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