Cardiology

Question 1

What blood tests should you organise if you suspect stable angina? (7)
What other test could you organise in primary care?

Answer 1

FBC (anaemia), U&Es, fasting glucose, HbA1c (diabetes), LFTs (before starting statins), lipid profile, TFTs (exclude other cause of angina)
ECG

Question 2

What is the gold standard for diagnosing stable angina?

Answer 2

CT coronary angiography

Question 3

What are the 3 features of typical angina?

Answer 3

Constricting discomfort in front of chest, arms, shoulders or jaw
Precipitated by exertion
Relieved by rest or GTN within 5 minutes

Question 4

What is the general management of stable angina?

Answer 4

Refer to cardiology
Advice
Medication
Procedure or surgery e.g. PCI

Question 5

What is the medical management of stable angina?

1. Primary prevention (2)
2. Secondary prevention (3)

Answer 5

1. GTN spray, Beta-blocker or CCB

2. Aspirin 75mg OD, atorvastatin 80mg, ACEI if diabetic

Question 6

What are second line options for managing stable angina? (4)

Answer 6

Long-acting nitrate
Nicorandil
Ivabridine
Ranolazine

Question 7

What ECG changes suggest previous ischaemia? (3)

Answer 7

Pathological Q waves
LBBB
ST segment and T wave changes (e.g. inversion, flattening)

Question 8

What ECG changes would indicate a STEMI? (3)

Answer 8

ST elevation or >2mm in 2 or more anterior leads
ST elevation of >1mm in 2 or more inferior leads
New LBBB

Question 9

What are the criteria for PCI to treat a STEMI?

Answer 9

Symptoms presented within 12h

Can be done in 120 minutes

Question 10

What should happen after giving fibrinolysis for a STEMI?

Answer 10

Repeat ECG after 60-90 minutes; if still ECG changes, go onto PCI
Give LMWH, unfractionated or fondaparinux

Question 11

What is the initial management for an NSTEMI or unstable angina?

Answer 11

Beta blocker
Aspirin 300mg STAT
Ticagrelor 190mg STAT or clopidogrel 300g STAT
Morphine 
Anticoagulant e.g. fondaparinux
Nitrates

Question 12

What score is used after an NSTEMI?

What do the scores mean in terms of management?

Answer 12

GRACE score
Low risk - 300mg clopidogrel STAT and continue for 12 months
Intermediate or high risk - 300mg clopidogrel STAT and subsequent coronary angiogrpahy with follow on PCI

Question 13

What are the complications of an MI? (5)

Answer 13

Death
Rupture of papillary muscles or muscle wall
Edema
Aneurysms and arrhythmias
Dressler's syndrome; manage with NSAIDs

Question 14

What blood pressure readings diagnose hypertension (clinic and ambulatory?

Answer 14

Clinic reading 140/90 or ambulatory reading 135/85

Question 15

What other investigations would you carry out after diagnosing hypertension?

Answer 15

Urine dipstick and ACR
Fundoscopy
ECG
Bloods: HbA1c, U&Es, eGFR, lipid profile

Question 16

Under what criteria would you medically treat stage 1 hypertension? (6)

Answer 16

Aged <80 with one of: target organ damage, CVD, renal disease, diabetes, QRISK >10%

Question 17

What are the blood pressure targets?

Answer 17

<140/90 if <80 years

<150/90 if >80 years

Question 18

What should you monitor when starting an ACEI or diuretic?

Answer 18

U&Es

Question 19

What are the causes of secondary hypertension?

Answer 19

Renal disease
Obesity
Pregnancy or pre-eclampsia
Endocrine e.g. Conn’s

Question 20

What are the complications of hypertension? (5)

Answer 20

Stroke
Hypertensive retinopathy 
Ischaemic heart disease
Heart failure
Hypertensive nephropathy

Question 21

What is the difference between malignant hypertension and a hypertensive urgency?

Answer 21

1. Systolic >200 or diastolic >130 with end organ damage

2. Systolic >180 or diatolic >120 with no end organ damage

Question 22

What signs would indiate malignant hypertension? (6)

Answer 22

Heart:

• Pulmonary oedema (acute LVF)
• Aortic dissection

Eyes and brain:

• Encephalopathy
• Papilloedema

Kidneys:
- Nephropathy

Angiopathic haemolytic anaemia

Question 23

What diagnostic criteria is used for infective endocarditis?

Answer 23

Duke’s criteria

Question 24

Which 2 investigations are important for diagnosing infective endocarditis?

Answer 24

Echo
Blood cultures (x2 in two different places)

Question 25

What are the gradings for heart murmurs? (6)

Answer 25

``` I - audible by an expert II - quiet III - moderately loud IV - markedly loud with thrill V - very loud with thrill VI - audible without stethoscope ```

Question 26

What causes the following murmurs? 1. Ejection systolic 2. Pan systolic 3. Early diastolic 4. Late diastolic

Answer 26

1. Aortic or pulmonary stenosis, ASD 2. Mitral or tricuspid regurgitation, VSD 3. Aortic or pulmonary regurgitation 4. Mitral or tricuspid stenosis

Question 27

What are some causes of aortic regurgitation?

Answer 27

``` Aortic dissection Infective endocarditis Connective tissue disorder Ankylosing spondylitis Takayasu's disease ```

Question 28

What is the difference between valvular AF and non-valvular AF? What are the causes of non-valvular AF? (5)

Answer 28

Valvular AF = mitral stenosis or a mechanical valve ``` Non-valvular: Sepsis Mitral regurgitation Ischaemic heart disease Thyrotoxicosis Hypertension ```

Question 29

Which patients should have rhythm control as first-line for their AF? (4)

Answer 29

New onset AF (within 48h) Reversible cause AF is causing heart failure Remain symptomatic despite being rate controlled

Question 30

What are the options for controlling AF? 1. Rate 2. Rhythm

Answer 30

1. Beta blocker, CCB (e.g. dilitazem), digoxin or combination if not controlled 2. Cardioversion - pharmacological (flecainide, amiodarone) or electrical NB - must anticoagulate anyone that has been in AF for >48h if stable and planning rhythm control

Question 31

What are the NHYA stages for heart failure?

Answer 31

I - no symptoms on ordinary activity II - slight limitation of activity by symptoms III - less than ordinary activity leads to symptoms IV - not able to carry out any activity without symptoms

Question 32

What blood test should you order for heart failure? | What should you do about the results?

Answer 32

NT pro BNP >2000 - echo in 2 weeks >400 - echo in 6 weeks <400 - heart failure unlikely

Question 33

What is the management for heart failure?

Answer 33

ACE I Beta blocker Aldosterone antagonists (if above not working) Loop diuretics (if overloaded)

Question 34

Which common cardiac medication should be avoided in heart failure?

Answer 34

Calcium channel blockers

Question 35

What is the management for acute heart failure? 1. Immediate 2. Long-term

Answer 35

1. Pour SOD Stop any IV fluids, sit upright, oxygen if <95%, diuretics 2. Fluid balance, daily U&Es and weight, if cardiogenic shock, refer to ICU

Question 36

What would you expect to see on ECG in someone with LVH?

Answer 36

T wave inversion | High voltage R waves

Question 37

What can long QTc turn into if untreated?

Answer 37

Torsades de Pointes

Question 38

How would you describe VT?

Answer 38

Regular, broad complex tachycardia usually at a rate of >120 bpm

Question 39

How do you investigate and manage pericarditis?

Answer 39

Echo and troponins | NSAIDs and colchicine