseline after starting ACEi?

Answer 7

30% rise in creatinine, K+ up to 5.5mmol/l
- check U&E 2 weeks after starting and 2 weeks after each dose change. Once maintenance dose established check U&E at 1, 3 and 6 months

Question 8

What are the features of aortic regurgitation?

Answer 8

• early diastolic murmur
• collapsing pulse
• wide pulse pressure
• Quincke’s sign (nailbed pulsation)
• De Musset’s sign (head bobbing)
• mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams

Question 9

What are the causes of AR: acute vs chronic

Answer 9

Chronic:
- rheumatic fever
- bicuspid aortic valve
- connective tissue disorders (SLE, RA)
- calcified valve disease
- Marfans/EDS
- HTN
- Syphilis

Acute:
- infective endocarditis
- Aortic root dissection

Question 10

Management of chronic refduced or mildly reduced EF heart failure

Answer 10

ABAL

1. A- ACEi
2. B- Beta blockers
3. A- Aldosterone antagonist (MRA) ie spiro
4. L- Loop diuretics ie furosemide when overload present

Question 10

What % ejection fraction = reduced, mildly reduce or preserved EF

Answer 10

<40% = HFrEF
41-49% =HFmrEF
>50%= HF-PEF

Question 11

Drugs that worsens HF?

Answer 11

NSAIDs, CCBs, BBs

Question 11

When to refer HF pts based on BNP

Answer 11

• If NT-pro-BNP >2000 ng/L (236 pmol/L), refer urgently for specialist assessment and echo to be seen within 2 weeks.
• If NT-pro-BNP between 400–2000 ng/L (47–236 pmol/L), refer for specialist assessment and echoto be seen within 6 weeks.
• If NT-pro-BNP <400 ng/L (47 pmol/L), be aware that a diagnosis of heart failure is less likely. Consider discussion with a physician with subspecialty training in heart failure if a clinical suspicion of heart failure persists.

Question 12

What are the clinical features of pericarditis?

Answer 12

chest pain: may be pleuritic. Is often relieved by sitting forwards
other symptoms include a non-productive cough, dyspnoea and flu-like symptoms pericardial rub

Question 13

What ECG changes are seen in pericarditis?

Answer 13

1. Global changes
2. PR depression
3. Saddle/concave ST elevation

Question 14

Medical Management of angina

Answer 14

1. Symptoms relief= GTN spray, rpt dose after 5 min, rpt dose after further 5 min, if after further 5 min symptoms remain call 999
   2.Prevent symptoms= beta blocker (bisoprolol) + CCB (amlodipine). Other options (initiated by specialist) = nicorandil, ivabradine, nitrates
2. Secondary prevention = 4As
   - Aspirin - 75mg
   - Atovastatin - 80mg
   - ACEi - ramipril
   - Atenolol (will likely already be on BB)

Question 15

Causes of pericarditis

Answer 15

• Idiopathic
• Infection- mainly viral ie TB, HIV, EBV
• Autoimmune- SLE, RA
• Injury to heart- MI, heart surgery, trauma
• Uraemia- renal impairment
• Cancer
• Medications- methotrexate

Question 15

What are the 4 As of angina secondary prevention

Answer 15

Aspirin - 75mg
Atovastatin - 80mg
ACEi - ramipril
Atenolol (will likely already be on BB)

Question 16

Features of pericarditis

Answer 16

• pleuritic chest pain- worse on lying down, relieved by sitting forward
• low grade fever

Question 17

what drug would you give to cardiovert a patient in AF WITH structural heart disease

Answer 17

Amiodarone (or can use flecinide if there is NO structural disease)

Question 18

What are the risk factors of AF?

Answer 18

SMITH
Sepsis
Mitral valve disease
Ischaemic heart disease
Thyrotoxicosis
HTN

Others: caffeine, alcohol, cardiomyopathy

Question 19

What are the risk factors for coronary heart disease?

Answer 19

Non-modifiable risk factors:
- Older age
- Family history
- Male

Modifiable risk factors:
- Raised cholesterol
- Smoking
- Alcohol consumption
- Poor diet
- Lack of exercise
- Obesity
- Poor sleep
- Stress

Medical Co-Morbidities
- Diabetes
- Hypertension
- Chronic kidney disease (CKD)
- Inflammatory conditions, such as rheumatoid arthritis
- Atypical antipsychotic medications

Question 20

What can cause falsely low BNP levels?

Answer 20

obesity, aldosterone antagonists, ACE inhibitors, angiotensin-II receptor antagonists, beta-blockers and diuretics can all falsely lower BNP levels,

Question 21

Symptoms of aortic stenosis

Answer 21

SAD
Syncope
Angina
Dyspnoea or exertion

Question 22

Features of AS

Answer 22

crescendo-decrescendo, high-pitched ejection systolic murmur
narrow pulse pressure
slow rising pulse
a thrill palpable over the cardiac apex

Question 23

What is the most common cause of death in patinets post MI?

Answer 23

VF