Medicine 1

• What medical co-morbidities increase the risk of atherosclerosis 

  diabetes 

   

  hypertension 

   

  chronic kidney disease (CKD)

   

  inflammatory conditions 

   

  atypical antipsychotic medications 
• Describe cardiovascular disease 

  It is the result of atherosclerosis in artery walls 

   

  involves atheromas (fatty deposits) and sclerosis (hardening/stiffening)
• What are atheromatous plaques in the artery walls caused by

  Chronic inflammation 

   

  activation of the immune system 

   

  lipid deposition 
• What can atheromatous plaques lead to 

  hypertension 

   

  angina (reduced blood flow)

   

  acute coronary syndrome (rupture of plaque which breaks off and blocks distal artery)
• What can atherosclerosis result in 

  angina 

   

  myocardial infarction 

   

  transient ischaemic attacks 

   

  strokes 

   

  periperheral arterial disease 

   

  chronic mesenteric ischaemia 
• What are some NON MODIFIABLE risk factors for CVD 

  Older age 

   

  family history 

   

  male 
• What are some MODIFIABLE risk factors for CVD 

  raised cholesterol 

   

  smoking 

   

  alcohol consumption 

   

  poor diet 

   

  lack of exercise 

   

  obesity 

   
• What medical co-morbidities increase the risk of atherosclerosis 

  diabetes 

   

  hypertension 

   

  chronic kidney disease (CKD)

   

  inflammatory conditions 

   

  atypical antipsychotic medications 
• What are the 2 types of preventive measures regarding CVD 

  Primary and secondary prevention
• What is extremley important to address when thinking of primary and secondary prevention 

  the modifiable risk factors such as;

   

  diet 

  exercise 

  smoking 

  obesity 

  Stop smoking

  reduce alcohol consumption

  treatment of co-morbities e.g diabetes  
• Which guideline is used when arranging primary prevention of CVD and what does this show 

  QRISK3 score

   

  estimates the percentage risk that a patient (aged 25-84) will have a stroke of myocardial infarction in the next 10 years 
• QRISK3 score above 10%


  should be offered a statin, atorvastatin 20mg at night 
• QRISK3 score below 10%


  DO NOT rule out giving a statin if they would like one or might be at higher risk 
• When is atorvastatin 20mg offered as primary prevention 

  in patients with;

   

  chronic kidney disease 

   

  type 1 diabetes (for over 10 years or over 40yo)
• What do statins do

  Reduce cholesterol production in the liver by inhibiting HMG CoA reductase 

   

  atorvastatin is first line 
• What could be some side effects of statins

  Myopathy

  rhabdomyolysis

  type 2 diabetes

  haemorrhagic strokes
• What do the NICE guidelines recommended to check when prescribing statins 

  Checking lipids after 3 months of statins and increasing dose? CHECK ADHERANCE

   

  checking liver function tests at 3 and 12 months after starting statins - they can cause transient rise in ALT or AST
• What are some other cholesterol lowering Drugs

  ezetimide - to inhibit absorption of cholesterol in intestines 

   

  ezetimide + bempedoic acid - to reduce cholesterol production in liver 

   

  PCSK9 inhibitors e.g evolocumab and alirocumab - these are monoclonal antibodies 
• How are PCSK9 inhibitors given

  Subcutaneous injection every 2-4 weeks
• what is the secondary prevention for CVD

  the 4 A’s !!!!

  A - antiplatelet e.g aspirin clopidogrel and ticagrelor 

   

  A - atorvastatin 80mg

   

  A - atenolol or other beta blocker (bisoprolol)

   

  A - ACE inhibitor e.g rampiril 
• What are patients normally given after a myocardial infarction

  A dual anti-platelet initially ;

  aspirin 75mg daily

  clopidogrel or ticagrelor (generally for 12 months)
• what is the normal prescribed antiplatelet medication of choice in peripheral arterial disease and ischaemic stroke

  clopidogrel
• what is angina 


  constricting chest pain when relieved on rest due to atherosclerosis in coronary arteries which narrows lumen and reduces blood flow to myocardium
• why do those with angina experience chest pain on exertion

  due to an insufficient blood supply to the heart to meet the bodies demand
• when is angina considered stable

  when symptoms only come with exertion and are always relieved by rest or glyceryl trinitrate
• when is angina considered unstable 


  when symptoms occur randomly at rest
• what are some baseline investigations in an individual with angina

  physical examination - heart sounds, BP and BMI

   

  ECG - a normal ECG does not exclude stable angina

   

  FBC - anaemia can worsen symtpoms 

   

  renal profile - before starting ACE inhibitor 

   

  liver function tests - before starting statins 

   

  lipid profile 
• Where are referrals for angina normally sent

  Rapid access chest pain clinic (RACPC)
• which investigations can be carried out in someone with angina

  cardiac stress testing

  CT coronary angiography

  invasive coronary angiography
• what is CT angiography

  injecting contrast and taking CT images timed with heart contractions to see the coronary arteries and which ones are narrowed
• what is invasive coronary angiography

  inserting a catheter into femoral or brachial artery through the arterial system to the aorta and coronary arteries under an x ray

  contrast is injected to see coronary arteries and any areas of stenosis
• what are the 3 main aims of medical management in someone with stable angina

  immediate symptomatic relief

  long term symptomatic relief

  secondary prevention of CVD
• how is immediate symptomatic relief given in those with stable angina

  sublingual glyceryl trinitrate (GTN) spray or tablet

  this causes vasodilation, improving blood flow to the heart
• what are some key side effects of GTN

  headaches and dizziness
• what is given as long term symptomatic relief for angina

  beta blocker e.g bisoprolol

  calcium channel blocker CCB e.g dilitizem or verapamil - avoided in heart failure with reduced ejection fraction
• What might a professional consider prescribing for other long symptomatic relief in someone with angina

  Long acting nitrates e.g isosorbide mononitrate

  ivabradine

  nicorandil

  ranolazine
• what are the medications given for secondary prevention of angina

  4 A’s !!!!

  A - aspirin 75mg once daily

  A - atorvastatin 80mg once daily

  A - ACE inhibitor (if diabetes, CKD or HF are present)

  A - already on a beta blocker for symptom relief
• what are the 2 surgical interventions when dealing with angina

  percutaneous coronary intervention (PCI)

  coronary artery bypass graft (CABG)
• what is percutaneous coronary intervention

  catheter inserted in arterial system to coronary arteries and identifying areas of stenosis

  stenosis can be treated by dilating a balloon to wide the lumen (angioplasty) and inserting a stent to keep it open (CAS)
• what is a coronary artery bypass graft

  opening the chest along the sternum with a midline sternotomy incision

  a graft vessel is attached to affected CA and bypasses the stenotic area