Cardiovascular

Question 1

NSTEMI

Acute coronary syndrome

non-ST elevation myocardial infarction

Answer 1

• Aspirin 300mg
• Nitrates or morphine to relieve chest pain if required
• Antithrombin treatment. Fondaparinux /Heparin
• Ticagrelor and prasugrel are now the preferred second antiplatelet instead o
• Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban)
• Coronary angiography

Question 2

Angina

drug management

Answer 2

Aspirin and \

Statin in the absence of any contraindication

GTN to abort angina attacks

Beta-blocker or

Calicum channel blocker

channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used

If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine).

Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)

if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)

if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa

a long-acting nitrate, ivabradine, nicorandil or ranolazine

if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

Question 3

Anti-platelets

Percutaneous coronary intervention

ACS (MI)

CVA & TIA

PVD

Answer 3

ACS (MI) & PCS

Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)

If aspirin contraindicated, clopidogrel (lifelong)

CVA & TIA

Clopidogrel (lifelong)

Aspirin (lifelong) & dipyridamole (lifelong

PVD

Clopidogrel (lifelong)

Asprin (lifelong)

Question 4

CHA2DS2-VASc

Anticoagulation

Atrial fibrillation

Answer 4

Congestive heart failure 1

Hypertension (or treated hypertension) 1

Age >= 75 years 2 : Age 65-74 years 1

Diabetes 1

Stroke or TIA 2

Vascular disease (IHD PVD) 1

Sex (female) 1

0 No treatment

1 Males: Consider anticoagulation
Females: No treatment (this is because their score of 1 is only reached due to their gender)

2 or more Offer anticoagulation

Question 5

HASBLED

Score

Answer 5

Hypertension, uncontrolled, systolic BP > 160 mmHg 1

Abnormal renal function (dialysis or creatinine > 200) Abnormal liver function (cirrhosis, bilirubin > 2 times normal, ALT/AST/ALP > 3 times normal

1 for any renal abnormalities

1 for any liver abnormalities

Stroke 1

Bleeding history 1

Labile INRs (unstable/high INRs, time in therapeutic range < 60%) 1

Elderly (> 65 years) 1

Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs) or Alcohol Use (>8 drinks/week)

1 for drugs 1 for alcohol

There are no formal rules on how we act on the HAS-BLED score although a score of >= 3

Question 6

Atrial fibrillation

rate control and

maintenance of sinus rhythm

Answer 6

Agents used to control rate in patients with atrial fibrillation

beta-blockers

calcium channel blockers

digoxin (not considered first-line anymore as they are less effective at controlling the heart rate during exercise. However, they are the preferred choice if the patient has coexistent heart failure)

Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation

sotalol

amiodarone

flecainide

others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine

Question 7

BNP

High levels > 400 pg/ml (116 pmol/litre)

NTproBNP > 2000 pg/ml (236 pmol/litre)

Raised levels

100-400 pg/ml (29-116 pmol/litre)

400-2000 pg/ml (47-236 pmol/litre)

Normal levels

< 100 pg/ml (29 pmol/litre)

< 400 pg/ml (47 pmol/litre)

Answer 7

Increase BNP levels

Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (including pulmonary embolism)
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis

Decrease BNP levels

Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists

Interpreting the test

if levels are ‘high’ arrange specialist assessment (including transthoracic echocardiography) within 2 weeks

if levels are ‘raised’ arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks

Question 8

DVLA
Specific rules

Answer 8

Hypertension - can drive unless treatment causes unacceptable side effects, no need to notify DVLA. If Group 2 Entitlement the disqualifies from driving if resting BP consistently 180 mmHg systolic or more and/or 100 mm Hg diastolic or more

angioplasty (elective) - 1 week off driving

CABG - 4 weeks off driving

acute coronary syndrome- 4 weeks off driving, 1 week if successfully treated by angioplasty

angina - driving must cease if symptoms occur at rest/at the wheel

pacemaker insertion - 1 week off driving

implantable cardioverter-defibrillator (ICD): if implanted for sustained ventricular arrhythmia: cease driving for 6 months. If implanted prophylatically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers

successful catheter ablation for an arrhythmia- 2 days off driving

aortic aneurysm of 6cm or more - notify DVLA. Licensing will be permitted subject to annual review. An aortic diameter of 6.5 cm or more disqualifies patients from driving

heart transplant: DVLA do not need to be notified

Question 9

LBBB

in LBBB there is a ‘W’ in V1 and a ‘M’ in V6

in RBBB there is a ‘M’ in V1 and a ‘W’ in V6

Answer 9

Causes of LBBB

ischaemic heart disease

hypertension

aortic stenosis

cardiomyopathy

rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia

Question 10

MI

ECG changes

Coronary artery

Answer 10

Anteroseptal V1-V4 Left anterior descending

Inferior II, III, aVF Right coronary

Anterolateral V4-6, I, aVL Left anterior descending or left circumflex

Lateral I, aVL +/- V5-6 Left circumflex

Posterior Tall R waves V1-2 Usually left circumflex, also right coronary

Question 11

ECG features of hypokalaemia

In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT

Answer 11

U waves

small or absent T waves (occasionally inversion)

prolong PR interval

ST depression

long QT

Question 12

ECG:
Normal variants

Answer 12

• Sinus arrhythmia
• Right axis deviation (tall and thin individuals)
• Left axis deviation (short, obese individuals)
• Partial right bundle branch block

Athletes often have a high vagal tone:

• Sinus bradycardia
• 1st degree atrioventricular block
• Wenckebach phenomenon (2nd degree atrioventricular block Mobitz type 1)
• Junctional escape rhythm

Question 13

CCF

Heart failure drug management

Answer 13

• ACE inhibitors (SAVE, SOLVD, CONSENSUS)
• beta-blockers (CIBIS)
• spironolactone (RALES)
• hydralazine with nitrates (VHEFT-1)

first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker*. Generally, one drug should be started at a time

second-line treatment is now either an aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate

if symptoms persist cardiac resynchronisation therapy or digoxin** should be considered. An alternative supported by NICE in 2012 is ivabradine. The criteria for ivabradine include that the patient is already on suitable therapy (ACE-inhibitor, beta-blocker + aldosterone antagonist), has a heart rate > 75/min and a left ventricular fraction < 35%

diuretics should be given for fluid overload

offer annual influenza vaccine

offer one-off*** pneumococcal vaccine

Question 14

NYHA

The New York Heart Association (NYHA) classification is widely used to classify the severity of heart failure:

Answer 14

Heart failure NYHA classification

NYHA Class I

no symptoms

no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations

NYHA Class II

mild symptoms

slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea

NYHA Class III

moderate symptoms

marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms

NYHA Class IV

severe symptoms

unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

Question 15

Hypertension

Stage 1 hypertension

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

Stage 2 hypertension

Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg

Severe hypertension

Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg

Answer 15

Step 1; Age <55 - ACE inhibitor. Age >55 or of black African or Caribbean origin - calcium channel blocker

Step 2; ACE inhibitor + calcium channel blocker

Step 3; ACE inhibitor + calcium channel blocker + thiazide-like diuretic

Step 4; consider further diuretic or beta-blockade or alpha blocker and seeking expert advice

Question 16

Hypertension

Secondary Causes

Answer 16

Renal disease accounts for a large percentage of the other cases of secondary hypertension. Conditions which may increase the blood pressure include:

glomerulonephritis

pyelonephritis

adult polycystic kidney disease

renal artery stenosis

Endocrine disorders (other than primary hyperaldosteronism) may also result in increased blood pressure:

phaeochromocytoma

Cushing’s syndrome

Liddle’s syndrome

congenital adrenal hyperplasia (11-beta hydroxylase deficiency)

acromegaly

Drug causes:

steroids

monoamine oxidase inhibitors

the combined oral contraceptive pill

NSAIDs

leflunomide

Question 17

Bacterial endocarditis

Answer 17

The vast majority of cases of are caused by gram positive cocci.

Common causes:

Streptococcus viridans

Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)

Staphylococcus epidermidis (in prosthetic valves)

Rarer causes:

Enterococcus

Streptococcus bovis

Candida

HACEK group

Coxiella burnetii

Question 18

QT interval

Prolonged

drugs block of potassium channels.

Answer 18

Causes of long QT syndrome:
1. Genetic:

LQT1 / LQT2 (potassium channel mutation); LQT3 (sodium channel mutation)

Jervell and Lange-Nielsen syndrome (associated with deafness)

Romano-Ward syndrome

2. Electrolytes:

Hypocalcaemia

Hypomagnesaemia

Hypokalaemia

3. Drugs:

Antiarrhythmics (e.g. amiodarone, sotalol)

Antibiotics (e.g. erythromycin, clarithromycin, ciprofloxacin)

Psychotropic drugs (e.g. serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic agents)

amiodarone, sotalol, class 1a antiarrhythmic drugs

tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram)

methadone

chloroquine

terfenadine**

erythromycin

haloperidol

ondanestron

electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia

acute myocardial infarction

myocarditis

hypothermia

subarachnoid haemorrhage

Question 19

Diuretics

Furosemide and bumetanide are loop diuretics that act by inhibiting the Na-K-Cl cotransporter

Answer 19

hypokalaemia, hypomagnesaemia

hypochloraemic alkalosis

ototoxicity

hypocalcaemia

renal impairment (from dehydration + direct toxic effect)

hyperglycaemia (less common than with thiazides)

gout

Question 20

Nicorandil

vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP.

Answer 20

Adverse effects

headache

flushing

anal ulceration

Contraindications

left ventricular failure

Question 21

So which features make pulmonary embolism more likely?

The PIOPED study1 in 2007 looked at the frequency of different symptoms and signs in patients who were diagnosed with pulmonary embolism.

The relative frequency of common clinical signs is shown below:

Tachypnea (respiratory rate >20/min) - 96%

Crackles - 58%

Tachycardia (heart rate >100/min) - 44%

Fever (temperature >37.8°C) - 43%

Answer 21

Clinical feature

Points

Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins)

3

An alternative diagnosis is less likely than PE

3

Heart rate > 100 beats per minute

1.5

Immobilisation for more than 3 days or surgery in the previous 4 weeks

1.5

Previous DVT/PE

1.5

Haemoptysis

1

Malignancy (on treatment, treated in the last 6 months, or palliative)

1

Clinical probability simplified scores

PE likely - more than 4 points

PE unlikely - 4 points or less

Question 22

PE

Treatment

Answer 22

a vitamin K antagonist (i.e. warfarin) should be given within 24 hours of the diagnosis

the LMWH or fondaparinux should be continued for at least 5 days or until the international normalised ratio (INR) is 2.0 or above for at least 24 hours, whichever is longer, i.e. LMWH or fondaparinux is given at the same time as warfarin until the INR is in the therapeutic range

warfarin should be continued for at least 3 months. At 3 months, NICE advise that clinicians should ‘assess the risks and benefits of extending treatment’

NICE advise extending warfarin beyond 3 months for patients with unprovoked PE. This essentially means that if there was no obvious cause or provoking factor (surgery, trauma, significant immobility) it may imply the patient has a tendency to thrombosis and should be given treatment longer than the norm of 3 months

for patients with active cancer NICE recommend using LMWH for 6 months

Question 23

Scoring systems

Answer 23

CHA2DS2-VASc

Used to determine the need to anticoagulate a patient in atrial fibrillation

ABCD2

Prognostic score for risk stratifying patients who’ve had a suspected TIA

NYHA

Heart failure severity scale

DAS28

Measure of disease activity in rheumatoid arthritis

Child-Pugh classification

A scoring system used to assess the severity of liver cirrhosis

Wells score

Helps estimate the risk of a patient having a deep vein thrombosis

MMSE

Mini-mental state examination - used to assess cognitive impairment

HAD

Hospital Anxiety and Depression (HAD) scale - assesses severity of anxiety and depression symptoms

PHQ-9

Patient Health Questionnaire - assesses severity of depression symptoms

GAD-7

Used as a screening tool and severity measure for generalised anxiety disorder

Question 24

Statins

Statins inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis

Answer 24

Cardiovascular disease: atorvastatin 20mg for primary prevention,

80mg for secondary prevention

Important for meLess important

Individuals with type 1 diabetes who do not have established cardiovascular disease (CVD) risk factors should be offered atorvastatin 20 mg for primary prevention of CVD if they are:

Older than 40 years of age

Have had diabetes for more than 10 years

Have established nephropathy

Have other CVD risk factors (such as obesity and hypertension)

Question 25

Supraventricular tachycardia

Whilst strictly speaking the term supraventricular tachycardia (SVT) refers to any tachycardia that is not ventricular in origin the term is generally used in the context of paroxysmal SVT. Episodes are characterised by the sudden onset of a narrow complex tachycardia, typically an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.

Answer 25

Acute management

vagal manoeuvres: e.g. Valsalva manoeuvre, carotid sinus massage

intravenous adenosine 6mg → 12mg → 12mg: contraindicated in asthmatics - verapamil is a preferable option

electrical cardioversion

Prevention of episodes

beta-blockers

radio-frequency ablation

Question 26

Thiazide diuretics

Thiazide diuretics work by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl− symporter. Potassium is lost as a result of more sodium reaching the collecting ducts. Thiazide diuretics have a role in the treatment of mild heart failure although loop diuretics are better for reducing overload. The main use of bendroflumethiazide was in the management of hypertension but recent NICE guidelines now recommend other thiazide-like diuretics such as indapamide and chlortalidone.

Answer 26

Common adverse effects

dehydration

postural hypotension

hyponatraemia, hypokalaemia, hypercalcaemia*

gout

impaired glucose tolerance

impotence

Rare adverse effects

thrombocytopaenia

agranulocytosis

photosensitivity rash

pancreatitis