core conditions- cardiovascular

Question 1

first line management of pericarditis

Answer 1

NSAID and colchicine

Question 2

What is the most common cause of secondary hypertension?

Answer 2

Chronic kidney disease

Question 3

What is secondary hypertension?

Answer 3

Secondary hypertension has a known underlying cause, such as renal, endocrine, or vascular disorder, or the use of certain drugs.

Question 4

Secondary causes of hypertension (mneumonic)

Answer 4

ROPED

Renal disease
Obesity
Pregnancy-induced hypertension or pre-eclampsia
Endocrine (e.g. hyperaldosteronism (Conn’s syndrome)
Drugs (e.g. NSAIDs, alcohol, steroids, oestrogen and liquorice)

Question 5

Complications of hypertension

Answer 5

High blood pressure increases the risk of:

Ischaemic heart disease (angina and acute coronary syndrome)
Cerebrovascular accident (stroke or intracranial haemorrhage)
Vascular disease (peripheral arterial disease, aortic dissection and aortic aneurysms)
Hypertensive retinopathy
Hypertensive nephropathy
Vascular dementia
Left ventricular hypertrophy (sustained and forceful apex beat)
Heart failure

Question 6

Next step if hypertension due to renal disease does not respond to treatment

Answer 6

consider renal artery stenosis

Question 7

how can renal artery stenosis be diagnosed?

Answer 7

duplex ultrasound or an MR or CT angiogram (xray)

Question 8

What is white coat syndrome?

Answer 8

When having blood pressure taken by a doctor or nurse often results in a higher reading

Question 9

NICE recommend all patients with a new diagnosis should have

Answer 9

Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
Bloods for HbA1c, renal function and lipids
Fundus examination for hypertensive retinopathy
ECG for cardiac abnormalities, including left ventricular hypertrophy

Question 10

What is QRISK score?

Answer 10

Estimates the percentage risk that a patient will have a stroke or myocardial infarction in the next 10 years. When the result is above 10%, they should be offered a statin, intially atorvastatin 20mg at night

Question 11

What are the medications used in management for hypertension?

Answer 11

ACE inhibitor e.g. ramipril
Beta blocker e.g. bisoprolol
Calcium channel blocker e.g. amlodipine
D- Thiazide-like-diuretic e.g. indapamide
ARB- angiotensin II receptor blocker e.g. candesartan

Question 12

What drug is an alternative if the person does not tolerate ACE inhibitors? (commonly due to a dry cough)

Answer 12

ARBs

Question 13

What 2 anti hypertension drugs are not used together?

Answer 13

ARBs and ACEi

Question 14

Angiotensin receptor blockers (ARBs) are recommended by NICE instead of ACE inhibitors in patients of … In the steps below, you can replace A with ARB for these patients.

Answer 14

Black African or African-Caribbean family origin

Question 15

… are used as an alternative if the patient does not tolerate calcium channel blockers (commonly due to ankle oedema).

Answer 15

Thiazide-like diuretics

Question 16

How does Spironolactone work?

Answer 16

Spironolactone is a potassium-sparing diuretic. It works by blocking the action of aldosterone in the kidneys, resulting in sodium excretion and potassium reabsorption. It can be helpful when thiazide diuretics are causing hypokalaemia.

Question 17

What anti hypertension drugs can cause hyperkalaemia?

Answer 17

Spironolactone or ACE inhibitors

Question 18

What is accelerated hypertension/ malignant hypertension?

Answer 18

Extremely high blood pressure, above 180/120, with retinal haemorrhages or papilloedema

Question 19

What are the intravenous options in a hypertensive emergency?

Answer 19

Sodium nitroprusside
Labetalol
Glyceryl trinitrate
Nicardipine

Question 20

What is peripheral arterial disease?

Answer 20

Peripheral arterial disease (PAD) refers to the narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas. It usually refers to the lower limbs, resulting in symptoms of claudication.

Question 21

What is intermittent claudification?

Answer 21

a symptom of ischaemia in a limb, occurring during exertion and relieved by rest. It is typically a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity.

Question 22

What is critical limb ischaemia?

Answer 22

is the end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest. There is a significant risk of losing the limb.. The features are pain at rest, non-healing ulcers and gangrene. Pain is worse at night when the leg is raised, as gravity no longer helps pull blood into the foot.

Question 23

What is acute limb ischaemia?

Answer 23

Acute limb ischaemia refers to a rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in myocardial infarction.

Question 24

What is ischaemia?

Answer 24

Ischaemia refers to an inadequate oxygen supply to the tissues due to reduced blood supply.

Question 25

What is necrosis?

Answer 25

death of tissue

Question 26

what is gangrene?

Answer 26

Death of the tissue, specifically due to an inadequate blood supply

Question 27

What is atherosclerosis?

Answer 27

Athero- refers to soft or porridge-like and -sclerosis refers to hardening. Atherosclerosis is a combination of atheromas (fatty deposits in the artery walls) and sclerosis (the process of hardening or stiffening of the blood vessel walls). Atherosclerosis affects the medium and large arteries. It is caused by chronic inflammation and activation of the immune system in the artery wall. Lipids are deposited in the artery wall, followed by the development of fibrous atheromatous plaques.

Question 28

What do atherosclerotic plaques cause?

Answer 28

Stiffening of the artery walls, leading to hypertension (raised blood pressure) and strain on the heart (whilst trying to pump blood against increased resistance)
Stenosis, leading to reduced blood flow (e.g., in angina)
Plaque rupture, resulting in a thrombus that can block a distal vessel and cause ischaemia (e.g., in acute coronary syndrome)

Question 29

what are the modifiable and non-modifiable risk factors of atherosclerosis?

Answer 29

Non-modifiable risk factors:

Older age
Family history
Male

Modifiable risk factors:

Smoking
Alcohol consumption
Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s)
Low exercise / sedentary lifestyle
Obesity
Poor sleep
Stress

Question 30

What medical co-morbidities increase the risk of atherosclerosis?

Answer 30

Diabetes
Hypertension
Chronic kidney disease
Inflammatory conditions such as rheumatoid arthritis
Atypical antipsychotic medications

Question 31

What are the end results of atherosclerosis?

Answer 31

Angina
Myocardial infarction
Transient ischaemic attack
Stroke
Peripheral arterial disease
Chronic mesenteric ischaemia

Question 32

what are the 6 P’s associated with acute limb ischaemia?

Answer 32

pain, pallor, pulseless, paralysis, paraesthesia (pins and needles), perishing cold

Question 33

Leriche syndrome occurs with occlusion of in the…

Answer 33

distal aorta or proximal common iliac artery

Question 34

what is the clinical triad of Leriche syndrome? and the signs on examination

Answer 34

Thigh/buttock claudication
Absent femoral pulses
Male impotence

tar staining and xanthomata

Question 35

What are the signs of arterial disease on inspection?

Answer 35

Skin pallor
Cyanosis
Dependent rubor (a deep red colour when the limb is lower than the rest of the body)
Muscle wasting
Hair loss
Ulcers
Poor wound healing
Gangrene (breakdown of skin and a dark red/black change in colouration)

Question 36

what are examination findings in arterial disease?

Answer 36

Reduced skin temperature
Reduce sensation
Prolonged capillary refill time (more than 2 seconds)
Changes during Buerger’s test

Question 37

Describe Buerger’s test

Answer 37

Buerger’s test is used to assess for peripheral arterial disease in the leg. There are two parts to the test.

The first part involves the patient lying on their back (supine). Lift the patient’s legs to an angle of 45 degrees at the hip. Hold them there for 1-2 minutes, looking for pallor. Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease. Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees.

The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour. In a patient with peripheral arterial disease, they will go:

Blue initially, as the ischaemic tissue deoxygenates the blood
Dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration

The dark red colour is referred to as rubor.

Question 38

arterial ulcers vs venous ulcers

Answer 38

Arterial ulcers are caused by ischaemia secondary to an inadequate blood supply. Typically, arterial ulcers:

Are smaller than venous ulcers
Are deeper than venous ulcers
Have well defined borders
Have a “punched-out” appearance
Occur peripherally (e.g., on the toes)
Have reduced bleeding
Are painful

Venous ulcers are caused by impaired drainage and pooling of blood in the legs. Typically, venous ulcers:

Occur after a minor injury to the leg
Are larger than arterial ulcers
Are more superficial than arterial ulcers
Have irregular, gently sloping borders
Affect the gaiter area of the leg (from the mid-calf down to the ankle)
Are less painful than arterial ulcers
Occur with other signs of chronic venous insufficiency (e.g., haemosiderin staining and venous eczema)

Question 39

Investigations of peripheral arterial disease

Answer 39

Ankle-brachial pressure index (ABPI) (using Doppler)
Duplex ultrasound – ultrasound that shows the speed and volume of blood flow
Angiography (CT or MRI) – using contrast to highlight the arterial circulation

Question 40

Management of intermittent claudification

Answer 40

-lifestyle

Medical:
Atorvastatin 80mg
Clopidogrel 75mg once daily (aspirin if clopidogrel is unsuitable)
Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)

Surgical:
Endovascular angioplasty and stenting
Endarterectomy – cutting the vessel open and removing the atheromatous plaque
Bypass surgery – using a graft to bypass the blockage

Question 41

Management of critical leg ischaemia

Answer 41

Urgent revascularisation can be achieved by:

Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply

Question 42

Management of acute limb ischaemia

Answer 42

Endovascular thrombolysis – inserting a catheter through the arterial system to apply thrombolysis directly into the clot
Endovascular thrombectomy – inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices
Surgical thrombectomy – cutting open the vessel and removing the thrombus
Endarterectomy (removal of plaque)
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply