Dilated cardiomyopathy may be caused by deficiency of which one of the following:
Correct Answer E:
Dilated cardiomyopathy:
Dilated cardiomyopathy (DCM) basics:
Causes often considered separate entities:
Other causes:
Inherited dilated cardiomyopathy:
Around a third of patients with DCM are thought to have a genetic predisposition
A large number of heterogeneous defects have been identified
The majority of defects are inherited in an autosomal dominant fashion although other patterns of inheritance are seen
*These causes may also lead to restrictive cardiomyopathy.
A 72-year-old man is started on amlodipine 5mg od for hypertension. He has no other past medical history of note and routine bloods (including fasting glucose) and ECG were normal.
What should his target blood pressure (based on clinic readings) be once on treatment?
Correct Answer D:
Blood pressure target (based on clinic readings) for patients < 80 years - 140/90 mmHg.
Hypertension: diagnosis and management:
NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include:
Blood pressure classification: This becomes relevant later in some of the management decisions that NICE advocate.
Diagnosing hypertension If a BP reading is >= 140 / 90 mmHg patients should be offered ABPM to confirm the diagnosis. Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment. Ambulatory blood pressure monitoring (ABPM):
Managing hypertension: ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension):
For patients < 40 years consider specialist referral to exclude secondary causes.
Step 1 treatment:
Step 2 treatment:
Step 3 treatment:
NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking expert advice.
Step 4 treatment:
If BP still not controlled seek specialist advice.
New drugs
Direct renin inhibitors:
Which one of the following agents is most useful in the maintenance of sinus rhythm in patients with atrial fibrillation?
Atrial fibrillation: rate control and maintenance of sinus rhythm:
The Royal College of Physicians and NICE published guidelines on the management of atrial fibrillation (AF) in 2006. The following is also based on the joint American Heart Association (AHA), American College of Cardiology (ACC) and European Society of Cardiology (ESC) 2012 guidelines.
Agents used to control rate in patients with atrial fibrillation:
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation:
The table below indicates some of the factors which may be considered when considering either a rate control or rhythm control strategy:
Which one of the following non-invasive methods provides the most accurate assessment of whether a patient has coronary artery disease?
Correct Answer A:
Cardiac imaging: non-invasive techniques excluding echocardiography:
The ability to image the heart using non-invasive techniques such as MRI, CT and radionuclides has evolved rapidly over recent years.
Nuclear imaging:
Nuclear imaging These techniques use radiotracers which are extracted by normal myocardium. Examples include:
The primary role of SPECT is to assess myocardial perfusion and myocardial viability. Two sets of images are usually acquired. First the myocardium at rest followed by images of the myocardium during stress (either exercise or following adenosine / dipyridamole). By comparing the rest with stress images any areas of ischaemia can classified as reversible or fixed (e.g. Following a myocardial infarction). Cardiac PET is predominately a research tool at the current time.
MUGA:
Cardiac Computed Tomography (CT):
Cardiac CT is useful for assessing suspected ischaemic heart disease, using two main methods:
If these two techniques are combined cardiac CT has a very high negative predictive value for ischaemic heart disease.
Cardiac MRI:
Cardiac MRI (commonly termed CMR) has become the gold standard for providing structural images of the heart.
It is particularly useful when assessing congenital heart disease, determining right and left ventricular mass and differentiating forms of cardiomyopathy. Myocardial perfusion can also be assessed following the administration of gadolinium. Currently CMR provides limited data on the extent of coronary artery disease.
You review a 69-year-old man who is known to have angina and heart failure. His current medications include aspirin, simvastatin, bisoprolol, glyceryl trinitrate, ramipril and frusemide. Despite his current medications he is still having frequent angina attacks when he exerts himself. You decide to add a calcium channel blocker.
Which one of the following is it most appropriate to add?
Verapamil and diltiazem should be avoided given his history of heart failure. Nimodipine and lacidipine are neither licensed nor used in patients with angina.
Angina pectoris: drug management:
The management of stable angina comprises lifestyle changes, medication, percutaneous coronary intervention and surgery. NICE produced guidelines in 2011 covering the management of stable angina.
Medication:
Nitrate tolerance:
Ivabradine:
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