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Cardiovascular Disease Flashcards

1
Q

A patient presents with an ejection systolic murmur, which radiates to the carotids? What is the likely diagnosis?

A

Aortic stenosis

It is loudest in the aortic area

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2
Q

Give a cause of aortic stenosis

A

Rheumatic fever
Congenital bicuspid valve
Calcification

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3
Q

A patient presents with a pansystolic murmur, radiating to the axilla. What is the likely diagnosis?

A

Mitral regurgitation.

Loudest in the mitral area

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4
Q

Give a cause of mitral regurgitation

A

Infective endocarditis
Myocardial infarction
Rheumatic heart disease, Congenital defects, Cardiomyopathy

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5
Q

A patient presents with an early diastolic murmur loudest at the left sternal edge. What is the likely diagnosis?

A

Aortic regurgitation

Features include collapsing pulse, hyperdynamic apex beat.

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6
Q

Give a cause of aortic regurgitation

A

Marfan’s syndrome
Endocarditis

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7
Q

A patient presents with a loud S1, a mid-diastolic murmur, loudest at apex. They also present with a malar flush and low volume pulse. What is the likely diagnosis?

A

Mitral stenosis.

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8
Q

Give a cause of mitral stenosis

A

Rheumatic heart disease Congenital defects
Myxoma
Connective tissue disorders

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9
Q

A patient presents with a mid-systolic click and murmur, loudest at apex. What is the likely diagnosis?

A

Mitral valve prolapse

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10
Q

A patient presents with a pansystolic murmur, loudest at tricuspid area, loudest on inspiration. They also have hepatic pulsations, and signs of right side heart failure. What is the likely diagnosis?

A

Tricuspid regurgitation

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11
Q

Give a cause of tricuspid regurgitation

A

Right ventricular dilatation Rheumatic fever
Infective endocarditis
Carcinoid syndrome
Congenital defects

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12
Q

A patient presents with an ejection systolic murmur, loudest at pulmonary area, radiating to the left shoulder. There is a wide split S2. What is the likely diagnosis?

A

Pulmonary stenosis

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13
Q

Give a cause fo pulmonary stenosis

A

Congenital syndromes
Rheumatic fever
Carcinoid syndrome

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14
Q

A patient presents with an early diastolic murmur, loudest at left sternal edge, loudest on inspiration. What is the likely diagnosis?

A

Pulmonary regurgitation

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15
Q

Give a cause of pulmonary regurgitation

A

Pulmonary hypertension
Infective endocarditis
Congenital heart disease

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16
Q

A patient presents with a mid-diastolic murmur, loudest at left sternal edge, loudest on inspiration. They have a raised JVP, peripheral oedema and ascites. What is the likely diagnosis?

A

Tricuspid stenosis

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17
Q

Give a cause of tricuspid stenosis

A

Rheumatic fever
Congenital disease
Infective endocarditis

features include raised JVP, peripheral oedema, ascites.

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18
Q

What causes the first heart sound (S1)?

A

Closure of the mitral and tricuspid valves.

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19
Q

What causes the second heart sound (S2)?

A

Closure of the aortic and pulmonary valves.

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20
Q

What is the Levine scale?

A

Scale of how loud a cardiac murmur is. From 1 (quiet) to 6 (audible without a stethoscope).

4-6 have a ‘thrill’ - a palpable vibration.

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21
Q

What is the diagnostic gold standard test for cardiac palpitations?

A

ECG recording at the time of the palpitation

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22
Q

Give an example of a valsalva maneuver you could use in primary care prior to sending a patient into hospital with suspected SVT?

A

Blow into a syringe while lying down face up for 15 seconds.

Carotid sinus massage

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23
Q

When assessing a patient with palpitations what vitals suggest haemodynamic instability?

A

Tachycardia
Hypotension

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24
Q

What is the difference betwen Group 1 and Group 2 driving entitlement?

A

Group 1 - Cars and motorcycles
Group 2 - Lorries and heavy vehicles

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25
For a patient with an arrhythmia, can they drive?
If arrhythmia has or is likely to cause incapacity e.g. syncope, then they cannot drive, until a cause has been identified and the symptoms have been controlled for at least 4 weeks (for Group 1) and 3 months (Group 2).
26
True or false, individuals working at height or with dangerous machinery will have to stop work if they have an arrhythmia?
If the arrhythmia has or is likely to cause syncope, then the person cannot work these jobs, until the cause is identified and treated.
27
When should you consider admission to hospital for a patient with palpitations?
Haemodynamically unstable Chest pain FHx sudden cardiac death <40yrs Provoked by exercise Breathlessness Lightheaded
28
What are the 4 types of atrial fibrillation?
Paroxysmal - episodes terminate <7days Persistent - episodes last >7 days Longstanding - Episodes > 12 months Permanent - No further attempts to restore sinus rhythm
29
What is the first line anticoagulant treatment for AF?
DOAC Apixaban, Dabigatran, Edoxaban, and Rivaroxaban,
30
What is the first line treatment for rate control in AF?
Beta Blocker (not sotalol) Rate-limiting CCB (Diltiazem / Verapamil) Sotalol is not very effective and can worsen arrhhthmias
31
What tool is used to assess stroke risk in patients with AF?
CHADSVASC Age Sex CHF HT Stroke/TIA Vascular disease Diabetes
32
How do you assess the bleeding risk of a patient with AF?
ORBIT Sex Age Bleeding history eGFR <60 Antiplatelets Bleeds per 100 patient-years 0-2 low risk 3 - medium risk 4-7 high risk
33
Should you withhold anticoagulation for AF in a patient solely due to falls risk?
No. NICE guidance states: "Do not withhold anticoagulation solely based on a person's age or falls risk"
34
What CHADSVASC score would cause you to initiate treatment with a DOAC in a patient with AF?
A person with a score of 2 or more Consider it in a male with a score of 1 or more
35
If a DOAC is contraindicated or not tolerated, what is second line treatment for AF?
Warfarin (Vit K antagonist)
36
Should you start rate control treatment in AF?
You can consider it in patients with stable AF. However,it should be avoided if A potentially reversible cause. Heart failure thought to be primarily caused by AF. New-onset AF within the past 48 hours. A rhythm-control strategy is felt to be more suitable clinically — this will usually be a specialist decision. See the section on Admission or referral for more information. Patients should be reviewed 1 week after dose initiation/changes.
37
What is the most important factor in the CHADSVASC score?
Age >75yrs (2 points)
38
What is the target INR for warfarin treatment of AF
2.5
39
What is angina?
Chest pain caused by insufficient blood flow to the myocardium
40
What is first line treatment for angina?
Lifestyle management: stop smoking, exercise, diet. Ensure good BP control (ACEi if not) 1st line: Sublingual GTN Beta Blocker / CCB Second line: long-acting nitrate (for example isosorbide mononitrate), nicorandil, ivabradine, or ranolazine
41
When should a patient with angina be referred to hospital?
Consider if: - Progressive chest pain - Chest pain at rest (often at night) - Pain on minimal exertion
42
True or false, low dose aspirin can be given to patients with angina?
True. Consider 75mg OD in stable angina to reduce risk of ACS
43
How should you advise a patient with angina to use sublingual GTN spray/tablets?
Take it when you experience chest pain. Stop activity. Sit down. 2nd dose after 5 mins Call ambulance 5 mins after 2nd dose if chest pain ongoing.
44
What tool is used to asses heart failure severity?
New York Heart Failure Classification Class I: No limitation of physical activity Class II: Slight limitation of physical activity Class III: Marked limitation of physical activity Class IV: Unable to carry out any physical activity without discomfort
45
What test should you do to assessa patient for heart failure?
Initially a BNP <400ng/L - unlikely HF 400-2000ng/L - HF likely. Specialist referral + echocardiogram in < 6 weeks. > 2000ng/L - Urgent specialist referral and echocardiogram in <2 weeks. All will need an ECG
46
How is HF treated?
Loop Diuretic e.g. furosemide ACEi BBlocker If still not controlled: + Spironolactone (reduces pressure on heart and reduces myocardial scarring) Consider replacing ACEi with Sacubatril valsartan if EF <35%. Also consider Hydralazine, ivabradine and digoxin.
47
What are the three beta blockers licensed for treatment of HF in the UK?
Bisoprolol Carvedilol Nebivolol
48
True or false, patients with heart failure should be advised to get an annual flu shot and once only pneumococcal vaccine.
True
49
True or false, heart failure patients should be screened for depression>=?
True Depression is commonly associated with heart failure
50
Define TIA?
Transient ischaemic attack (TIA) is a transient (less than 24 hours) neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction.
51
Which are more common, haemorrhagic or ischaemic strokes?
Ischaemic 85% Haemorrhagic 15%
52
What is FAST?
Face - asymmetry Arms - paralysis/paraesthesia Speech - Slurring/Aphasia Time - Time to call ambulance
53
When should a patient who has had a stroke be followed up in primary care?
6 months after hosptial admission Then annually To check for need for specialist review
54
How do you manage a TIA in primary care?
Aspirin 300mg (unless contraindicated or taking aspirin regularly). To be seen by neurology if TIA was in the last 7 days. If more than 7 days, they should be seen by a specialist within 7 days. Advise the patient not to drive until a specialist has reviewed and says they can.
55
What is secondary prevention for a stroke?
Clopidogrel 75mg OD is the standard treatment. Initially they may be started on dual antiplatlets Aspirin + Clopidogrel by secondary care for 3 months. If Clopidogrel is not tolerated then Aspirin or Dipyridamole can be given. High dose statin (20-80mg) with target reduction in non-HDL of 40%. If fails to meet target in 3 months and lifestyle/adherence not an issue, discuss with specialist. Don't prescribe fibrates, nicotinic acid, or omega 3 for ischaemic stroke. Ezetimibe is only for familial hypercholestraemia. BP control - normal tagets except for bilateral carotid artery stenosis where systolic 140-150 is tolerated. Anticoagulant (DOAC 1st line; Warfarin 2nd line) if AF. Lifestyle guidance.
56
What is the target range INR for a patient taking warfarin for AF with hx of stroke?
Target 2.5 (Range 2-3)
57
What are the driving restrictions following a TIA or stroke?
A single TIA = 1 month ban. Don't need to inform DVLA. Multiple TIA = 3 months (can resume after 3 month if no further TIAs). Need to inform DVLA. Stroke = 1 month then may return if sufficient clinical improvement after 1 month. Advise on-road screening and evaluation test. Only need to inform DVLA if persistent clinical signs after 1 month.
58
What is the difference between primary and secondary hypertension?
Primary (90% of cases) no known cause. Secondary is caused by something else e.g. renal, vascular, endocrine, drugs.
59
What are the three stages of hypertension?
Stage 1: > 140/90 (Home 135/85) Stage 2: > 160/100 (Home 150/90) Stage 3: > 180/120
60
What is accelerated (aka malignant hypertension)?
BP > 180/120 with signs of retinal haemorrhage or papilloedema.
61
Who should be referred into hospital for same day assessmend with hypertension?
BP > 180/120 + papilloedema / retinal haemorrhage or chest pain.
62
What is the test for phaeochromacytosis? When might you suspect it?
Plasma free metanephrines Suspect it if labile blood pressure, pulse, excessive sweating (diaphoresis), pallor, headache, palpitations.
63
True or false, statins are safe during pregnancy?
False. They should not be given in pregnancy due to risk of congenital abnormalities. They should be stopped 3 months prior to conceiving.
64
True or false, statins should be avoided in breastfeeding?
True.
65
What bloods should be assessed prior to starting a statin? How should it be monitored after?
Initially: Lipid profile LFT Thyroid U&E Then repeat LFT and Lipid within 3 months and at 12 months. Technically, patients with high risk of diabetes should have a fasting glucose / HBA1c before treatment and then at 3 months.
66
How high do live transaminases need to be to stop the statin?
3 times baseline for AST/ALT If ALT/AST are raised but not >3x baseline, then repeat in 4-6 weeks. Consider low dose, alternative statin once transaminases have normalised.
67
What blood test is important to check if a patient has muscle aches on a statin?
Creatine Kinase
68
What is the advice for cntraception while taking a statin?
Contraception throughout treatment and 1 month after stopping.
69
What is the initial dose of a statin for CKD (stage 3a or higher)
20mg OD
70
What is the difference between provoked and unprovoked DVT?
Provoked - a cause within 3 months e.g. pregnancy, surgery, trauma, immobility or on-going hormonal treatment (HRT/COCP). Unprovoked - No major recent risk factors and not on hormonal treatment.
71
What is the most serious complication of DVT?
PE
72
Give two typical signs of a DVT
Localized pain and swelling Tenderness Skin changes (oedema, redness, and warmth) Prominent superficial veins.
73
How do you manage a DVT in primary care?
Well's score. If likely 2 and above, then needs doppler US in secondary care in 4 hours. If longer than 4 hours, then start treatment (DOAC) + DDimer and arrange scan in 24hrs. If Well's 1, then do a DDimer and arrange a doppler within 4 hours, if +ve.
74
What is the appropriate drug treatment for suspected or confirmed DVT?
Rivaroxaban or Apixaban If unsuitable then: Low molecular weight heparin (LMWH) for at least 5 days, followed by dabigatran or edoxaban OR LMWH alongside a vitamin K antagonist (warfarin) for at least 5 days. Treatment for provoked DVT is usually 3 months. Can be much longer if unprovoked.
75
True or false, elastic compression stockings (ECS) should be offered patients who have had a DVT/PE?
False.
76
What should you consider testing for in patient with unprovoked DVT/PE?
Cancer Thrombotic disorder e.g. antiphospholipid syndrome
77
How do you test for antiphospholipid syndrome (aka Hughes syndrome)?
Antiphospholipid antibodies Requires 2 tests 12 weeks apart Harmless antiphospholipid antibodies can develop transiently sometimes.
78
What is the first line treatment of DVT in pregnancy?
LMWH is the first line (safer) (Not DOAC! DOAC may be considered post-partum).
79
True or false, DOACs are to be avoided in pregnancy or breast feeding?
True
80
What are the signs of acute limb ischaemia?
5 Ps Pulseless Pallor Paraesthesia Paralysis Pain Usually presents within 2 weeks
81
How does intermittent claudication present?
Pain on exertion e.g. walking which is relieved on rest (The most common presentation of peripheral arterial disease)
82
What is the most common cause of PE?
DVT in lower limbs
83
How do you assess chronic peripheral artery disease?
Ankle Brachial Pressure Index (ABKI) 0.9 or less indicates PAD
84
How is chronic peripheral artery disease treated?
Angioplasty Bypass If patient does not want to be referred for these then consider: treating with naftidrofuryl oxalate
85
What is the Wells score for PE which makes it likely?
5 and above (likely) - need CTPA 4 and below (unlikely) - DDimer (result in 4 hours)
86
Give an example of a cyanotic and acyanotic heart condition.
Acyanotic: PDA VSD ASD Coarctation of Aorta Cyanotic: Tetralogy of Fallot Transposition of Great Arteries Tricuspid atresia
87
How does a Still's murmur present?
Common innocent murmur in children Low-pitched, left sternal border, radiates to apex, loudest lying on back. Typically seen 2-7 years. Likely resolves by adolescence. The cause is actually not known.
88
What is Raynaud's phenomenon?
Cold or stress induced episodic peipheral vasospasm Primary (90%) idiopathic Secondary (10%) with known cause e.g connective tissue disorder, obstructive vascular disease, disorder or vibration
89
True or false, Raynaud's is more common in women?
True
90
What is the first line medical treatment for Raynaud's?
Nifedipine Immediate release is licensed, MR is not licensed but is often better tolerated. If nifedipine is not tolerated then try amlodipine.
91
Would you refer a 10 year old with Raynaud's to a specialist?
Yes. Anyone 12 and under with Raynaud's should be referred to a paediatrician or paediatric rheumatologist.

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