Cardiology

Question 1

MOA of ACEi

Answer 1

Prevent the conversion of angiotensin I to II in the lungs
No aldosterone secreted from the adrenal glands

Question 2

side effects of ACEi

Answer 2

cough
angioedema
hyperkalaemia
first dose hypotension (more common in patients taking diuretics)

Question 3

monitoring required for ACEi

Answer 3

U&Es before initiating treatment & after increasing the dose
acceptable rise of creatinine up to 30% from baseline, and potassium up to 5.5mmol/L

Question 4

when starting ACEi, significant renal impairment may be a sign of what

Answer 4

bilateral renal artery stenosis

Question 5

interaction of ACEi

Answer 5

high dose diuretic therapy e.g 80mg of furosemide
increases risk of hypotension

Question 6

cautions & contraindications of ACEi

Answer 6

pregnancy and breastfeeding
aortic stenosis (hypotension)
renovascular disease (renal impairment)
hereditary angioedema
potassium >5 mmol/L before initiating treatment

Question 7

role of anticoagulation in AF

Answer 7

preventing a stroke

Question 8

what is the CHA2DS2-VASc mneumonic?

Answer 8

C – Congestive heart failure
H – Hypertension (including treated HTN)
A2 – Age >75 (Scores 2)
D – Diabetes
S2 – Stroke or TIA previously (Scores 2)
V – Vascular disease (ischaemic heart disease, peripheral vascular disease)
A – Age 65-74
S – Sex (female)

Question 9

what happens if CHA2DS2-VASc score shows no need for anticoagulation

Answer 9

need to do a transthoracic echocardiogram to exclude valvular heart disease
valvular heart disease + AF = absolute indication for anticoagulation

Question 10

how to formalise the risk of anticoagulation therapy?

Answer 10

ORBIT score

Haemoglobin <130 g/L for males and < 120 g/L for females, or haemtocrit < 40% for males and < 36% for females = 2

> 74 years = 1

previous bleeding event = 2

renal impairment <60ml/min = 1

antiplatelet therapy = 1

Question 11

anticoagulation used in AF

Answer 11

first line = DOACs
then warfarin

Question 12

advantages of DOACs

Answer 12

no monitoring required
no major interactions
shorter half life than warfarin

Question 13

reversal agents of DOACs & warfarin

Answer 13

apixaban & rivaroxaban = Andexanet alfa

dabigatran = Idarucizumab

warfarin = vitamin K

Question 14

what is the target INR for AF

Answer 14

2-3

Question 15

MOA of warfarin

Answer 15

inhibits epoxide reductase, preventing the reduction of vitamin K to its active hydroquinone form

prevents carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C.

Question 16

what is warfarin

Answer 16

a vitamin K antagonist
Vitamin K is essential for the functioning of several clotting factors, warfarin blocks vitamin K and prolongs the prothrombin time

has a long half life, can take several days to achieve a stable INR (international normalised ratio)

Question 17

inducers of P450 system

Answer 17

decrease INR

rifampicin
smoking
chronic alcohol intake
antiepileptics: phenytoin, carbamazepine
barbiturates: phenobarbitone

Question 18

inhibitors of P450 system

Answer 18

increase INR

antibiotics e.g. ciprofloxacin, erythromycin, clarithromycin
isoniazid
omeprazole
amiodarone
SSRIs
fluconazole, ketoconazole
allopurinol

Question 19

what can potentiate warfarin

Answer 19

warfarin is affected by the cytochrome P450 system in the liver, where this system is normally involved in the metabolism of warfarin

general potentiators:
liver disease
cranberry juice
P450 enzyme inhibitors
NSAIDs

green leafy vegetables containing vitamin K

Question 20

what to do if BP is >180/20mmHg

Answer 20

admit for specialist assessment if signs of retinal haemorrhage/papilloedema or life threatening symptoms e.g. heart failure, AKI, new onset confusion

referral if phaechromocytoma suspected

if none of the above, arrange urgent end organ damage investigations e.g. urine dipstick & ACR, bloods (HbA1c, lipids, U&Es), ECG

Question 21

lifestyle advice for lowering BP

Answer 21

reduce caffeine
lower salt intake <6g a day
lose weight
exercise
stop smoking & drinking alcohol

Question 22

MOA of thiazide diuretics

Answer 22

work by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl− symporter

Question 23

side effects of thiazide diuretics

Answer 23

hypotension
dehydration
hyponatremia, hypokalaemia, hypercalcemia
gout
impotence

rare:
thrombocytopenia
pancreatitis
agranulocytosis

Question 24

what do thiazide diuretics decrease the incidence of

Answer 24

kidney stones due to hypocalciuria

Question 25

MI secondary prevention

Answer 25

dual antiplatelet therapy statin ACEi beta blocker post ACS = ticagrelor + aspirin, stop ticagrelor after 12 months post PCI = prasugrel/ticagrelor to aspirin, stop 2nd antiplatelet after 12 months *** this period of time can be altered if signs of heart failure e.g. reduced ejection fraction and physical signs, start eplerenone 3-14 days after Mediterranean diet exercise (20-30 mins a day until slightly breathless) stop smoking

Question 26

management of angina pectoris

Answer 26

aspirin & statin in the absence of any contraindication beta-blocker or calcium channel blocker first line CCB as monotherapy = use rate limiting one e.g. diltiazem, verapamil **if used in combination use a long-acting dihydropyridine calcium-channel blocker (nifedipine) if poor response, titrate drug up to maximum dose then add CCB/beta-blocker only add a 3rd drug whilst a patient is awaiting assessment for PCI or CABG

Question 27

beta blockers should not be concurrently prescribed with what

Answer 27

rate limiting CBB e.g. verapamil, diltiazem risk of complete heart block

Question 28

surgical options for angina pectoris

Answer 28

Percutaneous coronary intervention with coronary angioplasty coronary artery bypass graft with great saphenous vein ** used in severe stenosis

Question 29

what to look for when examining a patient you think may have coronary artery disease

Answer 29

midline sternotomy scar brachial/femoral scars inner calves scar (great saphenous vein harvesting scar)

Question 30

what are the secondary causes of HTN

Answer 30

ROPE renal disease = renal artery stenosis obesity pregnancy induced hypertension/pre-eclampsia endocrine e.g. hyperaldosteronism

Question 31

investigations for stable chest pain

Answer 31

first line = CT coronary angiography second line = non-invasive functional imaging (looking for reversible myocardial ischaemia) e.g. myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) OR stress echocardiography 3rd line = invasive coronary angiography

Question 32

criteria for anginal chest pain

Answer 32

1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms 2. precipitated by physical exertion 3. relieved by rest or GTN in about 5 minutes all 3 = typical angina 2 = atypical 1 = non-anginal chest pain

Question 33

presentation of cor pulmonale

Answer 33

hypoxia cyanosis raised JVP peripheral oedema hepatomegaly third heart sound murmurs (pan-systolic in tricuspid regurgitation)

Question 34

causes of cor pulmonale

Answer 34

COPD interstitial lung disease PE CF primary pulmonary hypertension

Question 35

side effects of statins

Answer 35

myopathy: myalgia myositis, rhabdomyolysis, asymptomatic raised creatine kinase ** risk increased if advanced age, female, low BMI, multi-system disease e.g. DM liver impairment: check baseline, 3 months, and 12 months

Question 36

contraindications for statins

Answer 36

macrolide antibiotics pregnancy intracerebral haemorrhage history

Question 37

MOA of statins

Answer 37

inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis should be taken at night, as this is when majority of cholesterol synthesis occurs

Question 38

who gets the primary & secondary prevention of statins

Answer 38

primary = 20mg QRISK >10% T1DM who were diagnosed >10 years ago OR >40 OR have established nephropathy secondary = 80 mg established CVD e.g. prior stroke, TIA, MI peripheral vascular disease

Question 39

what should you do with the dose with antihypertensive medication before adding another medication?

Answer 39

prescribe maximum dose

Question 40

MOA of clopidogrel

Answer 40

antagonist of the P2Y12 adenosine diphosphate (ADP) receptor, inhibiting the activation of platelets

Question 41

what concurrently prescribed with clopidogrel is a cause for concern

Answer 41

omeprazole & esomeprazole - might reduce the effectiveness of clopidogrel lansoprazole should be okay

Question 42

what are the reversible causes of cardiac arrest?

Answer 42

Hs & Ts Hypoxia Hypovolaemia Hypothermia Hypoglycaemia Hyper/hypokalaemia Acidosis Tension pneumothorax Tamponade Toxins Thrombosis (coronary/pulmonary)

Question 43

causes of RBBB

Answer 43

normal variant - increasing age PE right ventricular hypertrophy cor pulmonale MI cardiomyopathy/myositis

Question 44

indications of warfarin

Answer 44

mechanical heart valves second line after DOACs in VTE and AF

Question 45

target INR for warfarin in VTE and AF

Answer 45

VTE: 2.5, recurrent 3.5 AF = 2.5

Question 46

side effects of warfarin

Answer 46

haemorrhage teratogenic purple toes skin necrosis *** when warfarin first started protein C is reduced, putting the body into a procoagulant state normally avoided by concurrent heparin administration thrombosis may occur in venules leading to necrosis

Question 47

causes of chronic heart failure

Answer 47

hypertension ischaemic heart disease valvular disease e.g. aortic stenosis arrythmias e.g. AF

Question 48

presentation of chronic heart failure

Answer 48

breathlessness on exertion cough (frothy white/pink sputum) orthopnoea paroxysmal nocturnal dyspnoea peripheral oedema

Question 49

when do you offer ambulatory BP monitoring/home BP monitoring

Answer 49

when clinic BP is >140/90mmHg