ACT Cardiovascular

Question 1

Investigation of suspected Acute Coronary Syndrome

Answer 1

A to E
B - CXR ?cardiomegaly ?pulmonary oedema
C - ECG then continuous cardiac monitoring
Troponin - Take at 3h and 6-12h
FBC – anaemia, inflammation (?pericarditis)
U&Es – Potassium
Glucose – DM, ensure BM kept low (improves outcomes)
Lipids – optimise statin therapy
TFT – cause of arrhythmias

Question 2

Immediate management of Acute Coronary Syndrome

Answer 2

Risk - TIMI for STEMI, GRACE for NSTEMI
Oxygen? only if sats <95%
Morphine + Metoclopramide 10mg
Aspirin 300mg dispersed in water
Nitrates - 2 GTN sprays sublingual 
Ticagrelor 180mg or Clopidogrel 300mg 

PCI or Fondaparinux

Question 3

Long term management of Acute Coronary Syndrome

Answer 3

Patient education
Smoking cessation, Alcohol reduction
Weight loss if overweight
Diet - less fat, sugar, salt. More vegetable
Exercise - Cardiac rehab
DVLA - 4 weeks (Grade 2 = 6 weeks + assessment)

ACEi - Ramipril up to 10mg
B-blocker - Bisoprolol up to 10mg
Cholesterol - Atorvastatin 80mg Nocte
Dual antiplatelet -  Aspirin 75mg 
- Clopidogrel 75mg for 1 year 
Echocardiogram - follow up with cardiology
Follow up GP for bloods +
Influenza immunisation annually 
Manage comorbidities - DM

Question 4

Investigations for acute ventricular failure

Answer 4

A to E
B - ABG + CXR - Alveolar oedema, Kerley B lines, Cardiomegaly, Dilated upper lobe vessels, Pleural Effusion
C - ECG
Bloods: BNP + Troponin
FBC - exclude anaemia 
U&Es - check renal perfusion
TFTs - cause of arrhythmia 
lipids - optimise 
glucose - optimise
Echocardiogram within 48hrs

Question 5

Immediate management of Acute Ventricular Failure

Answer 5

Position - sit up
Oxygen - 
Diuretics - Furosemide 40-80mg IV
Morphine - 5mg
Antiemetic - Metoclopramide 10mg
Nitrates - 2 GTN sprays sublingual
Fluid balance - restriction + daily weights

Question 6

Assessment of suspected Chronic heart failure

Answer 6

Arrange admission if severe symptoms 
If previous MI - urgent 2 week referral 
No previous MI - measure BNP
BNP > 400 pg/mL = Urgent 2 week referral
BNP 100-400 pg/mL = 6 week referral 
BNP < 100 pg/mL = Heart failure unlikely
ECG for all patients 
Consider other tests for causes or differentials

Question 7

Management of chronic heart failure with reduced ejection fraction

Answer 7

Patient education, Screen mental health
Smoking cessation,
Low salt diet
Supervised exercise programme

Furosemide when symptomatic
1st ACEi + Bisoprolol one at a time
Refer if symptoms aren't controlled
Consider Statin + Aspirin if CAD
pneumococcal + annual influenza vaccine

Cardiac resynchronise therapy

Question 8

Assessment of suspected stable angina

Answer 8

Clinical diagnosis based on Hx
ECG - may or may not have evidence of ischaemia
Manage stable angina in Primary care
Refer to a cardiologist for angiography if:
- evidence of extensive ischaemia on ECG
- Angina persists despite optimal drug treatment and lifestyle interventions.
Admit to hospital if unstable angina

Question 9

Management of stable angina

Answer 9

Patient eduction, Screen mental health
Smoking cessation, Alcohol reduction
Diet, Exercise

GTN + Atorvastatin 80mg + Aspirin 75mg
1st: Betablocker or CCB
2nd: Dual therapy with BB and CCB
if CI then a long-acting nitrate, ivabradine, nicorandil

If pain persists despite medical management
Percutaneous Coronary Intervention
Coronary Artery Bipass Graft

Review every 6/12 or 1yr

Question 10

Management of new Atrial Fibrillation

Answer 10

1. Rate or Rhythm control?
   Rhythm: if new onset, reversible cause, if worsening HF
   Amidoarone -> Electrocardioversion
   ?Prophylaxis with 1st: Bisoprolol
   Rate: 1st Bisoprolol
   2nd Diltizem if active, Digoxin if sedentary
2. Anticoagulation + Risk factors
   CHA2DS2 VASc - risk of stroke
   HAS-BLED - risk of bleeding
   Apixaban or Warfarin life long

Question 11

Aetiology of Atrial Fibrillation

Answer 11

Ischaemic heart disease
Hypertension
Thyrotoxicosis

Question 12

Signs, description and aetiology of aortic stenosis

Answer 12

Slow rising pulse
Low volume pulse with low pulse pressure
JVP not elevated
Apex beat forceful but not displaced (pressure overload)
Ejection systolic murmur - carotid radiation

Narrowing of the valve orifice due to fusion of the commissures, causes pressure overload in the left ventricle

Degenerative calcification of normal valve
Congenitally bicuspid valve with degenerative changes
Rheumatic heart disease

Question 13

Causes of pressure overload on the left ventricle

Answer 13

Hypertension
Aortic stenosis
Coarctation of the aorta
Hypertrophic cardiomyopathy with subvalvular stenosis

Question 14

Management of aortic stenosis

Answer 14

Symptoms guide to severity
Valve replacement

Transcatheter aortic valve insertion (TAVI)
if unfit for cardiopulmonary bypass

Manage comorbidities

Question 15

Describe aortic sclerosis

Answer 15

Normal pulse and normal apex beat.

An ejection systolic murmur heart loudest over the aortic area with no carotid radiation.

Question 16

Signs and causes of mitral regurgitation

Answer 16

Apex beat usually displaced (volume overload)
Pansystolic murmur radiates to axilla

Leaflet: Congenital, Endocarditis, Degenerative
Papillary muscles + Chordae: MV prolapse, ACS, Marfans
Annular dilation: cardiomyopathy, IHD with HF

Question 17

Describe rheumatic heart disease

Answer 17

Preceding Group A beta haemolytic throat infection followed 2-4 weeks later by acute rheumatic fever.
Antibodies to strep M protein cross react with heart, joints and brain due to molecular mimicry
Chronic rheumatic heart disease causes leaflet thickening and fusion of commissures, lead to

Question 18

Signs of causes mitral stenosis

Answer 18

Malar flush - Pulmonary artery hypertension
Atrial fibrillation - 75%
JVP not raised until late
Apex beat not displaced
Apex beat tapping in quality - palpable 1st heart sound
Mitral stenosis = LUB de-derrr
Loud S1 - high left atrial pressure keeps value open until late diastole, systole then slams it shut.
Mid diastolic murmur - rubbing
CXR - Left atrial enlargement

Rheumatic fever
Congenital

Question 19

Management of mitral stenosis

Answer 19

Mild: Medical - anticoagulants, diuretics, rate control AF
Moderate: ? Trans-septal valvuloplasty
Severe: Valve replacement

Question 20

Signs and causes of Aortic regurgitation

Answer 20

Collapsing water hammer pulse 
Collapsing neck pulse (Corrigans sign)
JVP not raised
Apex beat displaced (Overload) 
Diastolic murmur follows S2
Aortic regurgitation = Lub taaarr

Rheumatic heart disease
Endocarditis
Ankylosing spondylitis
Leutic heart disease
Marfans syndrome

Question 21

Complications of a heart valve replacement

Answer 21

POSH Valve

Paravalvular leak - loosening of value stent
Obstruction - by thrombus
Subacute bacterial endocarditis 
Haemolysis due to turbulence
Valve failure

Question 22

What is the New York Heart Association grading of heart failure and angina?

Answer 22

1 = No symptoms, or only on exertion 
2 = Symptoms during ordinary physical activity 
3 = Symptoms on less that ordinary activity 
4 = Symptoms at rest

Question 23

Management of tachycardia with adverse features

Answer 23

Synchronised Direct Current shock
- up to 3 times

Amiodarone 300mg IV over 10-20mins
- repeat shock
Amiodarone 900mg over 24hrs

Question 24

Management of tachycardia with no adverse features and regular narrow QRS complex

Answer 24

Vagal manoeuvres 
Continuous ECG monitoring 
Adenosine 6mg IV bolus 
Adenonise 12mg 
Adenosine 12mg

If rhythm restored = re-entrant paroxysmal SVT
Record normal ECG,
consider antiarhythmic prophylaxis eg.

If rhythm not restored = Seek expert help
Possible atrial flutter - control rate

Question 25

Management of tachycardia with no adverse features and regular broad QRS complex

Answer 25

If Ventricular tachycardia: Amiodarone 300mg IV over 20-60mins Amiodarone 900mg over 24hrs If previously confirmed SVT with BBB: Adenosine 6mg - 12mg - 12mg As for regular narrow complex tachycardia

Question 26

Management of tachycardia with no adverse features and irrregular broad QRS complex

Answer 26

AF with BBB - treat as narrow complex Pre excited AF - consider amiodarone Polymorphic VT: eg. Torsade de point - Magnesium 2g IV over 10mins

Question 27

What are considered adverse features in tachycardia and Bradycardia?

Answer 27

Shock Syncope Myocardial ischaemia Heart failure

Question 28

In bradycardia without adverse features, what factors make a patient at risk of asystole

Answer 28

Recent asystole Mobitz type II AV block Complete heart block with broad QRS Ventricular pause > 3 seconds

Question 29

Management of bradycardia with adverse features

Answer 29

Atropine 500micrograms IV bolus If resolved - are they at risk of asystole? Yes = Observe ``` No = Atropine 500micrograms IV bolus - repeat to maximum of 3mg Isoprenaline 5 micrograms/min IV Adrenaline 2-10 micrograms/min IV Or Transcutaneous pacing SEEK EXPERT HELP Arrange Transvenous pacing ```

Question 30

What defines postural hypotension and what are its causes?

Answer 30

A drop of 20/10 mmHg after 1 and within 3 minutes of standing after 10 minutes of supine resting ``` Elderly - impaired vasomotor reflects Drugs - antihypertensives, sedatives Cardiac - aortic stenosis Neuro - autonomic neuropathy, parkinson's Endocrine - Addisons ```

Question 31

Management of postural hypertension

Answer 31

``` Treat cause + general advice Drink 1.5-2L of fluid a day Avoid excess alcohol More salt in diet if not CI Sit for 5 minutes before standing from supine Compression stockings Performing calf exercises ```

Question 32

What tool is used to assess cardiovascular risk for primary prevention?

Answer 32

QRISK2 = 10 year risk of developing CVD < 10% = Lifestyle advice to modify risk factors > 10% = Lifestyle advice + Atorvastatin 20mg Consider medical modification of other risk factors

Question 33

When should statins be prescribed for primary prevention of CVD?

Answer 33

Atorvastatin 20mg should be considered in: - QRISK2 of 10% or more - Hypercholesterolaemia - 85+ years if appropriate - T1DM if over 40yr or had T1DM for 10yr+ - All CKD stage 3 or worse (eGFR 60)

Question 34

Causes of acute left ventricular failure

Answer 34

CHAMP ``` Coronary syndrome Hypertensive emergency Arrhythmia Mechanical - valve leak Pulmonary embolus ```

Question 35

What are the Major and Minor criteria for diagnosing infective endocarditis?

Answer 35

2 Major, or 1 Major + 3 minor, or 5 minor Duke's Major criteria: - Two separate positive blood cultures > 12hrs apart - Clear evidence of endocardial involvement on Echo Duke's minor criteria: - positive blood culture but not major criteria - Echocardiogram signs but not clear - Predisposing risk factors - Fever > 38.0'C - Vascular phenomenon - Janeway lesions, splinter hem - Immunological phenomenon - Osler's nodes, Roth spots

Question 36

Investigation of suspected infective endocarditis

Answer 36

Urinalysis – microscopic haematuria ECG - long PR Fundoscopy - Roth spots Three blood cultures - different times within 24 hours, from different sites FBC - normocytic anaemia, neutrophilia ESR/CRP - raised CXR - cardiomegaly Echocardiogram - transoesophageal more sensitive

Question 37

Management of infective endocarditis

Answer 37

Urgent cardiology review with micro input Abx as per guidelines, empirical then focus - IV Amoxicillin and Gentamicin for 6/52 Consider surgery - abscess, focal valve lesion

Question 38

Six Ps of acute ischaemic limb

Answer 38

``` Pale Painful Pulseless Perishingly cold Parasthesia Paralysis ```

Question 39

Assessment and investigation of suspected acute limb ischaemia

Answer 39

Pain worse on raising limb Doppler to help identify reduced/absent pulse Bloods – FBC, U&Es (AKI), CK (muscle ischaemia), Clotting (cause), G&S Angiography – show obstruction R/V by senior surgeon

Question 40

Management of acute limb ischaemia

Answer 40

Oxygen 15L Analgesia – morphine IV access and fluids (if dry) – cell death can cause hyperkalaemia and CK, keep fluids running to prevent AKI Rx = Embolectomy (Fogarty)/Intra-arterial thrombolysis/Bypass/Amputation LMWH before/after procedure – can reduce thrombus developing Beware: post-op reperfusion and compartment syndrome

Question 41

What is the management of a suspected DVT

Answer 41

Wells sc􏰇ore 1 or 0 = do D-Dimer –ve = DVT unlikely, consider alternative Dx +ve = Arrange Doppler ultrasonography (USS) Wells s􏰇cor􏰄e 􏰀2+􏰋 = arrange USS if imaging delay will be > 4h = start LMWH If -ve USS but high risk and +ve D-dimer = repeat USS in 6-8 days +ve USS = Start LMWH immediately and warfarin with 24hrs. Bridge for at least 5 days or INR is above 2.0 for 24hrs, whichever is longer. Review Warfarin at 3 months

Question 42

What criteria are in the DVT wells score

Answer 42

``` Active cancer (ongoing, within 6 months, or palliative) = 1 Paralysis, paresis or recent plaster immobilisation of the lower extremities = 1 Recently bedridden for 3+ days or major surgery within 12 weeks requiring general or regional anaesthesia = 1 Localised tenderness along the distribution of the deep venous system = 1 Entire leg swollen = 1 Calf swelling 3cm+ larger than asymptomatic side = 1 Pitting oedema confined to the symptomatic leg = 1 Collateral superficial veins (non-varicose) = 1 Previously documented DVT = 1 An alternative diagnosis is at least as likely as DVT = -2 ```