GP ILA 1: Broken Heart

Question 1

Heart failure is a clinical syndrome that requires what 3 things?

Answer 1

Typical symptoms, typical signs and objective evidence of structural/functional abnormality

Question 2

HF

a) Typical symptoms: (i) LFH x4, (ii) RHF x2, (iii) General x3
b) What is liver cirrhosis caused by RHF called?
c) HF caused by lung disease is called…? Give a drug used to treat pulmonary hypertension.

Answer 2

(i) LHF - SOBOE, PND, orthopnoea, pink frothy sputum; (ii) RHF - ankle swelling, abdominal distention;
(iii) General - fatigue, weight loss, nausea
b) Cardiac cirrhosis
c) Cor pulmonale. Sildenafil

Question 3

HF
b) Typical signs: (i) LHF x3, (ii) RHF x2, (iii) General x3

Think observation, palpation, percussion, auscultation

Answer 3

(i) LHF - pulmonary oedema (bilateral basal end-insp crackles +/- wheeze), pleural effusion (dullness to percussion, decreased vocal resonance/tactile fremitus, pleural rub), cardiomegaly;
(ii) RHF - raised JVP, hepatomegaly, ascites
(iii) General - low BP, tachycardia, reduced pulse pressure, gallop rhythm (S3)

Question 4

HF

c) Objective evidence: (i) O/E x2, (ii) Bloods x2, (iii) Imaging x2

Answer 4

(i) Cardiomegaly, S3
(ii) BNP, NT-proBNP
(iii) CXR (ABCDE), Echo (EF < 40%)

Question 5

Systolic (LVSD) vs Diastolic (HFPEF):

a) EF cutoff for LVSD
b) Cause of HFPEF

Answer 5

a) <40%

b) Mitral stenosis (impaired filling); ASD/VSD

Question 6

High-output cardiac failure:

a) 2 features
b) 4 causes

Answer 6

a) Primary abnormality not cardiac

b) Anaemia, pregnancy, hyperthyroid, Paget’s, AVMs

Question 7

Aetiology (low-output HF):

a) 2 most common
b) 3 valvular (preload/afterload)
c) 2 other cardiac disease types
d) Drug-induced: (i) 2 prescription, (ii) 2 recreational
e) 5 endocrine
f) 2 nutritional
g) 2 infective
h) 2 infiltrative

Answer 7

a) HTN, MI
b) AS (afterload), AR/MR (preload)
c) Arrhythmias (e.g. AF), cardiomyopathies (DCM, HCM)
d) (i) ABCDE: Beta-blockers, Ca2+, (ii) Cocaine, alcohol
e) Hypo/hyperthyroid, Cushing, Phaeo, Acromegaly, DM
f) Thiamine
g) HIV, Chagas’
h) Sarcoid, amyloid, haemochromatosis

Question 8

HF Investigations:

a) If previous MI
b) If no previous MI - 2 main
c) Other bloods
d) CXR - 5 signs

Answer 8

a) 2/52 echo - if normal, measure BNP. If echo and BNP normal unlikely to be HF. If normal echo and raised BNP - HFPEF
b) BNP first; also ECG (98% specific)
c) FBC, U&Es, fasting lipids, glucose, TFTs, cardiac enzymes if acute
d) Alveolar oedema (fluid in fissures), kerley B lines, cardiomegaly (CT ratio >50%), upper lobe diversion, pleural effusions

Question 9

BNP/ NT-proBNP:

a) A measure of…?
b) If levels are high (BNP >400pg/ml or NT-proBNP level >2,000 ng/L) - management?
c) If levels are raised (BNP 100 - 400 or NT-proBNP 400 - 2000) - management?
d) If levels are normal (BNP <100 or NT-proBNP <400) - management?

Answer 9

a) Myocardial stress
b) 2 week echo
c) 6 week echo
d) Unlikely to be HF

Question 10

NYHA classification (stages 1-4)

Answer 10

Stage 1: asymptomatic on ordinary physical activity
Stage 2: some symptoms on ordinary physical activity
Stage 3: less than ordinary physical activity leads to symptoms
Stage 4: inability to carry out any activity without symptoms

Question 11

HF: 3 indications for urgent 2-week cardiology and echo referral

Answer 11

BNP >400, severe symptoms, pregnant, previous MI

Question 12

HF Management:

a) 5 lifestyle
b) Referral to …?
c) 4 drug classes to treat HF (1 symptomatic)
d) 2 to reduce CV mortality
e) 1 other drug to use if not fully managed by BBs
f) Drugs to avoid in heart failure (3)

Answer 12

a) Nutritional - wt loss if fat, appropriate stable weight if cachectic, alcohol, smoking, low salt diet, exercise
b) Community HF nurse
c) Loop diuretics, ACE, BBs, aldosterone antagonist
d) Statins, aspirin
e) Ivabradine - acts on If channel
f) Non-dihydropyridines (verapamil, diltiazem), lithium, fleicanide, TCAs

Question 13

ACE inhibitors

a) MoA in HF
b) CIs - give 3
c) Prior to treatment, and at 1, 3 and 6 months (then every 6m) - what blood tests?
d) Alternative if not tolerated

Answer 13

a) Improves LV function
b) history of angio-oedema, bilateral renal artery stenosis, hyperkalaemia (>5 mmol/L), severe renal impairment (serum creatinine >220 μmol/L) and severe aortic stenosis.
c) U&Es and creatinine
d) ARB

Question 14

Beta-blockers

a) MoA in HF
b) CIs - give 4
c) Monitor what two things with each increase in dose

Answer 14

a) Greater diastolic time
b) Asthma, second- or third-degree heart block, sick sinus syndrome (without pacemaker) and sinus bradycardia (<50 beats per minute (bpm)), Raynaud’s
c) HR and BP

Question 15

Diuretics

a) 2 commonly used in HF
b) 2 risks of excessive diuresis
c) 2 commonly used in HTN - types

Answer 15

a) furosemide, bumetanide
b) hypotension, renal failure
c) Chlortalidone, indapamide

Question 16

Aldosterone receptor antagonists

a) 2 common
b) Common side effects -
c) If not tolerated, alternative class (must be monitored strictly if combined with ACE)

Answer 16

a) spiro, eplerenone
b) Breast tenderness, gynaecomastia, sexual dysfunction
c) ARB

Question 17

Surgical options for HF

Answer 17

CABG, transplant, pacing

Question 18

Hypertension.

a) Stage 1
b) Stage 2
c) Severe

Answer 18

a) Clinic 140/90, ABPM/HBPM 135/85
b) Clinic 160/100, ABPM/HBPM 155/95
c) 180/110

Question 19

HTN aetiology.

a) Most common
b) Most common secondary causes
c) 5 endocrine causes
d) 1 extra cause in women
e) Drugs
f) Risk factors: (i) 4 modifiable, (ii) 4 non-modifiable

Answer 19

a) Essential
b) Renal disease - GN, RAS, vasculitis, systemic sclerosis, chronic pyelonephritis
c) Cushings, Conns, Acromegaly, Hyperthyroid, Phaeo
d) HTN in pregnancy, and pre-eclampsia
e) Alcohol, cocaine, antidepressants
f) (i) Weight, salt intake, poor exercise, alcohol use, stress; (ii) FHx, ethnicity, older age, gender (<65 men; >65 women)

Question 20

HTN diagnosis.

a) If clinic BP reading is 140/90 or more, what should be done?
b) How ABPM is used to diagnosis HTN
c) Those with high end of normal clinic BP values (130-139/85-89) should be monitored how often?
d) Look for a cause, especially in what patients?

Answer 20

a) Take 3 readings - record lowest. If still over 140/90, confirm with ABPM (135/85 or more)
b) Take at least 2 readings every waking hour over a day. Use the average of at least 14 readings: if 135/85 or more, diagnose HTN.
c) Annually
d) Young, treatment-resistant HTN, severe HTN

Question 21

HTN presentation.

a) Usually.
b) Episodic feelings ‘as if about to die’ or headaches, paroxysmal sweats, palpitations
c) Abdominal or loin bruit
d) Delayed or weak femoral pulses.
e) Weight gain, depression, bruising
f) Weak muscles, polyuria, hypokalaemia.
g) Diarrhoea, weight loss, vision problems

Answer 21

a) Asymptomatic
b) Phaeo
c) Renovascular disease
d) Coarctation
e) Cushing
f) Conn’s
g) Grave’s

Question 22

HTN may present with signs of end-organ damage.

a) Eyes (3 signs)
b) Kidneys
c) Heart
d) Acute events

Answer 22

a) Hypertensive retinopathy - cotton wool spots, flame haemorrhages, papilloedema,
b) Proteinuria (albuminuria), raised creatinine, deranged U&Es
c) LVH
d) Stroke/TIA, CHD, dissection

Question 23

Hypertensive crises

a) Malignant/accelerated HTN (hypertensive emergency) - (i) define, (ii) treatment urgency
b) Types of acute end-organ damage
c) Hypertensive urgency - (i) define, (ii) treatment urgency

Answer 23

a) >200/130 with end-organ damage, minutes to hours
b) Encephalopathy, aortic dissection, pappiloedema, pulmonary oedema
c) >180/110 without end-organ damage, days

Question 24

HTN investigations

a) For end-organ damage (4)
b) For CVD prevention
c) For suspected secondary causes i) Phaeo, ii) Cushing’s, iii) Conn’s, iv) Thyroid, v) RAS

Answer 24

a) 12-lead ECG, fundoscopy, eGFR, renal US, urinalysis, U&Es and creatinine
b) Fasting cholesterol, fasting glucose
c) i) 24-hour urinary metanephrines.
ii) Urinary free cortisol and/or dexamethasone suppression test.
iii) Renin/aldosterone levels.
iv) TFTs
v) Magnetic resonance imaging of the renal arteries.

Question 25

HTN lifestyle management

a) Dietary (5)
b) Alcohol
c) 2 other

Answer 25

a) Weight loss, lower salt intake, lower refined sugar intake, 5 portions fruit and veg/day, 2 portions oily fish/week, switch to wholegrain starches (bread, pasta, rice), switch from saturated to unsaturated fats, reduce caffeine consumption
b) No more than 14U/week and 2 alcohol-free days
c) Smoking cessation, more exercise, less time sedentary

Question 26

HTN medical management

a) Treat stage 1 HTN if under 80 and: (i) Signs of…? (ii) or, CVD mortality risk of >__%, (iii) or, with _____
b) Always treat stage 2 HTN - true or false?

Answer 26

a) …end organ damage, 20%, Diabetes

b) True

Question 27

Initial antihypertensive: (ABCD)

a) 55 and under (or alternative)
b) > 55 / Afro-Caribbean (or alternative class with 2 examples)
c) In what 3 patient groups might BBs (B) be the most appropriate choice?

Answer 27

a) ACE/ ARB (A)
b) CCB (C) / thiazide-like diuretic (D) - chlorthalidone, indapamide
c) Young, pregnant, sympathetic overactivity

Question 28

HTN: Step 2 management

a) If on ACE/ARB (A), add ___ or ___
b) If on CCB (C), add ___ or ___
c) If on BB (B), add ___
d) If Afro-Caribbean, should you add ACE or ARB?

Answer 28

a) CCB (A + C) or Thi-Diuretic (A + D)
b) ACE or ARB (A + C)
c) Thi-Di (B + D)
d) ARB

Question 29

HTN: Step 3 management

a) Most common combination

Answer 29

a) A + C + D

Question 30

HTN: Step 4 management

a) Two initial options
b) If this fails, consider what 2 classes?
c) At this point, consider what?
d) Is ACE plus ARB considered okay?

Answer 30

a) Add spiro, or raise thi-di dosage (A + C + D + D)
b) Alpha/beta-blocker
c) Specialist referral
d) No

Question 31

HTN treatment targets

a) <80 years
b) 80 years and above

Answer 31

a) People aged <80 years: clinic <140/90 mm Hg, ABPM/HBPM <135/85 mm Hg.
b) People aged ≥80 years: clinic <150/90 mm Hg, ABPM/HBPM <145/85 mm Hg.

Question 32

HTN treatments in comorbidities.

a) CCF - already on A + B, consider adding ___. If still not controlled, consider adding ___
b) Diabetes: (i) 1st step in Non-Afro Caribbean, (ii) 2nd line, (iii) 3rd line, (iv) 1st step if Afro-Caribbean,
c) AF: i) If rate control needed - 1st line; 2nd line, ii) If already on amlodipine - switch to ___

Answer 32

a) D, then Spiro
b) i) A, ii) D, iii) C, iv) A + C or A + D
c) BB, then CCB; diltiazem

Question 33

CV drugs

a) Why is bumetanide often used in preference to furosemide in severe HF?
b) What must be monitored in ACE inhibitors? What precaution should be taken?
c) Why NSAIDs and ACE can lead to AKI/CKD
d) What do thiazides increase the risk of?

Answer 33

a) Better gut absorption
b) BP, eGFR, K+; start low and titrate up
c) Prostaglandins - vasodilate the renal afferent arteriole (NSAIDS inhibit prostaglandin formation: lead to vasoconstriction and reduced blood flow and eGFR)
ANG II - vasoconstrict the efferent arteriole to maintain eGFR (ACE inhibitors inhibit ANG II formation, leading to efferent arteriole
d) Gout

Question 34

Elderly pharmacology.

a) Risk of antihypertensives
b) Risk of loop diuretics. Switch to…?
c) Antipsychotics - two considerations. What condition may it worsen?
d) Risk of TCAs in the elderly
e) NSAIDs risk. Do not prescribe ibuprofen if also on…? Other precaution to take
f) Steroids

Answer 34

a) Postural hypotension and falls
b) Hyponatraemia, hypokalaemia - confusion and falls. Switch to potassium-sparing (spiro?)
c) Much lower dose needed, dopamine inhibitory effects; may worsen PD
d) Cardiotoxic effects
e) UGIB, kidney failure; Aspirin, warfarin or NOAC; PPI
f) Osteoporosis, infection, UGIB

Question 35

Warfarin.

a) Interactions (what liver enzyme)
b) Reversible with…? (Administration)

Answer 35

a) Cytochrome P450

b) Vit K/prothrombin (IM injection). May also give FFP

Question 36

Risk calculator for:

a) CVD
b) Stroke risk in AF

Answer 36

a) QRISK-2

b) CHA(2)DS(2)VASc

Question 37

Polypharmacy.

a) Three causes
b) Three types of interaction. May affect what 4 elements of pharamacokinetics.
c) Common interactions
d) Other issues with polypharmacy
e) Solutions to issues of polypharmacy
f) What drugs mix very poorly with alcohol? What added antibiotic has reduced efficacy with alcohol?
g) What antibiotics cause reduced efficacy of contraception?

Answer 37

a) Increased age, chronic diseases, increased availability
b) Antagonism, synergism and potentiation ; Absorption, Distribution, Metabolism, Elimination
c) Thyroxine/FeSO4 ; macrolide/statins;
d) Unwanted SEs, non-compliance,
e) EMIS system interactions on SystmOne - 1 star (fine) to 4 stars (do not prescribe); Getting patients to bring all medications in and any OTC/secondary care meds; ensure effective communication and concordance with patient
f) Metronidazole, disulfiram; doxicycline
g) Rifampicin; rifabutin

Question 38

CVD prevention

a) Diet - give examples
b) Smoking - interventions
c) Exercise campaign
d) What 9 things should diabetics have checked each year?
e) Tertiary prevention of MI

Answer 38

a) Food labelling (red, amber, green), sugar tax, 5-a-day
b) LSSS + varenicline/NRT
c) Change4Life, Cycle To Work
d) BMI, HbA1c, BP, cholesterol, albumin, creatinine, smoking status, foot examination, retinopathy screen
e) Post-MI drugs (dual antiplatelet therapy, beta-blockers, statin, ACE inhibitor): after 1 year, discontinue clopidigrel and BB if low-risk. Also cardiac rehab - education, exercise, diet, community nurses, etc.

Question 39

If BP >180/110

• acute management
• long term management

Answer 39

Assess pupils, retina, signs of stroke (neuro), vitals, etc.
Same day assessment by specialist

Long-term: BP control