Master Clinical Problem Solving (CPS) - CVS
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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.
Exam Red Flags
- Sudden, severe, tearing chest/back pain with pulse deficit or new murmur: Aortic Dissection.
- Syncope/angina/dyspnoea (SAD triad) on exertion with a harsh systolic murmur radiating to carotids: Severe Aortic Stenosis.
- Unresponsive chest pain with ST elevation on ECG: STEMI.
- New-onset irregular-irregular pulse with signs of heart failure: AF with rapid ventricular response/uncontrolled AF.
- Unexplained dyspnoea, pleuritic chest pain, haemoptysis, tachycardia, hypotension in a patient with risk factors: Pulmonary Embolism (especially if massive).
- Hypotension, Tachycardia, Raised JVP, Muffled heart sounds (Beck's Triad): Cardiac Tamponade.
- Pulsatile abdominal mass with sudden severe abdominal/back pain and hypotension: Ruptured Abdominal Aortic Aneurysm (AAA).
Sample Practice Questions
A 62-year-old non-diabetic Caucasian man is diagnosed with essential hypertension after repeated blood pressure readings in clinic are consistently above 140/90 mmHg. He has no other significant medical history and his kidney function is normal. According to current guidelines (e.g., NICE), what is the most appropriate first-line antihypertensive medication for this patient?
A 68-year-old male with a 40-pack-year smoking history, hypertension, and hyperlipidaemia complains of pain in his left calf when walking about 150 metres, which is relieved by rest. He denies any rest pain or non-healing ulcers. On examination, his left dorsalis pedis and posterior tibial pulses are diminished. His Ankle-Brachial Pressure Index (ABPI) is 0.7 on the left. Besides smoking cessation and a supervised exercise program, which medication is most appropriate for secondary prevention and symptom improvement?
A 45-year-old male presents for a routine check-up. His blood pressure readings over several visits have consistently been 155/95 mmHg despite documented adherence to lifestyle modifications. He denies any specific symptoms but mentions a history of intermittent headaches. Physical examination is unremarkable. Routine blood tests reveal hypokalemia (potassium 2.8 mmol/L) and a mild metabolic alkalosis.
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