Master Clinical Problem Solving (CPS) - CVS
for MSRA

Core Concepts

• Cardiac Output (CO): HR x SV. Affected by preload (venous return), afterload (SVR), and myocardial contractility.
• Coronary Artery Disease (CAD): Caused by atherosclerosis leading to ischaemia (angina) or infarction (MI).
• Heart Failure: Inability of heart to pump sufficient blood to meet metabolic demands. Can be HFrEF (reduced ejection fraction) or HFpEF (preserved ejection fraction).
• Arrhythmias: Disturbances in heart's electrical activity (e.g., AF, SVT, VT).
• Valvular Heart Disease: Stenosis (failure to open) or regurgitation (failure to close) of heart valves. Most commonly aortic stenosis, mitral regurgitation.
• Hypertension: Persistently elevated blood pressure, major risk factor for CVD.
• Venous Thromboembolism (VTE): Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).
• Risk Factors: Modifiable (smoking, diabetes, HTN, dyslipidaemia, obesity, sedentary lifestyle) and Non-modifiable (age, male sex, family history).

Clinical Presentation

• Chest Pain:
  • Angina: Central, heavy, tight, squeezing, exertional, relieved by rest/GTN.
  • Myocardial Infarction (MI): Severe, prolonged (>20min) angina-like pain, radiating to arm/jaw, often with nausea, sweating, dyspnoea.
  • Pericarditis: Sharp, pleuritic, central, worse on inspiration/lying flat, relieved by leaning forward.
  • Aortic Dissection: Sudden onset, severe, 'tearing' or 'ripping' pain radiating to back. May have pulse deficit.
• Dyspnoea:
  • Heart Failure: Exertional, orthopnoea, paroxysmal nocturnal dyspnoea (PND).
  • Pulmonary Embolism (PE): Sudden onset, often pleuritic chest pain, tachypnoea, tachycardia, haemoptysis.
  • Valvular Disease: Especially aortic stenosis/mitral stenosis, initially exertional.
• Palpitations: Awareness of heart beat. Can be fast, slow, irregular, fluttering, pounding. Suggests arrhythmia.
• Syncope/Pre-syncope: Transient loss of consciousness due to global cerebral hypoperfusion.
  • Cardiac: Arrhythmias (brady/tachy), severe aortic stenosis, HOCM. Often sudden, no prodrome.
  • Vasovagal: Prodrome (nausea, sweating, dizziness), specific triggers.
  • Orthostatic: Change in position, associated with volume depletion/drugs.
• Oedema: Bilateral pitting oedema suggests Right Heart Failure (elevated JVP). Unilateral leg swelling suggests DVT.
• Claudication: Exertional leg pain relieved by rest, suggests Peripheral Artery Disease (PAD).
• Other: Cyanosis, fatigue, dizziness, cough, haemoptysis, ankle swelling.

Diagnosis (Gold Standard)

• Acute Coronary Syndromes (ACS): ECG (ST elevation/depression, T wave inversion), Cardiac Troponins (I or T). Definitive for CAD: Coronary Angiography.
• Heart Failure: Echocardiogram (measures EF, chamber size, valvular function). Brain Natriuretic Peptide (BNP) for exclusion/severity. CXR (cardiomegaly, pulmonary oedema).
• Arrhythmias: 12-lead ECG, Holter monitor (24-72hr), event recorder.
• Valvular Heart Disease: Echocardiogram (Transthoracic - TTE, Transoesophageal - TOE for detailed views).
• Hypertension: Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM) to confirm sustained hypertension.
• Pulmonary Embolism (PE): CT Pulmonary Angiography (CTPA) if stable. V/Q scan if renal impairment/contrast allergy. D-dimer for exclusion (high negative predictive value).
• Deep Vein Thrombosis (DVT): Duplex Ultrasound of affected limb.
• Peripheral Artery Disease (PAD): Ankle-Brachial Pressure Index (ABPI).

Management (First Line)

• Acute Coronary Syndromes (ACS):
  • STEMI: Immediate Primary Percutaneous Coronary Intervention (PPCI). Medical: Aspirin, Ticagrelor/Clopidogrel, LMWH, GTN, Morphine (if pain), Oxygen (if hypoxic).
  • NSTEMI/Unstable Angina: Aspirin, Ticagrelor/Clopidogrel, LMWH. Risk stratification (GRACE score) to guide early angiography. Beta-blockers (if no contraindications).
• Heart Failure (HFrEF): ACE-I/ARB + Beta-blocker + Mineralocorticoid Receptor Antagonist (MRA e.g., Spironolactone). Loop diuretics for symptom control. SGLT2 inhibitors (e.g., Dapagliflozin).
• Atrial Fibrillation (AF):
  • Rate Control: Beta-blockers (e.g., Bisoprolol), Calcium Channel Blockers (Diltiazem, Verapamil).
  • Rhythm Control: Cardioversion (electrical/pharmacological), antiarrhythmics (e.g., Amiodarone, Flecainide).
  • Anticoagulation: Oral anticoagulants (DOACs like Apixaban/Rivaroxaban preferred over Warfarin) based on CHA2DS2-VASc score.
• Hypertension (NICE guidelines):
  • Step 1: <55yrs & non-black: ACE-I/ARB. >55yrs or black: Calcium Channel Blocker (CCB).
  • Step 2: ACE-I/ARB + CCB.
  • Step 3: ACE-I/ARB + CCB + Thiazide-like diuretic (e.g., Indapamide).
  • Step 4: Add Spironolactone (if K+ <4.5) or alpha-blocker/beta-blocker.
• DVT/PE: Anticoagulation (e.g., LMWH bridging to Warfarin OR direct oral anticoagulants - DOACs like Rivaroxaban/Apixaban). Thrombolysis for massive PE with haemodynamic instability.
• Valvular Heart Disease: Medical management of symptoms (e.g., diuretics for HF). Surgical valve repair or replacement for symptomatic severe disease.