Cardiology Acute Management Quiz
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Questions and Answers

What is the recommended immediate management for a suspected acute coronary syndrome (ACS) patient?

  • Administer Clopidogrel immediately
  • Routine administration of oxygen
  • Administer glyceryl trinitrate (correct)
  • Perform a chest X-ray

    • When should a patient with current chest pain and an abnormal ECG be referred for emergency admission?

  • If they report no history of heart problems
  • If they have stable angina
  • If chest pain has been present for more than 72 hours
  • If chest pain has occurred within the last 12 hours (correct)

    • What is the target oxygen saturation (SpO2) for patients at risk of hypercapnic respiratory failure?

  • 94-98%
  • 88-92% (correct)
  • 95-100%
  • 80-85%

    • Which of the following characterizes typical anginal pain according to NICE?

    <p>Constricting discomfort in the chest, precipitated by exertion, and relieved by rest</p> Signup and view all the answers

    What action should be taken if a patient presents with chest pain that occurred more than 72 hours ago?

    <p>Perform a full assessment with ECG and troponin measurement</p> Signup and view all the answers

    Which statins are associated with a higher incidence of myopathy?

    <p>Simvastatin and atorvastatin</p> Signup and view all the answers

    When should statin therapy be discontinued according to the guidelines?

    <p>If serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range</p> Signup and view all the answers

    In which scenario should statins be avoided?

    <p>Patients with a history of intracerebral hemorrhage</p> Signup and view all the answers

    When should blood pressure be measured for diagnosing hypertension?

    <p>In both arms</p> Signup and view all the answers

    Which medication should be added first if a patient on monotherapy with a beta-blocker has poor response?

    <p>Calcium channel blocker</p> Signup and view all the answers

    What is the recommended action for patients on standard-release nitrates to prevent tolerance?

    <p>Use an asymmetric dosing interval with a nitrate-free time</p> Signup and view all the answers

    What is the primary recommendation for patients with established cardiovascular disease?

    <p>Statin and lifestyle modifications</p> Signup and view all the answers

    Which condition might warrant the use of aldosterone antagonists following an MI?

    <p>Patients with signs of heart failure and left ventricular systolic dysfunction</p> Signup and view all the answers

    Which is a recommended lifestyle change after a myocardial infarction?

    <p>Switch to a Mediterranean style diet</p> Signup and view all the answers

    Which medication is known to interact with statins and requires them to be stopped?

    <p>Macrolides</p> Signup and view all the answers

    What should patients with a history of acute coronary syndrome expected to receive?

    <p>Dual antiplatelet therapy and other medications</p> Signup and view all the answers

    What is recommended as a first-line treatment for angina based on patient conditions?

    <p>Beta-blocker or calcium channel blocker based on comorbidities</p> Signup and view all the answers

    When should subsequent blood pressure readings be taken from the arm with the higher reading?

    <p>If the difference between readings is greater than 20 mmHg.</p> Signup and view all the answers

    What is the recommended action if blood pressure readings are greater than or equal to 180/120 mmHg?

    <p>Admit for specialist assessment if specific alarming signs are present.</p> Signup and view all the answers

    What is the primary first-line therapy for chronic heart failure?

    <p>Both an ACE-inhibitor and a beta-blocker.</p> Signup and view all the answers

    Which of the following represents a second-line therapy for managing chronic heart failure?

    <p>Spironolactone.</p> Signup and view all the answers

    Which therapy should NOT be used to reduce mortality in patients with heart failure?

    <p>Loop diuretics.</p> Signup and view all the answers

    What is the correct action when a bleeding patient has an INR greater than 8.0 and minor bleeding?

    <p>Administer intravenous vitamin K and stop warfarin.</p> Signup and view all the answers

    What characterizes the third-line therapy for chronic heart failure management?

    <p>Initiation usually requires a specialist's involvement.</p> Signup and view all the answers

    What is typically used in ambulatory blood pressure monitoring (ABPM)?

    <p>Two measurements per hour during waking hours.</p> Signup and view all the answers

    In chronic heart failure, which group of patients may particularly benefit from hydralazine in combination with nitrates?

    <p>Afro-Caribbean patients.</p> Signup and view all the answers

    If a significant difference in blood pressure readings is noted between arms, which condition is advised to be assessed?

    <p>Supravalvular aortic stenosis.</p> Signup and view all the answers

    Which SGLT-2 inhibitor is NOT mentioned as part of the management for heart failure?

    <p>Stiglitazone.</p> Signup and view all the answers

    What blood pressure threshold necessitates repeat clinic measurements within 7 days if no target organ damage is identified?

    <blockquote> <p>= 140/90 mmHg.</p> </blockquote> Signup and view all the answers

    Which condition is associated with coarctation of the aorta?

    <p>Turner's syndrome.</p> Signup and view all the answers

    What is a common side effect of warfarin that necessitates careful monitoring?

    <p>Haemorrhage</p> Signup and view all the answers

    Which factor is NOT known to potentiate the effects of warfarin?

    <p>Calcium supplements</p> Signup and view all the answers

    In patients with aortic stenosis, which clinical feature is most characteristic?

    <p>Ejection systolic murmur</p> Signup and view all the answers

    What is the minimum duration a patient with CABG should refrain from driving?

    <p>4 weeks</p> Signup and view all the answers

    Which symptom is NOT typically associated with hypertrophic obstructive cardiomyopathy (HOCM)?

    <p>Chest pain at rest</p> Signup and view all the answers

    Which drug is recommended for rate control in fast atrial fibrillation?

    <p>Beta blocker (other than sotalol)</p> Signup and view all the answers

    Which characteristic is NOT associated with severe aortic stenosis?

    <p>Rapid rising pulse</p> Signup and view all the answers

    What is the recommended course of action for a patient with symptomatic aortic stenosis?

    <p>Valve replacement surgery</p> Signup and view all the answers

    In New York Heart Association (NYHA) classification, which class indicates the most severe symptoms of heart failure?

    <p>Class IV</p> Signup and view all the answers

    Which of the following is a potential complication following the initiation of warfarin therapy?

    <p>Skin necrosis</p> Signup and view all the answers

    What is a typical echo finding in hypertrophic obstructive cardiomyopathy (HOCM)?

    <p>Asymmetric hypertrophy</p> Signup and view all the answers

    Which of the following actions is required if a patient has an aortic aneurysm of 6 cm or more?

    <p>Notify DVLA</p> Signup and view all the answers

    What condition is associated with purple toes in the context of warfarin therapy?

    <p>Skin necrosis</p> Signup and view all the answers

    What is the first-line investigation for patients presenting with symptoms consistent with angina?

    <p>CT coronary angiography</p> Signup and view all the answers

    Which of the following is NOT a common adverse effect of loop diuretics?

    <p>Rhabdomyolysis</p> Signup and view all the answers

    According to updated hypertension management guidelines, what is the new threshold for treating stage 1 hypertension in patients under 80 years?

    <p>10%</p> Signup and view all the answers

    Which of the following blood pressure readings qualifies as stage 2 hypertension?

    <p>Clinic BP &gt;= 160/100 mmHg</p> Signup and view all the answers

    What treatment is recommended for a patient under 55 years with type 2 diabetes and high blood pressure?

    <p>ACE inhibitor or ARB</p> Signup and view all the answers

    In step 4 treatment for resistant hypertension, what is the next step if potassium levels are below 4.5 mmol/l?

    <p>Add a low-dose spironolactone</p> Signup and view all the answers

    Which of the following medications acts as an angiotensin-2 receptor blocker (ARB)?

    <p>Losartan</p> Signup and view all the answers

    What is a recommended lifestyle change for managing hypertension?

    <p>Quit smoking</p> Signup and view all the answers

    What is a potential outcome of untreated step 4 resistant hypertension?

    <p>Increased cardiovascular risk</p> Signup and view all the answers

    What class of medication is commonly used to lower cholesterol by inhibiting HMG-CoA reductase?

    <p>Statins</p> Signup and view all the answers

    Which side effect is commonly associated with statin use?

    <p>Myopathy</p> Signup and view all the answers

    What is the first treatment step for patients aged 55 years or older with hypertension?

    <p>Calcium channel blocker</p> Signup and view all the answers

    What defines severe hypertension in terms of clinic systolic blood pressure?

    <p>Systolic BP &gt;= 180 mmHg</p> Signup and view all the answers

    Which treatment option should be considered if a patient with hypertension is black African or African-Caribbean?

    <p>Calcium channel blocker as first-line</p> Signup and view all the answers

    What imaging techniques are necessary for diagnosing Takayasu's arteritis?

    <p>Magnetic resonance angiography (MRA) or CT angiography (CTA)</p> Signup and view all the answers

    For adults with a urine albumin:creatinine ratio (ACR) of 70 mg/mmol or more, what is the target clinic diastolic blood pressure?

    <p>Less than 80 mmHg</p> Signup and view all the answers

    What should be the first course of action for patients with varicose veins exhibiting skin pigmentation?

    <p>Refer to a vascular service for interventional treatment</p> Signup and view all the answers

    Which of the following is NOT a recommended management strategy for varicose veins?

    <p>Compression stockings as the primary treatment</p> Signup and view all the answers

    What is a common association with Takayasu's arteritis?

    <p>Renal artery stenosis</p> Signup and view all the answers

    Under what condition is digoxin monotherapy considered for patients with non-paroxysmal atrial fibrillation?

    <p>If they are sedentary.</p> Signup and view all the answers

    Which medication should not be offered for long-term rate control in patients with atrial fibrillation?

    <p>Amiodarone</p> Signup and view all the answers

    What is a major side effect of amiodarone related to its effect on the heart?

    <p>Bradycardia</p> Signup and view all the answers

    Which of the following is a side effect of beta-blockers?

    <p>Bronchospasm</p> Signup and view all the answers

    What is the primary mechanism of action for clopidogrel?

    <p>Antagonism of the P2Y12 receptor</p> Signup and view all the answers

    What condition requires monitoring TFT, LFT, and U&E in patients treated with amiodarone?

    <p>Thyroid dysfunction</p> Signup and view all the answers

    Which thiazide diuretic mechanism explains its effect on heart failure treatment?

    <p>Inhibiting sodium reabsorption at the distal convoluted tubule.</p> Signup and view all the answers

    Which beta-blocker is known to be lipid soluble and can cross the blood-brain barrier?

    <p>Propranolol</p> Signup and view all the answers

    Which of the following conditions is not associated with Turner's syndrome?

    <p>Sickle cell disease</p> Signup and view all the answers

    What effect does amiodarone have on the QT interval?

    <p>Lengthens the QT interval.</p> Signup and view all the answers

    What condition is characterized by the husband's QRS complexes sometimes not arriving at all?

    <p>2nd Degree Block, Type 2</p> Signup and view all the answers

    What is a recommended first-line treatment option for younger patients with hypertension?

    <p>Angiotensin-converting enzyme inhibitors</p> Signup and view all the answers

    What is a common side effect of angiotensin-converting enzyme inhibitors?

    <p>Cough</p> Signup and view all the answers

    What interaction may reduce the effectiveness of clopidogrel?

    <p>Concurrent use of proton pump inhibitors.</p> Signup and view all the answers

    In patients undergoing treatment with ACE inhibitors, what potassium level is considered significant when monitoring?

    <p>5.5 mmol/L</p> Signup and view all the answers

    Which of the following conditions may not be treated using beta-blockers?

    <p>Uncontrolled heart failure</p> Signup and view all the answers

    What does a CHA2DS2-VASc score of 2 indicate for anticoagulation management?

    <p>Offer anticoagulation</p> Signup and view all the answers

    What is a possible adverse effect of amiodarone that affects vision?

    <p>Corneal deposits</p> Signup and view all the answers

    Which condition would warrant a 2-week referral if BNP levels are above 2000?

    <p>Acute heart failure</p> Signup and view all the answers

    Which anticoagulant is now recommended as the first-line treatment for atrial fibrillation?

    <p>Apixaban</p> Signup and view all the answers

    What should be assessed in patients before starting anticoagulation for atrial fibrillation?

    <p>Bleeding risk factors</p> Signup and view all the answers

    What is the target INR for patients with atrial fibrillation receiving warfarin?

    <p>2.5</p> Signup and view all the answers

    Which of these factors increases the risk of first-dose hypotension in patients taking ACE inhibitors?

    <p>Concurrent diuretic therapy</p> Signup and view all the answers

    What is a defining characteristic of the ORBIT scoring system?

    <p>It evaluates bleeding risk in patients on anticoagulants.</p> Signup and view all the answers

    Which direct oral anticoagulant is not listed as recommended by NICE for atrial fibrillation?

    <p>Warfarin</p> Signup and view all the answers

    What is the main concern when prescribing ACE inhibitors in pregnant women?

    <p>Fetal kidney damage</p> Signup and view all the answers

    What is the primary benefit of using a 'validated risk stratification tool' for managing low-risk pulmonary embolism patients?

    <p>It assesses the need for outpatient management.</p> Signup and view all the answers

    Which is a common side effect of warfarin therapy?

    <p>Bleeding complications</p> Signup and view all the answers

    Which anticoagulant is now recommended as the first-line treatment following a diagnosis of pulmonary embolism?

    <p>Apixaban</p> Signup and view all the answers

    Which of the following indicates a need for anticoagulation according to CHA2DS2-VASc score?

    <p>CHA2DS2-VASc score of 3</p> Signup and view all the answers

    In the event of a provoked venous thromboembolism, how long should anticoagulation therapy typically continue?

    <p>3 months</p> Signup and view all the answers

    What is the main consideration when deciding the duration of anticoagulation therapy after a venous thromboembolism?

    <p>Provoked vs. unprovoked VTE</p> Signup and view all the answers

    What treatment is now recommended for massive pulmonary embolism accompanied by circulatory failure?

    <p>Thrombolysis</p> Signup and view all the answers

    For patients who cannot use DOACs, what combination is recommended for those with active cancer?

    <p>LMWH followed by dabigatran or edoxaban</p> Signup and view all the answers

    What should be explained to patients with unprovoked DVT or PE and a low bleeding risk regarding treatment?

    <p>They are likely to benefit from continuing treatment.</p> Signup and view all the answers

    Which of the following is NOT a common recommendation for individuals at risk of VTE during long-haul flights?

    <p>Taking aspirin regularly</p> Signup and view all the answers

    What is a key disadvantage of bioprosthetic heart valves?

    <p>Structural deterioration over time</p> Signup and view all the answers

    Which score can be used to assess the risk of bleeding in patients on anticoagulation therapy?

    <p>ORBIT score</p> Signup and view all the answers

    What has changed in the management of patients with suspected pulmonary embolism according to recent guidelines?

    <p>Increased use of DOACs as initial treatment.</p> Signup and view all the answers

    What factors are critical to ensure a patient is suitable for outpatient management of PE?

    <p>Hemodynamic stability and lack of comorbidities</p> Signup and view all the answers

    What is the implication of a 'provoked' venous thromboembolism compared to an 'unprovoked' one?

    <p>It is related to a specific triggering event.</p> Signup and view all the answers

    What is the major disadvantage of using mechanical heart valves?

    <p>Increased risk of thrombosis requiring long-term anticoagulation</p> Signup and view all the answers

    Which xanthoma type is associated with familial hypercholesterolemia?

    <p>Xanthelasma</p> Signup and view all the answers

    What is a common acute management option for supraventricular tachycardia?

    <p>Intravenous adenosine</p> Signup and view all the answers

    Which of the following is a major criterion for diagnosing rheumatic fever?

    <p>Sydenham's chorea</p> Signup and view all the answers

    What is an effective non-pharmacological approach to prevent nitrate tolerance?

    <p>Taking modified release isosorbide mononitrate</p> Signup and view all the answers

    What type of rash is characterized by multiple red/yellow vesicles on extensor surfaces?

    <p>Eruptive xanthoma</p> Signup and view all the answers

    Which drugs are known to potentially increase the INR when combined with warfarin?

    <p>Clarithromycin and amiodarone</p> Signup and view all the answers

    What is a characteristic finding of rheumatic carditis in the context of heart conditions?

    <p>Endocarditis evidence with regurgitant murmur</p> Signup and view all the answers

    Which of the following conditions can lead to right bundle branch block (RBBB)?

    <p>Acute myocardial infarction</p> Signup and view all the answers

    What is the typical target International Normalized Ratio (INR) for a patient with a mechanical mitral valve?

    <p>3.5</p> Signup and view all the answers

    Which method is a primary treatment for acute SVT episodes that may be contraindicated in asthmatics?

    <p>IV adenosine</p> Signup and view all the answers

    Which management option is recommended for xanthelasma?

    <p>Surgical excision</p> Signup and view all the answers

    In which condition is the use of warfarin crucial?

    <p>Long-term management of mechanical heart valves</p> Signup and view all the answers

    What is the primary recommendation for managing patients with atrial fibrillation presenting with haemodynamic instability?

    <p>Electric cardioversion</p> Signup and view all the answers

    Which of the following is a rare adverse effect of bendroflumethiazide?

    <p>Photosensitivity rash</p> Signup and view all the answers

    What is the CHA2DS2-VASc score primarily used for?

    <p>Determining the need for anticoagulation in atrial fibrillation</p> Signup and view all the answers

    When should rate control be offered as the first-line treatment strategy for atrial fibrillation?

    <p>In patients without heart failure or atrial flutter</p> Signup and view all the answers

    What is the significance of hypocalciuria in patients managed with bendroflumethiazide?

    <p>It may help reduce the incidence of renal stones</p> Signup and view all the answers

    Which medication is typically not considered for rate control in physically active patients with atrial fibrillation?

    <p>Digoxin</p> Signup and view all the answers

    What should be done if atrial fibrillation has lasted for 48 hours or if the duration is uncertain?

    <p>Only provide rate control</p> Signup and view all the answers

    What is the recommended duration for anticoagulation after catheter ablation for a CHA2DS2-VASc score of 0?

    <p>2 months</p> Signup and view all the answers

    Which score is utilized to evaluate the prognosis of a patient with pneumonia?

    <p>CURB-65</p> Signup and view all the answers

    What is the action for those considering catheter ablation for atrial fibrillation?

    <p>Continue anticoagulation for 4 weeks prior and during the procedure</p> Signup and view all the answers

    What common condition may contraindicate the use of beta-blockers in patients with atrial fibrillation?

    <p>Asthma</p> Signup and view all the answers

    In patients with deep vein thrombosis, what is the typical outpatient treatment approach?

    <p>Initiate anticoagulation therapy and monitor</p> Signup and view all the answers

    Which complication is notable following catheter ablation for atrial fibrillation?

    <p>Cardiac tamponade</p> Signup and view all the answers

    What is the main function of the Waterlow score?

    <p>To assess the risk of developing pressure sores</p> Signup and view all the answers

    Which measure assesses disease activity in rheumatoid arthritis?

    <p>DAS28</p> Signup and view all the answers

    What is the most common cause of secondary hypertension?

    <p>Primary hyperaldosteronism</p> Signup and view all the answers

    In the management of acute coronary syndrome, which combination therapy is typically given to patients undergoing percutaneous coronary intervention?

    <p>Aspirin &amp; prasugrel</p> Signup and view all the answers

    Which condition is associated with an increased risk of developing long QT syndrome?

    <p>Acute myocardial infarction</p> Signup and view all the answers

    What is the first-line treatment for a patient with a transient ischemic attack (TIA)?

    <p>Clopidogrel</p> Signup and view all the answers

    What ECG feature is typically seen in patients with Wolff-Parkinson-White syndrome?

    <p>Short PR interval</p> Signup and view all the answers

    How should anticoagulant therapy be managed in a patient with significant bleeding risks who is already on antiplatelet therapy?

    <p>Consider stopping the antiplatelets</p> Signup and view all the answers

    Which of the following conditions is least likely to be a secondary cause of hypertension?

    <p>Obstructive sleep apnea</p> Signup and view all the answers

    What is the recommended duration of dual antiplatelet therapy following acute coronary syndrome?

    <p>12 months</p> Signup and view all the answers

    Which drug is NOT typically associated with causing prolonged QT interval when taken?

    <p>Verapamil</p> Signup and view all the answers

    What is the definitive treatment for Wolff-Parkinson-White syndrome?

    <p>Radiofrequency ablation</p> Signup and view all the answers

    What primary concern is associated with combining antiplatelet and anticoagulant therapies?

    <p>Increased risk of bleeding</p> Signup and view all the answers

    Which electrolyte imbalance can lead to a prolonged QT interval?

    <p>Hypomagnesaemia</p> Signup and view all the answers

    In what scenario is triple therapy (two antiplatelets and one anticoagulant) typically used after an acute coronary syndrome?

    <p>For 4-6 weeks after the event</p> Signup and view all the answers

    What is a common systemic feature of Takayasu's arteritis?

    <p>Fatigue</p> Signup and view all the answers

    Study Notes

    Acute Chest Pain Management

    • Suspected Acute Coronary Syndrome (ACS): Immediate management involves administering glyceryl trinitrate and aspirin (300mg). Do not routinely give oxygen, only if oxygen saturation (SpO2) < 94%. Perform ECG promptly but do not delay hospital transfer. A normal ECG does not rule out ACS.

    • Referral Criteria:

      • Abnormal ECG or current chest pain/chest pain within last 12 hours: Emergency admission.
      • Chest pain 12-72 hours ago: Same-day hospital referral for assessment.
      • Chest pain > 72 hours ago: Full assessment with ECG and troponin measurement before further action.

    • Oxygen Therapy: Do not routinely administer oxygen. Monitor SpO2, ideally before admission. Supplemental oxygen is only given to patients with SpO2 < 94% (unless at risk of hypercapnic respiratory failure) aiming for SpO2 94-98%, or to patients with COPD at risk of hypercapnic respiratory failure (target SpO2 88-92% until blood gases available).

    Stable Chest Pain Management

    • Angina Definition: Angina is defined by constricting chest discomfort (or neck, shoulders, jaw, or arms), precipitated by exertion, and relieved by rest or glyceryl trinitrate (GTN) within 5 minutes. Patients with all three features have typical angina; two features, atypical angina; and one or none, non-anginal chest pain.

    • Investigation: If clinical assessment does not exclude stable angina, NICE recommends the following:

      • First-line: CT coronary angiography.
      • Second-line: Non-invasive functional imaging (identifying reversible myocardial ischaemia).
      • Third-line: Invasive coronary angiography.

    • Examples of Non-Invasive Functional Imaging:

      • Myocardial perfusion scintigraphy with SPECT.
      • Stress echocardiography.
      • First-pass contrast-enhanced MR perfusion.
      • MR imaging for stress-induced wall motion abnormalities.

    Loop Diuretics

    • Indications: Used for heart failure (acute and chronic) and resistant hypertension (especially in renal impairment).

    • Adverse Effects: Hypotension, hyponatraemia, hypokalaemia, hypomagnesaemia, hypochloraemic alkalosis, ototoxicity, hypocalcaemia, renal impairment, hyperglycemia (less common than with thiazides), and gout.

    Hypertension Management

    • 2019 NICE Guidelines: Lowered the threshold for treating stage 1 hypertension in patients under 80 from 20% to 10% CVD risk. ARB is recommended as alternative to ACEi if indicated. If a patient already takes ACEi or ARB, a calcium channel blocker or thiazide-like diuretic can be added.

    • Blood Pressure Classification:

      • Stage 1: Clinic BP ≥ 140/90 mmHg, ABPM/HBPM daytime average or average BP ≥ 135/85 mmHg.
      • Stage 2: Clinic BP ≥ 160/100 mmHg, ABPM/HBPM daytime average or average BP ≥ 150/95 mmHg.
      • Severe: Clinic systolic BP ≥ 180 mmHg or diastolic BP ≥ 120 mmHg.

    • Management:

      • Lifestyle Advice: Low-salt diet (<6g/day ideal 3g/day). Reduced caffeine, stop smoking, limit alcohol, balanced diet, exercise, weight loss.

      • Treatment Decisions:

        • < 80 years/Stage 1: Treat if target organ damage, established cardiovascular disease, renal disease, diabetes, or 10-year CVD risk ≥ 10%. Consider treatment for <60-year-olds with stage 1 hypertension and <10% 10-year CVD risk.
        • ≥ 80 years/Stage 1: Treat if target organ damage, established cardiovascular disease, renal disease, diabetes, or 10-year CVD risk ≥10%
        • Stage 2: Drug treatment regardless of age.

      • Specialist Referral: <40 years, secondary cause suspected.

      • Stepwise Treatment:

        • Step 1: ACEi/ARB for <55 patients or type 2 diabetes; Calcium channel blockers (CCB) for ≥55 or Black African/Caribbean origin patients. ACEi are less effective in Black African/Caribbean patients.
        • Step 2: Add CCB or thiazide-like diuretic to existing ACEi/ARB. If already on CCB, add ACEi/ARB or thiazide-like diuretic. For Black African/Caribbean patients on CCB, consider ARB in preference to ACEi.
        • Step 3: Add a third drug.
        • Step 4 (Resistant Hypertension): Add a fourth drug or consult a specialist. Ensure elevated clinic BP with ABPM/HBPM; assess for postural hypotension; address adherence. Add low-dose spironolactone if K+ < 4.5 mmol/L, alpha/betablocker if K+ > 4.5 mmol/L.

    Blood Pressure Targets

    • Targets for different age groups are defined by clinic BP and ABPM/HBPM.

    Statins

    • Mechanism: Inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.

    • Adverse Effects: Myopathy (myalgia, myositis, rhabdomyolysis, CK elevation), liver impairment (check LFTs at baseline, 3, and 12 months; discontinue if transaminases >3x ULN), and potential increased risk of intracerebral haemorrhage in stroke patients (not in primary prevention).

    • Contraindications: Macrolides, pregnancy, breastfeeding.

    • Who should receive a statin?:

      • Patients with established cardiovascular disease (stroke, TIA, IHD, PAD).
      • Patients with 10-year CVD risk ≥ 10%.
      • Type 2 diabetics should be assessed using QRISK2.
      • Type 1 diabetics diagnosed > 10 years ago, >40 years old, or with established nephropathy.

    • Timing: Take at night due to higher cholesterol synthesis then.

    Stable Angina Medication

    • Treatment: Aspirin and statin (unless contraindicated), sublingual glyceryl trinitrate, beta-blocker or CCB first-line. -CCB Monotherapy: Rate limiting CCB (Verapamil or Diltiazem) used.
    • CCB in Combination: Longer-acting dihydropyridine CCB (amlodipine, modified-release nifedipine). Avoid concurrent use with beta-blockers (especially verapamil due to risk of complete heart block)
    • Treatment escalation: Increase medication to maximum tolerated dose if needed. If monotherapy fails, add the other drug. Other drugs may be used if monotherapy is not tolerated (long-acting nitrates, ivabradine, nicorandil, ranolazine).

    Myocardial Infarction (MI)

    • Drug Treatment: Dual antiplatelet therapy (aspirin + second agent), ACE inhibitor, beta-blocker, statin.

    • Lifestyle Advice: Mediterranean diet, increase plant-based fats, 20-30 min exercise 5 days a week. No omega-3 supplements or oily fish. Sexual activity may resume 4 weeks after an uncomplicated MI. PDE5 inhibitors can be used 6 months post-MI, but avoid co-administration with nitrates or nicorandil.

    • Dual Antiplatelet Therapy (DAPT): Post-ACS (medically managed) use ticagrelor. Post-PCI use prasugrel or ticagrelor. Stop the second antiplatelet after 12 months, alter period based on patient risk.

    • Aldosterone Antagonists: For patients with symptoms or signs of heart failure and left ventricular systolic dysfunction, start these within 3–14 days of the MI (preferably after ACE inhibitors).

    Diagnosing Hypertension

    • Blood Pressure Measurement: Check both arms and repeat measurements if difference > 20 mmHg (using higher-reading arm). Auscultate the heart if difference is very large. Take a second reading during consultation if first >140/90 mmHg. Lower of two readings determines further action.

    • Further investigations: Offer ABPM or HBPM if clinic BP ≥ 140/90 mmHg. If BP ≥180/120 mmHg:

      • Admit for specialist assessment if signs of accelerated hypertension (retinal haemorrhage or papilloedema) or life-threatening symptoms.
      • Refer if phaeochromocytoma suspected (labile/postural hypotension, headache, palpitations, pallor, diaphoresis).
      • Otherwise, arrange investigations for end-organ damage (bloods, ACR, ECG); Consider starting antihypertensive treatment immediately if target organ damage identified. If no damage, repeat clinic BP in 7 days.

    Ambulatory/Home Blood Pressure Monitoring (ABPM/HBPM)

    • ABPM: At least 2 measurements/hour during waking hours (e.g. 08:00-22:00). Use average of at least 14 measurements.

    • HBPM: Two readings ≥1 minute apart, seated. Record twice daily (morning/evening), for at least 4 days (ideally 7). Discard measurements from first day, use average of remaining.

    Chronic Heart Failure: Drug Management

    • First-line: ACE inhibitor and beta-blocker. Commence one agent at a time based on clinical judgement. Licensed beta-blockers: bisoprolol, carvedilol, nebivolol. These drugs do not reduce mortality in heart failure with preserved ejection fraction.

    • Second-line: Mineralocorticoid receptor antagonist (e.g. spironolactone, eplerenone). Monitor potassium.

    • Increasing role for SGLT-2 Inhibitors: Reduce glucose reabsorption and increase urinary glucose excretion (e.g. canagliflozin, dapagliflozin, empagliflozin).

    • Third-line: Specialist-initiated. Options include ivabradine, sacubitril/valsartan, hydralazine/nitrate combination, digoxin, cardiac resynchronisation therapy. Criteria for each therapy are specific and listed.

    • Other Treatments: Annual influenza vaccine and one-off pneumococcal vaccine. Boosters for asplenia, splenic dysfunction, or chronic kidney disease occur every 5 years for those with these conditions.

    Other Cardiovascular Conditions (Aortic Stenosis, HOCM, etc.)

    • Detailed descriptions and management strategies are provided for specific conditions like aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM), atrial fibrillation, etc. Including diagnostic criteria, causes, features, and management options (e.g., valve replacement, ablation).

    Atrial Fibrillation: Anticoagulation

    • CHA2DS2-VASc Score: Used to determine anticoagulation strategy. Consider transthoracic echocardiogram for valvular heart disease (absolute indication for anticoagulation in presence of AF).

    • ORBIT Score: Formalizes bleeding risk assessment.

    • Direct Oral Anticoagulants (DOACs) Preferred: Apixaban, dabigatran, edoxaban, rivaroxaban for reducing stroke risk in AF. Warfarin second-line.

    Warfarin

    • Indications: Mechanical heart valves (target INR depends on valve type), second-line after DOACs (venous thromboembolism, AF).

    • Monitoring: Using the INR (International Normalized Ratio). Warfarin has a long half-life, and achieving a stable INR takes several days. Loading regimes exist and computer software may be used to alter doses.

    • Factors Potentiating Warfarin: Liver disease; P450 enzyme inhibitors (e.g. amiodarone, ciprofloxacin); cranberry juice, drugs displacing it from albumin (e.g. NSAIDs); drugs inhibiting platelet function (e.g. NSAIDs).

    Other Relevant Information

    • DVLA Rules: Hypertension, specific blood pressure values for driving (Group 2). Information on specific procedures (angioplasties, CABG procedures etc).

    • Antiplatelet Agents (Clopidogrel): Mechanism, interactions (PPIs), use in ACS, stroke, and peripheral arterial disease.

    • BNP: Factors that reduce BNP (drugs, obesity), referral criteria for BNP values.

    • Heart Block: Different degrees (1st, 2nd type 1 and 2, 3rd degree) and associated changes/symptoms are described.

    • Thiazide Diuretics: Mechanism, indications, adverse effects (dehydration, postural hypotension, hypokalemia, hyponatremia, hypercalcemia).

    • Various Scoring Systems: CHA2DS2-VASc, NYHA, ORBIT, Child-Pugh, Wells, MMSE, etc.

    • Detailed management of various conditions such as Pulmonary Embolism (PE), Warfarin interactions, etc. are discussed.

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    Test your knowledge on the immediate management of acute coronary syndrome (ACS) and other related cardiac issues. This quiz covers guidelines for chest pain, oxygen saturation goals, and medication management for cardiac patients. Perfect for medical students and healthcare professionals.

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