Cardiovascular

Question 1

Angina questions

Answer 1

Pain characteristics
Relationship to exertion
Associated symptoms (SOB)
Exercise tolerance
Some patients (especially those with diabetes) may not describe pain but may have reproducible exercise-induced symptoms (nausea/SOB)

Question 2

CVD risk factors

Answer 2

CVD hx (MI, CABG, CCF, TIA, PVD)
ejection systolic murmur suggesting aortic stenosis.
Hypertrophic cardiomyopathy, e.g. family history, examination, or ECG changes.
Age
Male
Smoker or ex-smoker
FHx IHD<60
Ethnic background, South Asian and Afro-Caribbean
Lifestyle, sedentary, unhealthy diet, alcohol
CKD
Diabetes
Hyperlipidaemia
Hypertension
Obesity or overweight
RA, PCOS
Serious mental health problems

Question 3

Non cardiac causes of chest pain

Answer 3

Gastrointestinal cause, GORD, biliary colic- Check relation to food
MSK
Pericarditis
Anxiety or panic disorder
Respiratory cause
Breast pain
Shingles
Viral cause

Question 4

Initial management angina

Answer 4

Atorvastatin 20mg
Aspirin 75mg
GTN
Bisoprolol 2.5mg
Urgent referral rapid access chest pain clinic

Question 5

Symptoms of unstable angina

Answer 5

Pain at rest, which may occur at night
Pain on minimal exertion
Angina that seems to be rapidly progressing despite increasing medical treatment

Question 6

Advice to reduce CVD risk factors

Answer 6

Smoking cessation
Diabetes control
Weight management
Appropriate exercise

Question 7

ECG changes suggesting STEMI

Answer 7

S–T elevation 1 mm or greater in 2 or more I, II, III, AVR, AVL, AVF
S–T elevation 2 mm or greater in 2 or more V1 to V6
New LBBB
widespread ST depression.
T‑wave inversion esp V2, V3, and V4

Question 8

STEMI management

Answer 8

999, 300mg aspirin, GTN, pain relief

Question 9

Pericarditis signs

Answer 9

Chest pain, sharp, pleuritic, improved by sitting up + leaning forward
Pericardial friction rub
ECG widespread concave S–T segment elevation or PR depression
Pericardial effusion
Fever, flu-like symptoms, raised CRP
Pericarditis can cause raised troponin.

Question 10

Underlying causes of AF

Answer 10

Infection
Dehydration
Surgery
Cardiac- MI, HTN or valvular heart disease, ischaemic or non-ischaemic cardiomyopathy
Respiratory- exacerbation COPD, sleep apnoea, PE, pneumonia
Excessive alcohol intake
Thyrotoxicosis
Obesity

Question 11

CHA2DSVASc

Answer 11

Congestive heart failure
Hypertension hx
Age>75
Diabetes
Stroke
Vascular disease (CVD, PVD)
Age 65-74
Female

Question 12

ORBIT

Answer 12

Hb under 120 F, 130 M
Age >74 years +1

Bleeding history +2
Any history of GI bleeding, intracranial bleeding, or hemorrhagic stroke

GFR <60 mL/min/1.73 m2 +1

Treatment with antiplatelet agents +1

Question 13

Admit AF if

Answer 13

Pulse>150
SBP<90 mmHg
Myocardial ischaemia
Severe dizziness or SOB
Haemodynamic instability
Pulmonary oedema
Chest pain
Syncope or presyncope

Question 14

Rate control medication

Answer 14

Bisoprolol
Diltiazem
Verapamil (NOT WITH B-BLOCKER)
Digoxin

Question 15

pAF management

Answer 15

Routine cardiology referral for holter to diagnose
Anticoagulate as in AF
Routine cardiology ref re ablation/pill in pocket flecainide

Question 16

Symptoms CCF

Answer 16

Dyspnoea
Peripheral oedema
Fatigue
Weakness
Decreased exercise tolerance

Question 17

Ix CCF

Answer 17

FBC, electrolytes and renal function, LFT, TFT, lipids, HBa1c, ferritin, urinalysis
BNP
ECG
CXR
Urgent cardio ref if BNP>400

Question 18

Lifestyle modification for CCF

Answer 18

Reduce salt intake (2g/day)
Stop alcohol + smoking
Cardiac rehab for breathlessness
Annual influenza + one off pneumococcal

Question 19

CCF exacerbation causes

Answer 19

MI
Arrhythmia
Poor adherence to treatment
New medication
Diet/exercise
Anaemia
Infection

Question 20

Murmur hx

Answer 20

Chest pain
Syncope
Palpitations
SOB
Fatigue
Congenital heart disease
Rheumatic fever
Heart failure

Question 21

Positions of murmurs

Answer 21

The apex in the left lateral position in expiration (mitral murmurs)
The left sternal border sitting forward in expiration (aortic regurgitation)
The neck for radiation (aortic stenosis).
MRS ASS

Question 22

When do you need fasting lipids?

Answer 22

For LDL, needs 12 hrs fast overnight

Question 23

Secondary causes of hyperlipidaemia

Answer 23

T2DM (TGs)
Hypothyroidism (cholesterol + TGs)
Nephrotic syndrome (cholesterol)
Cholestatic liver disease (cholesterol)
Alcohol excess (TGs)
Obesity (TGs)
Anorexia nervosa (cholesterol)
Drug causes:
Olanzapine, clozapine
Sertraline, venlafaxine, quetiapine, mirtazapine
Cyclosporin

Question 24

New high lipid Ix

Answer 24

HbA1c, TFTs, U+E, urine dip, LFT

Question 25

How do you diagnose familial hypercholesterolaemia?

Answer 25

Definite if: Cholesterol>7.5 + tendon xanthomas (or in 1st or second degree relative) OR LDL-receptor mutation, familial defective apo B100, or a PCSK9 mutation Possible if MI<50 2nd degree or 60 1st degree Cholesterol>7.5 adult or 6.7 child LDL-C>4.9 adult 4.0 child

Question 26

When do you offer statin regardless of QRISK?

Answer 26

T1DM if -older than 40 years. -diabetes diagnosed>10 yrs -established nephropathy. -other CVD risk factors. Any CKD

Question 27

Which medications cause long QT?

Answer 27

Antiarrhythmics, e.g. flecainide, amiodarone, sotalol Lithium TCAs SSRIs- citalopram, escitalopram Antipsychotics, e.g. haloperidol, phenothiazines such as chlorpromazine Domperidone Methadone Erythromycin, clarithromycin, quinolones such as ciprofloxacin Fluconazole Quinine

Question 28

High risk Vs med risk Vs low risk CCF And referral

Answer 28

High risk – any of: BNP greater than 2000 nanogram/L Previous MI Major ECG changes, ischaemia or LBBB or QRS>120 Medium risk – BNP> 400 Low risk – BNP less than 400 no cardiac history, no cvd risk factors High + medium both urgent referral cardiology

Question 29

CCF treatment

Answer 29

ACEi/ARB Ramipril 2.5mg Bisoprolol 2.5mg OD Spironolactone 12.5-25mg OD Consider dapagliflozin Consider aspirin 75mg if CVD, consider atorvastatin 20mg

Question 30

Dapagliflozin details

Answer 30

10mg once daily Risk fourniers gangrene, normoglycaemic ketoacidosis Sick day rules UTIs and genital infections

Question 31

Red flags palpitations

Answer 31

breathlessness, chest pain, syncope, or pre-syncope Sudden onset and offset, very rapid, and can be described as too fast to count + haemodynamic instability (?SVT/VT) Triggered by exercise Hx sudden death

Question 32

Common triggers palpitations

Answer 32

Caffeine Alcohol Ilicit drugs Salbutamol Theophylline Decongestants Citalopram TCAs

Question 33

Underlying cause palpitations

Answer 33

Cardiac structural disease- cardiomyopathy, valvular disease Psychiatric- anxiety, PTSD High output state-infection, anaemia, pregnancy Endocrine- hyperthyroid, phaeochromocytoma Electrolyte imbalances

Question 34

Stages of hypertension

Answer 34

Stage 1 Clinic BP 140/90-159/99 mmHg HBPM average BP 135/85-149/94 Stage 2 Clinic BP 160/100-180/120 HBPM average BP 150/95+ Stage 3 Clinic BP 180 /120+

Question 35

Treatment HTN

Answer 35

1st line If age<55 or T2DM =A If age>55 or black African = C If CCF = D 2nd line A + C or A + D or C+D 3rd line A + C + D 4th line- refer + B or alpha blocker A = ACEi or ARB (ARB if black African) B= bisoprolol C= CCB D= indapamide/thiazide

Question 36

Ix HTN

Answer 36

Assess for end organ damage -ECG for LVH -Retinopathy -U+E and urine ACR, HbA1c, lipids