Master Cardiology
for PLAB 1

What the PLAB 1 Tests in Cardiology

The PLAB 1 Cardiology section tests your ability to manage common and emergency cardiovascular presentations in UK primary and secondary care. You must know the diagnostic criteria for heart failure (NICE guidelines), ECG interpretation for ACS and arrhythmias, and first-line pharmacotherapy for hypertension, angina, and atrial fibrillation. Clinical scenarios often require you to choose the most appropriate investigation (e.g., echo, CT coronary angiogram) or urgent referral pathway. Key decision points include when to thrombolyse vs. primary PCI, when to start anticoagulation in AF (CHA₂DS₂-VASc, HAS-BLED), and how to manage acute coronary syndromes with dual antiplatelet therapy. You will also be tested on valvular disease murmurs, pericarditis, and endocarditis prophylaxis. The exam emphasises UK-specific guidelines from NICE and ESC, and expects familiarity with drug names (e.g., bisoprolol, ramipril, apixaban) and common doses.

High-Yield Concepts

• Acute Coronary Syndrome (ACS) Management: For STEMI: primary PCI within 120 minutes of diagnosis; if not possible, give thrombolysis (tenecteplase) within 30 minutes. Loading dose: aspirin 300mg + ticagrelor 180mg or prasugrel 60mg. For NSTEMI: risk stratify with GRACE score; high-risk (GRACE >140) requires urgent angiography within 24 hours. Dual antiplatelet therapy (aspirin + ticagrelor) for 12 months.
• Heart Failure Diagnosis (NICE CG187): Suspect in breathlessness, ankle swelling, fatigue. First test: NT-proBNP (>2000 pg/mL urgent echo within 2 weeks; 400-2000 pg/mL within 6 weeks). Echo confirms reduced (HFrEF: LVEF <40%) or preserved (HFpEF: LVEF ≥50%) ejection fraction. First-line for HFrEF: ACE inhibitor (ramipril) + beta-blocker (bisoprolol) + MRA (spironolactone) if still symptomatic.
• Atrial Fibrillation: Rate vs. Rhythm Control: Rate control first-line (beta-blocker or calcium channel blocker) in most patients. Rhythm control (amiodarone, flecainide) if symptomatic despite rate control, or if AF is new-onset (<48 hours) and patient is young. Anticoagulate if CHA₂DS₂-VASc ≥2 in men, ≥3 in women; use HAS-BLED to assess bleeding risk. DOACs (apixaban, edoxaban) preferred over warfarin.
• Hypertension Thresholds and Targets (NICE NG136): Clinic BP ≥140/90 mmHg confirms hypertension. Ambulatory BP monitoring (ABPM) daytime average ≥135/85 mmHg confirms diagnosis. Target: clinic BP <140/90 mmHg (or <130/80 mmHg if under 80 with CKD, diabetes, or CVD). First-line: ACEi/ARB (if under 55), CCB (if over 55 or black), then add thiazide-like diuretic (indapamide).
• Aortic Stenosis Murmur and Management: Ejection systolic murmur loudest at right upper sternal border, radiating to carotids, with slow-rising carotid pulse. Severe AS: aortic valve area <1.0 cm², mean gradient >40 mmHg, or jet velocity >4 m/s. Symptomatic severe AS requires urgent valve replacement (surgical or TAVI). Avoid vasodilators (e.g., ACEi) in severe AS.
• Pericarditis and Myocarditis: Pericarditis: pleuritic chest pain, worse lying flat, relieved sitting forward, with diffuse ST elevation and PR depression on ECG. First-line: high-dose ibuprofen (or aspirin) + colchicine. Myocarditis: often viral, with troponin rise, ECG changes, and reduced LV function; avoid NSAIDs, treat heart failure, consider biopsy if giant cell suspected.
• Infective Endocarditis Prophylaxis and Diagnosis: Prophylaxis (amoxicillin 3g PO 1 hour before) only for high-risk patients (prosthetic valves, previous IE, specific congenital heart disease) undergoing dental procedures involving gingival manipulation. Diagnosis: modified Duke criteria (2 major: positive blood culture, echo vegetation; or 1 major + 3 minor). Blood cultures before antibiotics.
• ECG Interpretation: Ischaemia and Arrhythmias: STEMI: ST elevation ≥1mm in limb leads, ≥2mm in chest leads, in contiguous leads. NSTEMI: ST depression or T wave inversion. Atrial flutter: sawtooth flutter waves, rate ~300/min, ventricular rate ~150/min (2:1 block). Ventricular tachycardia: wide QRS, rate >100, AV dissociation. Always check for hyperkalaemia (peaked T waves) and pericarditis.

Common Traps in Cardiology Questions

• Confusing NSTEMI with unstable angina: both have normal troponin initially, but NSTEMI shows troponin rise; unstable angina does not.
• Thinking all atrial fibrillation patients need rhythm control: rate control is first-line for most, especially elderly.
• Giving beta-blockers in acute decompensated heart failure with pulmonary oedema: they are contraindicated until stable.
• Using aspirin as monotherapy for stroke prevention in atrial fibrillation: it is not recommended; anticoagulate based on CHA₂DS₂-VASc.
• Forgetting to check for contraindications to thrombolysis (e.g., recent surgery, bleeding risk) before giving tenecteplase in STEMI.
• Assuming a normal ECG rules out ACS: up to 20% of NSTEMI patients have a normal initial ECG; serial troponins are key.

How to Revise Cardiology for the PLAB 1

Focus on NICE and ESC guideline-based management algorithms for ACS, heart failure, and AF. Practise ECG interpretation with a systematic approach (rate, rhythm, axis, intervals, ischaemia). Questions often present a clinical vignette with a single best answer; prioritise the 'next step' (e.g., investigation, drug, or referral). Memorise key cut-offs: CHA₂DS₂-VASc scores, GRACE risk thresholds, NT-proBNP levels, and BP targets. Be comfortable with drug classes and their side effects (e.g., ACEi cough, amiodarone thyroid/eye toxicity). Review common murmurs and their associated valve lesions. Use the 'PLAB 1 question bank' to simulate timed practice, focusing on why the correct answer is chosen over distractors. Revise the UK sepsis guidelines (qSOFA, NEWS2) as they intersect with cardiology infections like endocarditis.

Practise it: MedLumen has 50 Cardiology questions for the PLAB 1, each with a full explanation and references.