Diabetes + Cardiovascular Health Flashcards
Newly diagnosed T2DM requiring medication. What is initial management?
Metformin
+
(if high risk CVD) - Consider gliflozin
(if CVD/ IHD/ TIA/ HF etc) - Offer gliflozin
What are the indications for prescribing gliflozins in diabetes?
1st line with metformin for those with increase CVD risk (For cardioprotection)
1st line with metformin for renoprotection in CKD
Gliclazide:
A) Starting dose
B) Maximum dose
C) Key side effects
A) 40-80mg OD (higher than this split doses, i.e. 160mg BD)
B) 320mg daily
C) High risk hypo’s, weight gain
(note gliclazide one of the best drugs to reduce HbA1c)
What is the HbA1c target of a diabetic patient controlled by lifestyle?
48mmol/mol
What is the HbA1c target of a diabetic patient controlled by metformin?
48mmol/mol
What is the HbA1c target of a diabetic patient controlled with gliclazide and metformin?
53mmol/mol
(Note any drug which has tendency to hypos or if on multiple drugs target relaxed to 53mmol)
You are choosing between a gliptin and a sulphonylurea - what are the pros and cons of each?
Sulphonylurea (Gliclazide) - Most effective at lowering HbA1c but hypo risk and weight gain
Gliptins (Allogliptin) - Lower hypo risk and weight neutral but less effective at lowering HbA1c
How is CKD diagnosed in diabetics? (2 and/ or criteria)
- eGFR is less than 60 for 4 months or more
AND/OR - Urine ACR >3 for 3 months or more
A T2DM patient (only taking metformin and no other medicines) has a persistent ACR of 3.8 and 4 taken 3 months apart. What additional medication should be considered? (3)
Now has diabetic related CKD
1) Ramipril (renoprotective)
2) Dapagliflozin (renoprotective)
3) Atorvastatin 20mg (higher risk as now also CKD as well as DM)
On average, how much will the following medicines reduce HbA1c following initiation?
a) Metformin
b) Gliclazide (Sulfonylurea)
c) Gliptins
d) Flozins (SGLT2)
Metformin: 10-20
Gliclazide: 15-20+ (one of most effective)
Gliptins: 5-10
Flozins (SGLT2): 10-30
What three drugs are ‘mets mates’ and what indication would there be for selecting each of them?
1) Gliclazide - One of the most effective
- Risks: Hypos and weight gain
2) Gliflozins
- Generally 1st line if CKD/ CVS risk factors along with metformin
3) Gliptins - One of the least effective
- Low risk of hypos and weight neutral
What are the three ‘use because you need to choose’ drugs in diabetes?
Use only for specific reasons
1) GLP-1’s (i.e. liraglutide) - If obesity
2) Pioglitazone - Use if insulin resistance
- Increases heart failure risk, causes weight gain
3) Insulin
- Requires good understanding to use well
- NICE said indicated if on two oral agents
A patient presents to clinic with new BP 164/105. What investigations do you do to assess for target organ damage?
ECG
Urine dip (haematuria) + send ACR
Bloods (U+E, HbA1c, cholesterol + FBC)
Fundoscopy
A patient presents to clinic with new BP 184/112. What indications would require same day referral?
1- Life threatening features (chest pain, confusion, new AKI, heart failure)
2- Accelerated hypertension (papilloedema/ retinal haemorrhage/ blurred vision)
3- Suspect phaeochromocytoma (labile BP, headache, palpitations, excessive sweating)
You are about to see one of your patients who is 4 weeks post MI, what medication do you expect them to be on?
Aspirin - lifelong
(+/- dual antiplatlet with ticagrelor or clopidogrel, length of dual decided by specialist team)
ACEI - usually lifelong
Beta blocker - usually for at least 12 months if no LVSD and lifelong if LVSD
Statin - usually high dose
A 65yM consults after an MI, he wants to know when he can have sex again, and if he can still use his viagra?
Sex resumed when comfortable, usually around 4 weeks
Viagra (Sildenafil) safe to use post MI but usually wait 2 weeks and NOT if any of: (Taking nitrates, unable angina, severe heart failure)
For primary prevention of CVD, high-intensity statin treatment (atorvastatin 20 mg daily) should be offered to people:
(Name 3 groups)
A) Under 84 with QRISK > 10%
B) T1DM, either over 40, diabetes for more than 10 years or other CVD risk factors
C) CKD 3 or beyond
D) Familial hypercholesterolaemia
What is the recommended statin + dosage for primary prevention?
Atorvastatin 20mg
When should statin treatment be initiated with relation to CVD risk?
QRISK > 20%
QRISK >10% and lifestyle measures not effective
What is the NHS Health Check Programme for CVD?
Everyone age 40-74yrs (without diagnosis of CVD, diabetes or CKD) is invited every 5 years for free health check
Name 5 modifiable risk factors for cardiovascular disease to discuss in each relevant consultation?
Smoking
Diet
Exercise
Weight
Alcohol
(Blood pressure, T2DM etc. also modifiable)
What is the definition of stage 1 hypertension?
Clinic 140/90 to 159/99
HBPM 135/85 to 149/94
What is the definition of stage 2 hypertension?
Clinic: 160/100 to 179/119
HBPM over 150/95
What is the definition of stage 3 (severe) hypertension?
Systolic >180
Diastolic >120
What are clinic targets for a hypertensive patient who:
a) 64yr
b) 86yr
c) 43 yr diabetic
a) 140/90 (all under 80, ABPM target 135/85)
b) 150/90 (over 80’d, ABPM target 145/85)
c) 140/90 unless any renal disease/ impaired ACR, then 130/80
A patient presents with a confirmed ABPM of 145/92, what are the considerations for drug/ no drug treatment?
<80 yrs + no RF/ Qrisk < 10% - Consider (option to)
<80, any RF or QRisk over 10 - Discuss (stronger advice)
>80 yrs - Don’t start drug tx unless over 150/90
First line management for hypertension, when to consider ACEI/ARB and when CCB?
Diabetic - Always ACEI/ARB
For non diabetic:
Over 55 or Afrocarribean- CCB
Under 55, not Afrocarribean - ACEI/ARB
Second line management for 52year old Caucasian male with hypertension, already on 10mg Ramipril?
1) ACEI/ ARB
2) Add either CCB (amlodipine - 5mg up-to 10mg) or thiazide (indapamide - start 2.5mg)
Third line management for hypertension - what three medications?
ACEI/ ARB (Ramipril 1.25mg-10mg)
CCB (Amlodipine 5-10mg)
Thiazide (Indapamide 2.5mg)
How should a patient with stage 2 hypertension be managed with regard to considering medication?
(Stage 2 is HBPM readings over 150/95 or clinic over 160/100)
- Offer drug treatment
What is the presentation of acute limb ischemia?
6p’s
Pale, pallor, pulselessness, perishing cold, paraesthesia, paralysis
How does chronic limb threatening ischemia present (history)?
Night pain (relieved hanging over edge), tissue loss
May be minimal/ no claudication as either not/ unable to walk sufficient distance or comorbid with peripheral neuropathy
What examination finds suggest chronic limb threatening ischemia?
Absent foot pulses
Could also be cold with discolouration
(Always examine lying not sitting)
Burgers test - elevate foot, goes white, lower below bed, goes red (reactive hyperaemia)
How should acute limb ischemia be managed?
Immediate discussion with vascular surgeons
How should chronic limb threatening ischemia be managed?
Immediate discussion with vascular surgeons
(Don’t need all 6p’s)
What is the first symptom of PAD?
Intermittent claudication
- Pain on walking, worse with hurry or a hill
- Relieved within <5mins rest and not present once rested
(Also can affect hips and buttocks)
How do you distinguish between pain from likely PAD and pain from spinal stenosis?
Both give foot pain on walking
SS - Relieved by leaning forwards, may also be weakness, may be minimal CVD risk factors
PAD - Standing still (without leaning forward) relieves pain. No weakness or numbness
A patient presents with intermittent claudication, how do you manage?
1st line - Exercise programme
- If not keen for this, or not worked - refer for angioplasty/ bypass
CVD risk: Discuss smoking, diet, weight etc. Check HTN/ T2DM etc.
Meds: Start atorvastatin 80mg and clopidogrel 75mg
What is the most predictive examination finding for PAD? Does more signs increase likelihood of PAD diagnosis?
The most predictive sign is cool skin in those with leg symptoms.
Combination of signs does not increase the chance of diagnosis, so take any single sign seriously in PAD
What is the clinical triad of typical angina?
Contracting discomfort in chest, neck, shoulders, jaw or arms
Precipitated by physical exertion
Relieved by rest of GTN
(ALL 3 = typical angina pain)
What is the definition of atypical angina?
2 of (but not 3):
- Contracting discomfort in chest, neck, shoulders, jaw or arms
- Precipitated by physical exertion
- Relieved by rest of GTN
Also possible GI discomfort/ breathlessness/ nausea
You are taking a chest pain history, what factors make a diagnosis of stable angina less likely? (3)
Pain is continous or prolonged
Pain unrelated to activity
Pain brought on by breathing
Pain associated with dizziness, palpitations, tingling or difficulty swallowing
What drug treatments should be prescribed for a patient with stable angina?
- GTN spray
- Beta blocker or calcium channel blocker
- Aspirin 75mg
- Statin
- ACEI if coexisting (diabetes, heart failure, HTN, CKD or previous MI)
What are the recommended beta blocker doses of:
a) Metoprolol
b) Bisoprolol
c) Atenolol
a) 50-100mg BD/ TDS if standard release, 200-400mg OD if modified release
b) 5-10mg OD
c) 50mg BD (or 100mg OD)
Name three groups of patients who should not be prescribed beta blockers?
Asthma/ bronchospasm
Reversible or severe COPD (can be used if not reversible obstruction)
Bradycardia <60bpm
2nd/3rd degree heart block (unless paced)
What is the calcium channel of choice prescribed in angina?
(If BB therapy is contraindicated or not tolerated then use a CCB for angina)
For Angina use a rate limiting CCB (Diltiazem or verapamil)
If a patient is taking a beta blocker, what CCB can’t be prescribed and what should be?
NOT rate limiting (No diltiazem or verapamil)
Px amlodipine/ nifedipine or felodipine instead
What are the DVLA driving guidelines for angina for group 1?
Group 1 entitlement (cars, motorcycles):
- Driving must cease when symptoms occur at rest, with emotion, or whilst driving
- Can recommence when satisfactory symptom control
- DVLA need not be notified.
What are the DVLA driving guidelines for angina for group 2?
For group 2 entitlement (lorries, buses):
- Must not drive and must notify the DVLA when symptoms occur
- May be permitted if symptoms free for at least 6 weeks
What advice should be given regarding sexual activity to a patient with newly diagnosed angina?
Mostly can continue
- If it precipitates angina GTN immediately before can be helpful
- Viagra contraindicated with nitrates (not within 24 hours of each other)
A 65year old male is taking atorvastatin 80mg, aspirin 75mg, and bisoprolol 10mg but anginal symptoms are still poorly controlled, what is the next step?
Add in long acting CCB (MR nifedipine/ felodipine or amlodipine)
(After monotherapy step 2 is dual therapy with CCB and BB)
*Rate limiting are CI
A 65year old male is taking atorvastatin 80mg, aspirin 75mg, bisoprolol 10mg and amlodipine 10mg but anginal symptoms are still poorly controlled, what is the next step?
One of:
- Nitrates (Isosorbide mononitrate)
- Nicorandil
- Ivabradine (with specialist)
- Ranolazine (with specialist)
Name three symptoms AF could present with?
Breathlessness.
Palpitations.
Chest discomfort.
Syncope or dizziness
What is the diagnostic pathway for assessing if you suspect paroxysmal AF?
Check pulse > Perform ECG > Perform 24 tape if episodes more than once every 24 hours, if longer may need to refer for 7 day tape
You have just received the ECG of a patient with a new diagnosis of AF, they remain irregularly irregular but are haemodynamically stable with no obvious reversible causes, they remain asymptomatic and well. What actions should be taken?
1) Assess stroke (CHADSVASC) and bleed (ORBIT)
2) Start on anticoagulation if appropriate (Apixaban)
3) Rate control with beta blocker (1st) or calcium channel blocker
4) Consider if further ix (i.e. echo for structural heart disease) are appropriate
5) Assess and manage CVD risk (HTN, statin etc)
If not sending to medical SDEC or similar review within 1 week of starting rate control
AF review at least annually
What are DVLA guidelines for AF?
Group 1: Driving to cease if symptomatic and may cause incapacity, do not need to inform DVLA. Restart driving when symptoms controlled at least 4 weeks.
Group 2: Needs to be controlled 3 months, EF >0.4. Check guidelines.
What blood tests should be performed annually for DOAC monitoring?
FBC (check no bleed)
LFT
U+E - If GFR <60 may need more frequent monitoring. Frequency is CrCl/ 10 (so if GFR is 30 do every 3 months)
Also check age and weight to see if dosing is correct
A 63-year-old woman has type 2 diabetes. She has normal renal function and her blood pressure is 128/78 mmHg.
What is the MAXIMUM recommended interval before her blood pressure is next checked?
12 months
According to NICE , patients with diabetes should have their blood pressure monitored at least annually if they do not have hypertension or renal disease.
What is the blood pressure target for a patient aged 71-years with chronic kidney disease diagnosed following a routine blood test three years ago; no proteinuria. Medical history of osteoarthritis, mitral regurgitation and atrial fibrillation.
140/90
For patients with CKD, the target blood pressure is set at 140/90 mmHg (if not proteinuria)
If proteinuria target is 130/80
What should the hba1c target be for a patient preparing for surgery?
The aim should be to control glycaemic control to less than 69mmol/mol within 3 months of referral if practical and safe.
A 35-year old-woman has been diagnosed with maturity-onset diabetes of the young (MODY). She has recurrent thrush and skin infections. What is the most appropriate first anti-diabetic therapy to start?
Gliclazide
(As she has symptoms)
MODY causes reduced insulin secretion and symptoms may not be severe. First-line treatment aims to stimulate the pancreas, and most patients with MODY are very sensitive to sulfonylureas.
What is Monogenic diabetes?
Previously called MODY
- Autosomal dominant family history of diabetes
- Typically mild, non-ketotic disease
- Presenting in adolescence or early adulthood
How do you summise the clinic blood pressure targets for all hypertensives?
Everyone is 140/90 other than those over 80 (150/90) or those with proteinuria (ACR >70) then it’s 130/80
If you can decrease a patients LDL by 1mmol/L what decrease of CVD risk does this confer?
21% reduction in all cause CV risk
When should a patient with T1DM take a statin?
(Atorvastatin 20mg as primary prevention)
- > 40y
- Had diabetes for >10y
- Nephropathy
- Other CV risk factors
CONSIDER statins for ALL other adults with type 1 diabetes
What do NICE recommend RE assessment for statin treatment in over 85’s?
Do NOT do risk calculation: age alone puts them at increased risk, particularly if
they smoke or have raised BP
CONSIDER atorvastatin 20mg
How many HbA1c results are needed to diagnose pre-diabetes?
1 test only
(T2DM needs two HbA1c results whereas pre-diabetes only needs 1)
You are seeing a patient in your GP clinic who you suspect an ACS. What treatment should be given whilst waiting for ambulance?
300mg aspirin
GTN spray
+/- opioid if available
Oxygen titrate to sats of 94-98%
It’s Monday morning and you suspect a patient has had an ACS event. They are now pain free, how should they be referred if:
a) The pain was earlier this morning
b) The pain was yesterday
c) The pain was 4 days ago
a) + b) Same day assessment
c) To be seen within 2 weeks
Basically if <72 hours needs to be seen same day, if >72 hours seen within 2 weeks
What is the DVLA guidance post MI?
Group 1: Don’t need to inform DVLA
If successful PCI - resume driving within 1 week
Otherwise - resume driving within 4 weeks
Group 2: Must notify DVLA
Stop driving until told otherwise
What is the NICE guidance regarding sexual intercourse post MI?
Resume when comfortable
(usually around 4 weeks post MI)
When should a hypertensive patient be referred for same day assesment?
BP over 180/120
AND
- Signs retinal haemorrhage/ papilloedema OR
- Chest pain, new confusion, AKI, heart failure
QRISK3:
- What ages is it used for?
- Is deprivation taken into account?
- Name 3 conditions it takes into account
- What medications does it ask about?
a) Used 25-84
b) Takes into account deprivation (from postcode)
c) AF, CKD, angina, MI, migraines, rheumatoid arthritis, HTN, lupus, severe mental illness, erectile dysfunction
d) Atypical antipyschotics and regualar steroids
What murmur would be heard in hypertrophic cardiomyopathy? What are the other differentials for this kind of murmur?
Ejection systolic
DDx of ejection systolic murmur: Aortic stenosis, hypertrophic cardiomyopathy (causing AS), pulmonary stenosis, innocent (stills) murmur
What is stills murmur and how is it characterised?
Benign paediatric heart murmur
Most commonly 2-7yrs - usually disappears in adolescence
Ejection systolic murmur
What murmur is heard in mitral regurgitation? What are 2 other differentials for this kind of murmur?
Pan systolic murmur
DDx: Mitral regurgitation, VSD, tricuspid regurgitation
When may you hear a ‘continuous machinery murmur’?
Patient ductus arteriosus
What is prinzmental angina? How does it present and how should it be managed?
Coronary artery vasospasm
- Angina occuring at rest, usually 5-30mins, usually between midnight and early morning - can be triggered by stress/ alcohol etc
- Can present very similar to MI so always send into secondary care same day
Is white coat hypertension the same when patients see all practioners?
The white coat effect is smaller for blood pressure measurements made by nurses than by doctors.
For patients with stable coronary artery disease on antihypertensive treatment, which SINGLE range of blood pressure is associated with the LOWEST rate of cardiovascular events and mortality?
120/70 - 139/79
Blood pressures of under 120 systolic and 70 diastolic, are associated with an increased rate of cardiovascular events. Blood pressures of 140 systolic and over or 80 diastolic and over are also associated with an increased rate of cardiovascular events. This is a ‘J shaped curve’.
You see a 63-year-old patient with known atrial fibrillation awaiting a hernia repair procedure.
What is the SINGLE MOST important primary objective for GPs optimising patients with atrial fibrillation for surgery? Select ONE option ONLY:
Rate control/ rhythm control, INR control, managing anticoagulants, managing other co-morbidity
Rate control
Typically a heart rate of 60-80 at rest is considered optimal, and heart rates exceeding 90 beats per minute require further management in line with usual practice.
Patients should expect to receive clear instructions from preoperative assessment clinic about anticoagulants or antiplatelets in the immediate perioperative period as they have prime responsibility for this.
With regards to home ABPM:
a) How often should measurements be taken?
b) What’s the minimum number of measurements to be averaged?
c) What should be done if ABPM is not available?
a) Every hour during waking hours
b) At least 14 values
c) Do HBPM - 2 blood pressures, 1 min apart, twice daily for 4-7 days
How often should patients take readings for HBPM?
2 blood pressures, 1 min apart, twice daily for 4-7 days
- Ignore readings taken on first day
In patients over 55 or those who are black - if a CCB is unsuitable what is the second line monotherapy in hypertension?
Thiazide diuretic (bendoflumethiazide/ indapamide)
- Over 55/ black < Thiazide before ACEI
For the purposes of selecting hypertensive drugs, which patients are considered to be black?
Black patients are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese.
Which are the 4th line add-on medication options for the treatment of drug-resistant hypertension?
K+ 4.5 or less = Add spironolactone (first choice)
K+ > 4.5 - Doxazosin (only if spiro contraindicated) or beta blocker
If a patient has microvascular angina, which drugs should be initiated as secondary prevention treatment?
Patients with microvascular angina have been found to have normal coronary arteries at angiography. The National Institute for Health and Care and Excellence (NICE) recommends that patients are not routinely offered the usual secondary prevention treatment.
How is ABPI performed?
The ankle brachial pressure index (ABPI) is the ratio of the highest recorded systolic pressure recorded in the affected leg over the highest recorded systolic pressure in either arm.
(So in PAD expecting leg to be lower pressure than arm, if leg pressure is significantly higher than arm this suggests calcification)
What is the classification of HFrEF?
A reduced LVEF of < 40% is HFrEF (heart failure with reduced ejection fraction).
A patient has newly diagnosed HFrEF on echo, with EF 35%. What is the initial management?
Symptoms of fluid overload - Start furosemide (titrated up and down as per syx)
Offer ACEI and BB - Don’t start together (clinical judgement on which to start first)
You have a patient with newly diagnosed HFrEF and you are trying to decide what medication to start first other than furosemide - what are the considerations?
ACEI and BB - Don’t start together
BB first if angina symptoms
ACEI first if diabetes or signs of fluid overload
Your patient is taking an ACEI and BB for HFrEF. Symptoms not controlled, what is 2nd line management?
MRA (mieralocorticoid receptor antagonist)
Spironolactone/ eplerenone
(if K+ remains under 4.5)
Your patient is taking an ACEI and BB and spironolactone for HFrEF. Symptoms not controlled, what is 3nd line management?
Seek specialist advice. Consider:
- Replace ACEI with valsartan if EF<35%
- Ivabradine
- Hydralazine and nitrate
- Digoxin
- SGLT2 inhibitor
In the context of heart failure, in addition to ACE/ BB and furosemide tx, what other two drugs and non drug management should be considered?
Antiplatlets- If any CAD or atherosclerotic disease
Statin
Non drug - Supervised exercised base group rehab for HF (unless uncontrolled AF/ uncontrolled HTN)
Your patient with HF has symptomatic fluid overload. What dose/ checking is required for furosemide?
Start 20-40mg daily
Check U+E’s after 1-2 weeks (may need sooner if higher risk)
Upto 80mg daily
You suspect heart failure. What investigations and referral?
Perform BNP:
<400 - HF unlikely
400-2000 - Refer for echo witihn 6 weeks
>2000 - Refer for echo within 2 weeks
Name 3 factors which may falsely lower BNP levels?
BMI >35kg
ACEI/ ARB/ BB/ MRA
Afrocarribean
Name 3 factors which may elevate BNP levels?
Age over 70
CKD (eGFT <60)
COPD
Diabetes
Liver cirrhosis
LVH/ tachycardia
Pulmonary hypertension
How should suspect HF be managed in pregnant women or those who have given birth in the last 6 months?
Emergency hospital admission
Name 2 possible contraindications to ACEI therapy?
Haemodynamically significant valve disease (until specialist assessment)
Hx of angioedema
Your patient has newly diagnosed heart failture with preserved ejection fraction. What is the EF cut off for this and how is it managed?
EF > 55% is preserved EF
- Loop diuretic if fluid overload
- Dapagliflozin recommended on advice of specialist
- Antiplatlet/ statin if indicated
- Exercise group rehab
Name 3 GSF poor prognostic indicators to suggest a patient may be becoming EoL in heart failture?
NYHA Stage 3 or 4 (SOB at rest. minimal exertion)
Repeated hospital admissions
Care team feel to be in last year of life
Difficult physical/ pyschological syx despite max therapy
You are rechecking renal function 1 week post starting furosemide for your patient with HF. What results would prompt you to change/ stop the furosemide?
Creatine increase 50% or over 256mmol - Stop diuretic
Creatinine increase 30-50%, over 200mmol or eGFR < 30 - reduce or stop
Creatinine increase more than 20% (or eGFR falls by 15%) continue diuretic but recheck U+E within 2 weeks
Name 4 possible clinical signs of heart failure?
Tachycarida/ tachypneea
Pulmonary crackles
Raised JVP
Peripheral oedema
Hepatomegaly
How is heart failure classified?
Reduced LVEF (HFrEF): 40% or less
Mildly reduced LV systolic function (HFmrEF): LVEF between 41% and 49%.
Preserved ejection fraction (HFpEF): 50% or higher (some say 55%)
What is the NYHA classification of heart failure?
Class I - No symptoms on ordianary activty
Class II - Slight limitation of physical activity
Class III - Less than ordinary activity leads to symptoms
Class IV - Inability to carry out any activity without symptoms
What are the features of acute pulmonary oedema caused by exacerbation of HF?
Severe dyspnoea
Sweaty/ nausea/ anxious
Dry/ pink frothy cough
Noctural dyspnoea or orthopnea
Cyanosis, raised JVP, basal or widespread crackles
- If R sided failure then also peripheral oedema
What is the definition of a AAA?
Pathalogical dilatation over 1.5x expected AP diameter
- 3 cm or greater
What screening is offered for AAA?
Locally led by UKHSA
Single screening to all men over age 65
- Small (3-4.4cm) = 12 month scans
- Med (4.5-5.5) - 3 month scans
- Large (>5.5cm) - refer surgeons
Name 3 risk factors for dissection of aorta?
Athersclerosis of aorta
Pre-exisiting aneurysm
Biscuspid aortic valve
Cocaine use
Trauma to chest
Genetic (Marfan, turners)
CTD (Ehlers-Danlos)
When does aortic disection most commonly occur in pregnancy?
Post partum
(one of most common causes of death in pregnancy)
What two features suggest cardiogenic shock in the presence of adequite LV filling pressure?
Sustained hypotension (<90mmHg) for more than 30 mins
Tissue hypoperfusion (<30ml/hr urine, cold peripheries or both)
What is the most common cause of cardiogenic shock - name 3 symptoms?
MI
Chest pain, N+V, dyspnea, sweating, confusion, palpitations, syncope
What is the DVLA guidance on SVT for group 1?
Must inform DVLA and stop driving if has or might cauuse any symptoms when driving
May be allowed to resume after 4 weeks symptom free
Name 3 possible treatments for SVT?
Avoid: Caffeine, alcohol, stress, smoking
Beta blocker or verapamil
Catheter ablation
What defines first degree heart block?
How is it managed in primary care?
1st degree - PR interval over 0.2s
All P waves followed by QRS with 1:1 correspondance
Usually asymptomatic and often incidental finding - no action needed (other than maybe avoiding some drugs)
What defines second degree heart block?
How is it managed in primary care?
2nd degree:
Mobitz 1 (Wenckebach) - Progressive prolongation of PR until atrial impulse fails to reach ventrocle
Mobitz 2 - Intermittent failure of impulse to reach ventricle - either 2:1, 3:1, 4:1 etc
Type 1 usually good prognosis, Mobitz T2 often progresses to heart block - both urgent referral
What defines third degree heart block?
How is it managed in primary care?
3rd degree or complete heart block
Non conduction, P waves unassociated with QRS complex
Same day admission
Name 3 ventricular rythm abnormalities?
VT - Broad complex, usually rate >120 bpm
Torsades de points - Polymorphic VT
VF - Most common arrythmia in cardiac arrest (70%)
Name 3 conditions which can cause arterial emboli?
Atherosclerosis and plaque rupture
Atrial fibriliation - May be associated with valve disease etc
Mural thrombus following MI
Septic emboli from endocarditis
How might mesenteric ischemia present?
Pain, poorly localised, out of keeping with physical signs (may be normal physical exam)
Look for RF’s such as AF in examination
What percentage of strokes are ischemia, what are haemorrhagic?
85% ischemic
15% haemorrhagic
There is a patient in your consultation room who you suspect if having an acute stroke. How do you manage?
Emergency admission to stroke unit
- Do not give antiplatlet treatment until haemorrhagic stroke excluded
There is a patient in your consultation room who you suspect if having an acute TIA this morning, symptoms have now resolved. How do you manage?
Aspirin 300mg
Same day assessment
(If TIA over 7 days ago then refer to be seen within 7 days)
Advise not to drive until seen by specialist
What factors determine anticoagulation following a stroke or TIA?
If no AF:
- All on clopidogrel 75mg OD (may have DAPT initially with aspirin - all guided by secondary care)
If paroxysmal/ or permenant AF:
- DOAC or warfarin, usually started at D14 with aspirin in the interim
Same treatment whether single event or multiple events
What is the definition of cardiomyopathy?
Heart muscule structually and functionally abdnormal without CAD/ HTN/ valve or congenital disease
What are the 4 main types of cardiomyopathy - what are the key characteristics of each?
Dilated - Most common form, usually secondary to ischemia, alcohol, thyroid or valve disease
Hypertrophic - Second most common, inherited as autosomal dominant
Restrictive - Rare, causes amyloidosis, fibrosis etc
ARVC - Progressive genetic cardiomyopathy from fat and fibrous tissue replacling muscle - Autosomal dominant usually
How is HOCM inherited?
Second most common cardiomyopathy - Autosomal dominant
How might HOCM present? (4 symptoms, 1 examination finding)
Any age
Dyspnoea (most common), chest pain, palpitations, syncope
Variable from mild symptoms and profound exercise limitation or sudden death
Exam: Late ejection systolic murmur
How does dilated cardiomyopathy usually present?
Similar to heart failure
(Dyspnoea, weakness, oedema, raised JVP, pulmonary congestion etc)
What are the 4 most common causes of AF?
IHD
Hypertension
Valvular heart disease
Hyperthyroidsim
What are indications for admission of a patient with AF?
Any haemodynamic instability
Onset within last 48 hours and candiate for cardioversion
Any signs of severe heart failure
Name 3 possible indications to refer a patient with AF to cardiology?
AF with:
- Valvular heart disease
- Suspect heart failure
Name the components of CHA2DS2VASc?
Congestive heart failure - 1
Hypertension - 1
Age over 75 - 2
Diabetes - 1
Stroke/ TIA - 2
Vascular disease (MI, PAD) - 1
Age 65-74 - 1
Sex (F) - 1
What scoring system should be used to assess bleed risk in patients following a diagnosis of AF and consideration of anticoagulation?
ORBIT
What CHADSVAC score would suggest benefit from anticoagulation?
NICE says offer to anyone with chadsvasc 2 or above, and consider for me with score of 1
(For most people benefits of anticoag outweigh risks)
Which standard Beta Blocker can’t be used for rate control in AF?
Sotalol
What are the first choice rate control treatments in AF?
Beta blocker
OR
Rate limiting CCB (verapamil or diltiazem)
Digoxin possible alternative in those who don’t exercise
What is the DVLA group 1 guidance for patients with with AF?
Driving must stop if arrythmia has caused or is likely to cause incapacity whilst driving
DVLA don’t need to be notified
May be permitted once symptoms controlled for at least 4 weeks
What are group 2 DVLA driving rules regarding AF?
Must inform DVLA
Disqualified from driving if has or likely to cause incapacity whilst driving
May be permitted when controlled for at least 3 months
What is guidance around flying with AF?
No issues - fly and travel as normal as long as stable
What is the characteristic murmur of:
a) Aortic stenosis
b) Mitral regurg
c) Aortic regurg
d) Mitral stenosis
a) Ejection systolic
b) Pan systolic
c) Early diastolic
d) Mid diastolic
What is the characteristic murmur of:
a) Pulmonary stenosis
b) Tricuspid regurg
c) Pulmonary regurg
d) Tricuspid stenosis
a) Ejection systolic
b) Pansystolic
c) Early diastolic decrecendo
d) Mid-diastolic (rarely audible)
What are the key characteristics of mitral valve prolapse?
Most common valve abnormality (5%) prevalence
Mid systolic click
Mid-late systolic murmur
Name 3 possible causes of PAH (pulmonary artery hypertension)
Idiopathic/ inherited - Rare
Secondary to:
- Cardiac (Left heart disease, valve disease, cardiomyopathy)
- Respiratory - Chronic lung disease, fibrosis, recurrent emboli
Name 3 possible clinical signs of pulmonary hypertension?
R sided heart strain:
- Parasternal heave
- Raised JVP
- Peripheral oedema
Name 3 risk factors for infective endocarditis
Valve disease
Valve replacement
Structural congenital heart disease
Hypertrophic cardiomyopathy
Which valve is most commonly affected in IE? What pathogen is most commonly responsible?
Mitral
Pathogen: Staph aureus
How does infective endocarditis present?
Rapidly progressive infection
Fatigue, fever, flu like illness, polymyalgia
Pleuritic sounding pain, new heart murmur
Consider if stroke/ TIA and fever (think septic emboli)
How may pericarditis present (name 3 symptoms and 2 signs)
Syx: Sharp, constant sternal pain, relieved sitting forward, worse lying/ on inspiration and swallow/ cough
Signs: Pericardial friction rub, possible signs tamponade (Becks triad - muffled heart founds, hypotension, raised JVP)
How is pericarditis managed?
NSAIDS
Settle in a few weeks
Colchicine also recommended 1st line but not licenced
How might you distinguish between pericarditis and viral myocarditis?
Pericarditis - Inflammation pericardium, sharp chest pain
Viral myocarditis - Heart muscule affected - More cardiac sounding pain, can resemble MI in presentation/ can caused severe heart failure
What are the 3 most important complications of rheumatic fever?
Carditis
Mitral stenosis
Congestive cardiac failure
Name 5 common renal causes of secondary hypertension?
CKD (Most common)
Chronic pyelonephritis
Diabetic nephropathy
Glomerulonephritis
Polycystic kidney disease
Renal artery stenosis
Name 3 non-renal causes of secondary hypertension?
Phaeochromocytoma
Coarctation of aorta
Primary hyperaldosteronism
Cushings syndrome
Acromegaly
Hypo/ hyperthyroidism
Pregnancy
OSA
Name three classes of drugs that can cause heart failure?
Cytotoxics
Recreational (cocaine, alcohol)
Beta blockers
CCB’s
Anti-arrythmics
What is a mural thombus and where does it most commonly occur?
Thrombi that adhere to the wall of a large blood vessel or heart chamber.
Most common in the aorta (descending aorta)
What is dresslers syndrome?
Dressler’s syndrome — a pericarditis that occurs in about 4% of people post-MI. People typically present 2–4 weeks after an MI with a self-limiting febrile illness accompanied by pericardial or pleural pain
What is the most common cause of ventricular aneurysm?
MI
(Followed by cardiomyopathy)
Complications - mural thrombus, cardiac failure, predisposed to arrythmia and sudden cardiac death)
Name the three most common non-cyanotic congenital heart problems?
VSD
ASD
PDA
Co-arctation of aorta
(Aortic, pulmonary stenosis also non-cyanotic)
Name the three most common cyanotic congenital heart problems?
Tetralogy of fallot
Transposition of great arteries
Tricuspid ateresia
THINK the T’s
Name 3 risk factors for congenital heart disease?
1st degree relative
Consangunious parents
Rubella/ drugs/ toxins in pregnancy
Genetic (Downs, DiGeorge etc)
Maternal diabetes
How might VSD/ ASD/ PDA present?
Babies with significant left-to-right shunts (VSD, ASD, PDA, aorto-pulmonary window) are asymptomatic at birth but can present with signs of heart failure and faltering growth in early infancy
- SOB, poor feeding, FTT, blue episodes, sweating
What are the characteristics of an innocent murmur?
Sensitive - changes with position or respiration
Short duration
Small (limited to small area, not radiating)
Soft
Systolic
How do you manage a murmur detected in a 3week old?
Murmurs arising during the first days or weeks of life should be referred to a pediatrician for assessment.
(innocent murmurs usually as we get older)
What is the DVLA guidance around pacemakers for group 1 or group 2?
Group 1: Need to inform DVLA
- Can drive after 1 week following fitting as long as asymptomatic and has regular check ups
Group 2: Need to inform DVLA
- Can drive 6 weeks after insertion as long as above (asymptomatic and regular appointments)
What distinguishes acute limb ischemia from chronic limb ischemia?
Acute - Develops over less than 2 weeks
Chronic - Starts with intermittent claudication and develops - can become critical limb ischemia or chronic limb threatening
What are the main two CV risk factors for PAD?
Smoking
Diabetes
Name 3 symptoms of chronic leg ischemia?
Progressive development of a cramp-like pain in the calf, thigh, or buttock on walking which is relieved by resting; unexplained foot or leg pain; or non-healing wounds on the lower limb
What are the DVLA rules for peripheral arterial disease (Group 1 and 2)
Group 1: Can drive and don’t need to tell DVLA
Group 2: Need to tell DVLA, need exercise of other functional requirements to be met
What is the DVLA angina guidance for group 1?
Do not drive if symptoms occur:
At rest, with emotion or at the wheel
Driving can resume when satisfactory syx control
Don’t need to tell DVLA
What is the DVLA angina guidance for group 1?
Must tell DVLA
Licence may be revoked if symptomatic. May be able to continue if asymptomatic for more than 6 weeks
Name 3 conditions that would indicate antiplatelet therapy?
All secondary prevention
Post ACS, angina, PAD, stroke/ TIA etc
What is the NICE guidance on long term antiplatelet therapy for
a) stable CAD
b) stable cerbrovascular diease
c) PAD
a) Aspirin 75mg
b) Clopidogrel 75mg
c) Clopidogrel 75mg
What are the indications for thrombolysis in acute stroke? What agent is used?
Alteplase
- Within 4.5 hours of onset of symptoms
- Hemorrhagic disease excluded on imaging
How is raynauds phenomenon classified?
Vasospasm of arteries or arterioles
Primary (80%)
Secondary (20%) - usually CTD like scleroderma or SLE
Name 5 features which may increase your suspicion of secondary raynauds as opposed to primary?
Onset over 30yrs
Ulcers, ischemia, gangrene
Episodes that are asymetrical
Hx connective tissue disorder
Positive ANCA
Which patients with new raynauds disease should be referred?
Children under age 12
Suspected secondary raynauds
How should raynauds disease be managed? (lifestyle x3) and medication?
Keep whole body warm
Use gloves etc
Avoid sudden temp changes
Stop smoking
Exercise
Prophylaxis - nifidepine (off label)
Name 3 side effects of nifedipine - what % may experience SE’s on it?
Upto 75% patients get SE’s from nifedipine
Oedema, palpitations, headache, flushing, or dizziness
How does a cerebral aneurysm usually present?
Usually on rupture - as sub-arachnoid haemorrhage
Sudden onset thunderclap headache
Stiff neck
Vomiting
Photophobia
With regard to cerebral aneurysms:
a) Where are they most commonly located
b) Average age
c) Management options
a) 80% in anterior circulation
b) Average age around 50’s (important as younger patients and up to half with rupture can die)
c) Coil or clip
Name 5 risk factors for AAA?
COPD
Coronary/ cerebrovascular disease or PAD
FHx AAA
Hyperlipidaemia
Hypertension
Smoker or ex-smoker
Name 3 possible symptoms of a leaking or ruptured AAA
New abdo/ back pain
Cardiovascular collapse
LoC
More likely if over 60, smoker, HTN etc
Name 3 groups of patients where QRISK should not be used?
Existing CVD
High risk (T1DM, egfr <60, familial hypercholesterolaemia)
Age 85 and over
What are the indications for exercise ECG?
To assess for CHD
Either if syx (chest pain, palpitations, dizzy, SOB)
OR
Post coronary angioplasty etc
When may you suspect LADA, what is the criteria?
Age 30-50yrs
Usually low/ normal weight. New onset of diabetes, not as acute as T1 - usually 6 months or so before insulin needed
Use GAD antibodies
Which two specific tests may be used to aid a diagnosis of LADA?
Anti GAD antibodies
C-peptide levels (marker of insulin production to determine whether needs insulin therapy)
Name 3 things that can false raise HBa1C and 3 things that can falsely lower?
Raise:
- IDA/ B12/ folate deficienct
- Increase bilirubin
- Increased triglycerides
Lower (anything reduced RBC life)
- Haemoglobinopathies
- Thalassemia
- Pregnancy
- Splenectomy
A 68-year-old woman had an uncomplicated myocardial infarction (MI). She is allergic to aspirin. Accoridng to NICE what’s the most appropriate lifelong secondary prevention?
Clopidogrel if aspirin not tolerated
1st line diuretic in HF?
What about if gut oedema?
Furosemide
bumetanide 1st if gut oedema
What is the ABPM definitions of stage 1 hypertension?
ABPM is 135/85 mmHg or greater but less than 150/95 mmHg
PAD with rest pain. What is a) Risk death b) Risk amputation?
Patients with rest pain are at significant risk with approximately 25% dying within a year and 33% requiring a major lower limb amputation.
Which lipid measurement (with DNA testing) is most useful to identify FH in relatives of those affected?
LDL’s
Resolved chest pain - what are the timings in GP for emergency or same day referral?
Emergency - Pain within last 12 hours and abnormal or no ECG
Same day - Pain 12-72 hours ago OR if pain within last 12 hours and normal ECG
How does Brugada syndrome show on an ECG:
ST segment elevation of at least 2mm in V1 and/or V2, followed by a negative T wave
What is Brugada syndrome?
Autosomal dominant genetic defect - sudden death in young, usually south asian males
What is the classic triad of sub-acute bacterial endocarditis (SBE)?
Persistent fever, embolic events and new or changing murmurs
