Cardiovascular

Question 1

What BP target are chosen for those with CKD?

Answer 1

for those with CKD BP target depends on albumin:creatinine ratio (ACR).

• if ACR is 70 or more - BP target of <130/80.
• if ACR is <70, BP target is <140/90.

Home BP reading target for those under 80 is <135/85. For those >80 without co-morbidities target is <145/95.

Question 2

When would you treat HTN?

Answer 2

• if clinic reading is equal or more than 140/90 - offer ABPM or HBPM, the subsequent Tx depends on these readings.
  1. if <135/85 - not HTN, monitor.

2. If =>135/85 (stage 1 HTN), treat if <80 AND one of:
   a) target organ damage
   b) established CVD
   c) renal disease
   d) diabetic
   e) 10 yr CV risk 10% or more.
3. if =>150/95 (Stage 2 HTN), treat all pts regardless of age.

Question 3

what lifestyle advice would you give for management of HTN?

Answer 3

1. low salt diet, aiming for <6g/day, ideally 3g/day (average salt intake in UK is 8-12 g daily).
2. reduce caffeine intake.
3. Generic stuff: stop smoking, drink less etOH, eat balanced diet rich in fruit and veg, exercise more and lose weight.

Question 4

When would you consider secondary causes of HTN?

Answer 4

for patients <40yrs, specialist referral to exclude secondary causes should be considered.

Question 5

What drug treatment options are there for management of HTN?

Answer 5

This largely depends on age, ethnicity and diabetic status.

1. < 55 yrs OR diabetics
   - ACE i or ARB.
2. =>55yrs + non-diabetic OR Afro-Caribbean + non-diabetic
   - Calcium channel blocker (ca-channel blocker).
3. if above options (step 1) infective, then can combine ACE/ARB with CCB OR ACE/ARB + thiazide-like diuretics. (for black pts, add ARB in preference to ACEi)
4. if above not working, then triple therapy of ACEi/ARB + CCB + Thiazide-like diuretic.
5. If triple therapy didn’t work, the next bit depends on K status:
   - if K <= 4.5, add low dose spironolactone.
   - if K>4.5, add alpha or B-blocker.
6. if BP not controlled on 4 anti-HTN, refer to specialist for review.

Question 6

How is Familial hypercholesterolaemia diagnosed?

Answer 6

Based on Simon Broome criteria:
- In adults TC>7.5 and LDL-C >4.9 OR
in children TC>6.7 and LDL-C>4 plus:

a) for definite FH: tendon xanthoma in pt or 1st or 2nd degree relative or DNA evidence of FH.
b) for possible FH: FHx of MI below age 50 in 2nd degree relative, below 60 in 1st degree relative, or a Fhx of raised cholesterol level.

Question 7

When should we suspect FH?

Answer 7

Suspect FH as possible in adults with:

• total cholesterol of >7.5 and/or
  a) personal or FHx of premature CHD (an event before age 60 in index or 1st degree relative).

Children of affected parents:

• if one parent affected - arrange testing for child by age 10.
• if both parents affected, arrange testing in child by age 5.

Question 8

When can sexual activity begin after an MI?

Answer 8

4 weeks after an uncomplicated MI.

Question 9

When can Sildenafil be prescribed after an MI?

Answer 9

PDE5 inhibitors (e.g. sildenafil) may be used 6 months after an MI.

• Should not be co-prescribed in those using nicorandil or nitrates.

Question 10

What are the drug treatment options for stable angina?

Answer 10

• all pt should be on aspirin and statin (unless contra-indicated).
• GTN PRN
• B-blocker or CCB (non-rate control ones) - if CCB monotherapy is used, rate-controlling one can be used.
• Increase monotherapy to maximum tolerated dose before adding the next one.
• B-blocker + CCB is next step (non-rate controlling CCB)
• If pt cannot tolerate one of the B-blocker or CCB, then can add on one of - long-acting nitrate, ivabradine, nicorandil or ranolazine.
• if pt already on B-blocker + CBB and need more drugs, refer and while waiting assessment add on a third one from above, while pt waiting for review for possible PCI/CABG.

Question 11

What is Nitrate tolerance?

Answer 11

• those who take nitrates develop tolerance and experience reduced efficacy.
• those who take standard release ISMN, should use asymmetric dosing interval to maintain daily nitrate-free time of 10-14 hours to minimise this.
• this is not seen in those who take once daily modified-release ISMN.

Question 12

what’s the recommendation around anti-coagulation in those who have catheter-ablation for AF?

Answer 12

Anticoagulation should be used 4 weeks before and during the procedure.

• it should be remember that 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 there CHA2DS2-VASc score
• if score = 0: 2 months anticoagulation recommended
• if score > 1: longterm anticoagulation recommended

Question 13

which CCB do we use for angina that is not controlled with b-blocker?

Answer 13

Felodipine.

• Verapamil and diltiazem are not used in heart failure.
• If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine).
• if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine