cvs

Question 1

What is the management of stable angina?

Answer 1

First line= Mono therapy of a beta blocker or calcium channel blocker
Symptomatic relief- GTN spray

Second line= the above two together

Third line= add an additional anti angina- ivabradine or nicorandil and refer to cardiology for revascularisation

Question 2

How does GTN work?

Answer 2

Converted to nitrous oxide which stimulates vascular smooth muscle relaxation through stimulation of cGMP dependent protein kinase with resultant reduction in intracellular calcium

Question 3

State the effects of nitrates…

Answer 3

Venous dilatation- decreases preload
Arterial dilatation- decreases afterload
Coronary dilatation- improved myocardial oxygen supply

Question 4

What are the uses of nitrates?

Answer 4

Oesophageal spasm
Angina
Heart failure
Topical use in anal fissure (GTN cream)

Question 5

What are the side effects of nitrates?

Answer 5

Headache
Postural hypotension
Nausea and vomiting

Question 6

What is the first line of heart failure?

Answer 6

ACE-I and beta blocker

Question 7

What is the second line treatment for heart failure?

Answer 7

Aldosterone antagonist (spironolactone)

Question 8

What is an important consideration of ACE-I and aldosterone anatagonist use?

Answer 8

Likely to be on both in heart failure, can cause hyperkalaemia therefore potassium should be monitored.

Question 9

What is digoxin strongly indicated in?

Answer 9

It is strongly indicated in heart failure if there is co-existent heart failure

Question 10

What vaccinations should be offered to heart failure patients?

Answer 10

Annual influenza and pneumococcal vaccination

Question 11

What is the difference between cardio selective and non cardio selective drugs?

Answer 11

Cardio selective- selectively bind to and competitively inhibit the action of adrenaline and noradrenaline on beta 1 receptors, resulting in suppression of sympathetic nervous system

No cardio selective- inhibit the action of adrenaline and noradrenaline on both the beta 1 and beta 2 receptors

Question 12

What effects do beta blockers have?

Answer 12

Reduce contractility, reduce heart rate, reduce electrical conduction, vasoconstrict

Question 13

What are beta blockers used for?

Answer 13

Hypertension 
Post MI 
Migraine prophylaxis 
Rate control for AF 
Stable AF

Question 14

Side effects of beta blockers?

Answer 14

Fatigue, headache, brachycardia, postural hypotension, nausea and vomiting

Question 15

What is the 3rd line management for heart failure?

Answer 15

Cardiac resynchronisation therapy

Question 16

What are examples of ACE-I

Answer 16

RAMIPRIL, LISINOPRIL etc

Question 17

How do ACE- I work?

Answer 17

Inhibit ACE which usually converts angiotensin 1 to 2 and therefore prevents aldosterone production
Ultimately results in a reduced preload and afterload

Question 18

What are the clinical indications of ACE-I

Answer 18

First line for under 55 year olds in hypertension 
First line in heart failure 
Used post MI 
Used in stable angina 
Diabetic nephropathy

Question 19

What effect do ACE- I have on the kidneys?

Answer 19

Ang 2 is the major determinant of efferent vasoconstriction
This helps to maintain the GFR when-renal perfusion is low (old people with CCF, bilateral renal artery stenosis) blocking this protective mechanism in these patients can cause deterioration in kidney function and AKI.

Question 20

What are the side effects of ACE-I?

Answer 20

Dry cough (build up of bradykinin) 
Hypotension 
Angio oedema 
Hyperkalaemia 
Renal impairemem t

Question 21

When shouldn’t ACE-I be used?

Answer 21

Pregnancy and renal artery stenosis

Question 22

Give an example of an angiotensin 2 receptor and what the MOA is

Answer 22

Competitively inhibit the action of angiotensin 2 at AT1 receptors

Question 23

What are the effects of angiotensin 2 receptors?

Answer 23

Vascular smooth muscle relaxation
Reduced tubular sodium and water reabsorption
Reduced aldosterone secretion

Question 24

How do aldosterone antagonists work?

Answer 24

They inhibit the action of aldosterone on the sodium- potassium exchange pumps in the distal convoluted tubule

Question 25

What are aldosterone antagonists used in?

Answer 25

Conns Refractory hypertension Refractory heart failure Peripheral oedema

Question 26

What is the important adverse effect of spironolactone?

Answer 26

Hyperkalaemia

Question 27

What is the secondary prevention medical management for those with angina?

Answer 27

``` Atorvastatin AMLODIPINE Aspirin Another anti platelet ACE-I Spironolactone in those with CCF ```

Question 28

What is first line management for stable angina?

Answer 28

Aspirin Statin Sublingual GTN Beta blocker or rate limiting CCB

Question 29

When would you offer cardioversion for AF?

Answer 29

If it is reversible If it has presented within the last 48 hours If it causing heart failure They remain asymptomatic despite being effectively rate controlled

Question 30

What are the treatment opetions for AF?

Answer 30

Rate control- beta blockers and non dihypyridone CCBs are first line Rythm control is favourable over rate control in persistent AF in a young patient/ disabling features of AF Flecainide Amiodarone (for structurally abnormal hearts)

Question 31

What is paroxysmal AF and how should you treat this?

Answer 31

When AF comes and goes in episodes, not lasting more than 48 hours Patients should be anti coagulated based on their CHADSVASC score and may be appropriate for a pill in the pocket, they have to have infrequent episodes without any underlying structural heart disease,

Question 32

How do you reverse warfarin?

Answer 32

Vit K

Question 33

How do you monitor warfarin and what are the side effects?

Answer 33

INR SE: bleeding Alopecia, nausea, vomiting

Question 34

A patient with tachycardia and adverse features should be offered synchronised shock, what are these adverse features?

Answer 34

Heart failure Ischaemia Shock Syncope

Question 35

How do you treat a stable patient with tachycardia?

Answer 35

IV amiodarone

Question 36

What is the treatment of tachycardia if the patient is unstable?

Answer 36

Synchronised DC shocks- 3 atempts then give 300mg Amiodarone and repeat then give amiodarone 900mg over 24 hours

Question 37

How do you treat narrow complex tachycardia in a stable patient

Answer 37

AF- rate control with a beta blocker or CCB A trial flutter- beta blockers SVT- treat with vagal manoeuvres and adenosine

Question 38

How do you treat broad complex tachycardia in a stable patient?

Answer 38

Ventricular tachycardia/unclear= amiodarone infusion

Question 39

How would you treat a patient in atrial flutter?

Answer 39

Rate/ rythm control with beta blockers or cardioversion Treat the underlying condition- hypertension, thyrotoxicosis Radio frequency ablation of the re entrant rythm Anticoagulation based on CHA2DS2VASc

Question 40

What is the definition of AF?

Answer 40

Uncoordinated atrial contraction

Question 41

What is the management of stable patients with SVT?

Answer 41

``` Valsalva manouvre Carotid sinus massage Adenosine (Verapamil as an alternative) If above fails then Direct current cardioversion ```

Question 42

How does adenosine work?

Answer 42

Primarily works through the AV node and interrupts the AV node and accessory pathway during SVT and resets it back to sinus rhythm. It actually briefly causes a period of asystole or bradycardia which is scary for both the patient and the doctor, however it is quickly metabolised and sinus rythm should return

Question 43

When should you avoid using adenosine?

Answer 43

If patient has asthma, heart failure, heart block or severe hypotension

Question 44

What is the dose for adenosine

Answer 44

Initially 6mg then 12mg | Can give a further 12mg if no improvement between doses

Question 45

What is the long term management in patients with paroxysmal SVT?

Answer 45

Meds- CCB, beta blockers, amiodarone | Radio frequency ablation