Dr Nonso’s Cardiology AKT Mastery — The Complete Doctor Academy

AF & Arrhythmias

⚡ High-Yield Core Teaching

Atrial fibrillation essentials

Stroke risk: Score with **CHA₂DS₂-VASc**; bleeding risk with **ORBIT** (anaemia and renal impairment are ORBIT components).
Who to anticoagulate: Men **≥1**, women **≥2**. A woman scoring 1 (for sex alone) does **not** need anticoagulation.
Drug of choice: **DOAC first-line**; warfarin second-line if a DOAC is unsuitable. Valvular AF (e.g. mechanical valve, moderate–severe mitral stenosis) → warfarin, not a DOAC.
Rate vs rhythm: Rate control first-line for most (beta-blocker or rate-limiting CCB; digoxin only if sedentary/heart failure). Rhythm control if <65, first presentation, obvious precipitant, or heart failure.

CHA₂DS₂-VASc scoring

Factor	Points
Age ≥75	2
Age 65–74	1
Female sex	1
Heart failure	1
Hypertension	1
Diabetes	1
Stroke/TIA/thromboembolism	2
Vascular disease	1

DOAC reversal agents

DOAC	Reversal
Apixaban / rivaroxaban	Andexanet alfa
Dabigatran (direct thrombin inhibitor)	Idarucizumab

Cardioversion timing

Onset <48 h: Heparinise then cardiovert.
Onset >48 h / unknown: Anticoagulate 3 weeks first (or TOE-guided).
High recurrence risk: Amiodarone or sotalol for 4 weeks first.

Clinical pearlIf CHA₂DS₂-VASc suggests no anticoagulation, still do an echo to exclude valvular heart disease. Old age or falls risk alone is not a reason to withhold anticoagulation.

Red flag / must-knowIf anticoagulation is contraindicated, do NOT use aspirin or clopidogrel alone — a combination may be considered, but antiplatelets are far inferior to anticoagulation for stroke prevention in AF.

New AF, onset <48 h

↓

Any of: low BP, pulse >150, syncope, chest pain, breathless, stroke signs, or HF/PE/pneumonia/thyrotoxicosis?

↓

YES → admit

↓

NO → treat in primary care (rate control + anticoagulation per CHA₂DS₂-VASc)

🎯 SBA Test Bank (4)

An 83-year-old woman with hypertension and type 2 diabetes is found to have atrial fibrillation. What is her CHA₂DS₂-VASc score and does she need anticoagulation?

AScore 2 — no anticoagulation
BScore 4 — offer anticoagulation
CScore 1 — no anticoagulation
DScore 6 — offer anticoagulation
EScore 3 — aspirin only

Correct answer: B — Score 4 — offer anticoagulation

Why it’s right: Age ≥75 (2) + female (1) + hypertension (1) + diabetes (1) = 4, so anticoagulation with a DOAC is indicated. Antiplatelets are not used for stroke prevention in AF.

Options:

Underestimates the score.
(correct)
Underestimates the score.
Overestimates the score.
Aspirin is not used for AF stroke prevention.

A 70-year-old man with AF and a mechanical mitral valve needs anticoagulation. Which agent is appropriate?

AApixaban
BDabigatran
CWarfarin
DRivaroxaban
EEdoxaban

Correct answer: C — Warfarin

Why it’s right: DOACs are contraindicated with mechanical heart valves; warfarin is required. Dabigatran specifically increased events in mechanical-valve trials.

Options:

DOAC — contraindicated.
DOAC — contraindicated.
(correct)
DOAC — contraindicated.
DOAC — contraindicated.

A 68-year-old with persistent AF has a resting heart rate of 105 and no heart failure. He is asymptomatic. What is the most appropriate first-line rate-control drug?

ADigoxin
BBisoprolol
CAmiodarone
DFlecainide
ESotalol

Correct answer: B — Bisoprolol

Why it’s right: Rate control is first-line for most AF, using a beta-blocker (or rate-limiting CCB). Digoxin is reserved for sedentary patients or those with heart failure.

Options:

Digoxin is for sedentary/HF patients.
(correct)
Amiodarone is a rhythm-control drug.
Flecainide is rhythm control.
Sotalol is rhythm control.

A patient with AF develops classic 'sawtooth' baseline waves on the ECG. What is the rhythm?

AAtrial flutter
BVentricular tachycardia
CWolff-Parkinson-White
DSinus tachycardia
ETorsades de pointes

Correct answer: A — Atrial flutter

Why it’s right: Sawtooth flutter (F) waves are the hallmark of atrial flutter. Management mirrors AF: rate/rhythm control and anticoagulation by risk score.

Options:

(correct)
VT is a broad-complex tachycardia.
WPW shows a delta wave.
Sinus tachycardia has normal P waves.
Torsades is polymorphic VT.

Angina & ACS / MI

⚡ High-Yield Core Teaching

Angina drug ladder

First-line: Beta-blocker **or** calcium-channel blocker. Titrate the first drug to maximum before adding the second.
Combining: BB + a dihydropyridine CCB (e.g. modified-release nifedipine). **Never** combine a beta-blocker with verapamil/diltiazem (heart-block/collapse risk).
If BB/CCB not tolerated: Long-acting nitrate, ivabradine, nicorandil or ranolazine.
Contraindication to BB (asthma): Isosorbide mononitrate or a rate-limiting CCB (mind heart block/HF).

ACS antiplatelet strategy

Situation	Regimen
ACS, medically managed	Aspirin (lifelong) + ticagrelor 12 months
ACS with PCI	Aspirin (lifelong) + ticagrelor or prasugrel 12 months
Aspirin allergy	Clopidogrel

Chest pain timing rule

Within 12 h of onset: Emergency admission.
12–72 h: Same-day assessment.
Over 72 h: ECG and troponin to decide.

Complications of MI

Complication	Clue
Left ventricular aneurysm	Persistent ST elevation weeks later + HF
Dressler’s syndrome	2–6 weeks post-MI: fever, pleuritic pain, effusion, ↑ESR
Acute pericarditis	Within 48 h: fever + pericardial rub
VSD (septal rupture)	Pansystolic murmur, left sternal edge + HF
Acute mitral regurgitation	Pansystolic murmur at apex → axilla (papillary muscle rupture)
Free-wall rupture / tamponade	Raised JVP, pulsus paradoxus, muffled sounds

Cardiac arrest — shockable (VF / pulseless VT)

↓

Single shock → 2 min CPR

↓

Adrenaline 1 mg after 3rd shock, then every 3–5 min

↓

Amiodarone 300 mg after 3rd shock; treat 4 Hs & 4 Ts

Clinical pearlDrugs that reduce mortality after MI: dual antiplatelets, ACE inhibitor, beta-blocker and spironolactone. After MI, no sexual activity for 4 weeks and no sildenafil for up to 6 months.

Red flag / must-knowNever combine a beta-blocker with verapamil or diltiazem — the risk is complete heart block and collapse.

🎯 SBA Test Bank (4)

A 58-year-old with stable angina is on maximum-dose bisoprolol but still has attacks. He has no heart failure. What is the most appropriate next step?

AAdd verapamil
BAdd a dihydropyridine CCB (e.g. modified-release nifedipine)
CAdd diltiazem
DStop the beta-blocker
EAdd ivabradine as monotherapy

Correct answer: B — Add a dihydropyridine CCB (e.g. modified-release nifedipine)

Why it’s right: When a beta-blocker at maximum dose fails, add a dihydropyridine calcium-channel blocker such as modified-release nifedipine. Verapamil/diltiazem must not be combined with a beta-blocker.

Options:

Verapamil + BB risks heart block.
(correct)
Diltiazem + BB risks heart block.
No need to stop an effective drug.
Ivabradine is a later add-on, not monotherapy here.

A patient is 4 weeks post-MI with persistent ST elevation, an S3 and bibasal crackles. What complication is most likely?

ALeft ventricular aneurysm
BAcute pericarditis
CDressler’s syndrome
DVentricular septal defect
EFree-wall rupture

Correct answer: A — Left ventricular aneurysm

Why it’s right: Persistent ST elevation weeks after MI with heart-failure signs indicates a left ventricular aneurysm, which risks thrombus. Treat the heart failure and anticoagulate.

Options:

(correct)
Pericarditis is within 48 h.
Dressler’s gives pleuritic pain + effusion + ↑ESR.
VSD gives a pansystolic murmur.
Free-wall rupture causes tamponade.

After a STEMI treated with PCI, which antiplatelet regimen is standard for the first 12 months?

AAspirin alone
BAspirin plus ticagrelor or prasugrel
CClopidogrel alone
DWarfarin plus aspirin
ETicagrelor alone

Correct answer: B — Aspirin plus ticagrelor or prasugrel

Why it’s right: Standard secondary prevention after PCI for ACS is aspirin (continued long-term) plus a potent P2Y12 inhibitor (ticagrelor or prasugrel) for 12 months. Some lower-bleeding-risk patients may de-escalate, but 12-month DAPT remains the default.

Options:

Under-treats.
(correct)
Clopidogrel alone under-treats ACS.
Triple therapy only if AF present.
Aspirin is retained long-term.

During an adult cardiac arrest with a shockable rhythm, when is the first dose of adrenaline given?

AImmediately
BAfter the third shock
CBefore the first shock
DAfter the first shock
EOnly if asystole develops

Correct answer: B — After the third shock

Why it’s right: In a shockable rhythm, adrenaline 1 mg is given after the third shock once compressions resume, then every 3–5 minutes. Amiodarone 300 mg is also given after the third shock.

Options:

Immediate adrenaline is for non-shockable rhythms.
(correct)
Not before shocks in a shockable rhythm.
Not after the first shock.
Adrenaline is given in shockable rhythms too.

Heart Failure

⚡ High-Yield Core Teaching

Diagnosis & the four pillars (current NICE)

Diagnose: NT-proBNP first-line then echo. >2000 → 2-week specialist + echo; 400–2000 → 6-week.
Four pillars (HFrEF), started together: ACE inhibitor (switch to ARNI if still symptomatic) + beta-blocker + MRA + SGLT2 inhibitor — titrate each to the maximum tolerated dose.
Symptom relief: Add a loop diuretic for congestion (no mortality benefit).
Add-ons: Ivabradine (sinus HR >75, EF <35%); digoxin (esp. with AF); CRT/ICD in selected patients.

Natriuretic peptide referral

	BNP	NT-proBNP
Urgent (2 weeks)	>400	>2000
Routine (6 weeks)	100–400	400–2000
HF unlikely	<100	<400

Drugs that improve mortality in HFrEF

Class list: Beta-blockers, ACE inhibitors, ARBs, spironolactone (MRA), hydralazine + nitrate (esp. African patients), and SGLT2 inhibitors (dapagliflozin/empagliflozin).
Licensed beta-blockers in HF: Bisoprolol, Carvedilol, Nebivolol (‘BCN’).

Clinical pearlHFpEF: ACE inhibitors and beta-blockers have no mortality benefit — but SGLT2 inhibitors now reduce hospitalisation and are recommended. Manage congestion with a loop diuretic and treat comorbidities.

Red flag / must-knowNever start a beta-blocker during acute decompensation — start low and slow only when stable.

🎯 SBA Test Bank (3)

A breathless 68-year-old has an NT-proBNP of 2500 ng/L. How urgently should specialist assessment and echocardiography occur?

AWithin 6 weeks
BWithin 2 weeks
CWithin 24 hours
DRoutine, no urgency
EOnly if symptoms worsen

Correct answer: B — Within 2 weeks

Why it’s right: An NT-proBNP above 2000 ng/L mandates specialist review and echo within 2 weeks. Levels of 400–2000 allow a 6-week pathway.

Options:

6 weeks is for 400–2000.
(correct)
Not required within 24 h unless unstable.
Delay is inappropriate.
A high level needs action now.

A 72-year-old with HFrEF remains symptomatic on ramipril and bisoprolol. Which addition is most appropriate?

ADigoxin
BSpironolactone (an MRA)
CAmlodipine
DIvabradine as monotherapy
EFurosemide as the only change

Correct answer: B — Spironolactone (an MRA)

Why it’s right: An MRA such as spironolactone is added to an ACE inhibitor and beta-blocker when symptoms persist in HFrEF, improving mortality. An SGLT2 inhibitor is also now core.

Options:

Digoxin is later-line (esp. AF).
(correct)
Amlodipine has no mortality benefit.
Ivabradine is an add-on with specific criteria.
A diuretic treats symptoms but not mortality.

Which criteria must be met before starting ivabradine in heart failure?

AHeart rate >75 and EF <35% on optimal therapy
BHeart rate <60
CEF >50%
DAny patient with AF
ESystolic BP <100

Correct answer: A — Heart rate >75 and EF <35% on optimal therapy

Why it’s right: Ivabradine is indicated when the patient is in sinus rhythm with a heart rate above 75 and EF below 35% despite optimal ACE inhibitor, beta-blocker and MRA therapy.

Options:

(correct)
Ivabradine is for higher rates.
Preserved EF is not the indication.
Ivabradine needs sinus rhythm, not AF.
BP is not the criterion.

Hypertension

⚡ High-Yield Core Teaching

Diagnosis

Clinic ≥140/90: Offer ABPM (or HBPM) to confirm.
Stage 1: ABPM ≥135/85. **Stage 2** ABPM ≥150/95.
HBPM technique: Twice daily for 7 days, discard day 1.

Treatment steps

Step	Therapy
Step 1 (<55 or T2DM)	ACE inhibitor / ARB
Step 1 (≥55 or African/Caribbean)	Calcium-channel blocker
Step 2	A + C
Step 3	A + C + thiazide-like diuretic (D)
Step 4, K⁺ ≤4.5	Add spironolactone
Step 4, K⁺ >4.5	Add alpha- or beta-blocker

Blood-pressure targets

Group	Clinic	ABPM/HBPM
Under 80	140/90	135/85
80 or over	150/90	145/85
T1DM	135/85	—
Any + ACR ≥70 or T2DM end-organ damage / stroke	130/80	—

Secondary & surgically-correctable causes

Screen for: Renal artery stenosis, coarctation, phaeochromocytoma, Conn’s, Cushing’s, unilateral renal disease, hyper/parathyroid.
Diabetic + proteinuria: ACE inhibitor / ARB regardless of age.

Red flag / must-knowIf new BP ≥180/120 with retinal haemorrhage or papilloedema → admit for same-day specialist assessment. With no worrying signs → urgent investigation for end-organ damage.

Clinical pearlFor a person of Black African/African-Caribbean origin already on a CCB who needs a second agent, prefer an ARB over an ACE inhibitor.

🎯 SBA Test Bank (3)

A 62-year-old man of African-Caribbean origin has confirmed stage 1 hypertension, a QRISK of 14% and no diabetes. What is the first-line drug?

AACE inhibitor
BCalcium-channel blocker
CBeta-blocker
DThiazide-like diuretic
ESpironolactone

Correct answer: B — Calcium-channel blocker

Why it’s right: For patients ≥55 or of African/Caribbean origin without diabetes, a calcium-channel blocker is first-line; ACE inhibitors are less effective as monotherapy in this group.

Options:

ACEi less effective here as monotherapy.
(correct)
Beta-blockers are not first-line.
Thiazide-like is step 3.
Spironolactone is step 4.

A patient on A + C + D has resistant hypertension with a potassium of 4.2 mmol/L. What should be added at step 4?

ASpironolactone
BAn alpha-blocker
CA beta-blocker
DDoxazosin
EAnother CCB

Correct answer: A — Spironolactone

Why it’s right: At step 4, if potassium is 4.5 or below, add low-dose spironolactone; if above 4.5, add an alpha- or beta-blocker.

Options:

(correct)
Alpha-blocker is for K⁺ >4.5.
Beta-blocker is for K⁺ >4.5.
Doxazosin is for K⁺ >4.5.
Doubling CCB is not the step.

A clinic blood pressure reads 146/92. What is the most appropriate next step?

AStart an ACE inhibitor immediately
BOffer ABPM or HBPM to confirm
CAdmit for assessment
DRepeat in one year
EStart two agents

Correct answer: B — Offer ABPM or HBPM to confirm

Why it’s right: A raised clinic reading should be confirmed with ambulatory or home monitoring before diagnosing and treating hypertension, unless severe (≥180/120) or end-organ damage is present.

Options:

Confirm before treating.
(correct)
Admission is for ≥180/120 with red flags.
One year is too long.
Not without confirmation.

Valvular Heart Disease

⚡ High-Yield Core Teaching

Murmurs at a glance

Lesion	Murmur
Aortic stenosis	Ejection systolic → carotids; slow-rising pulse, narrow pulse pressure
Aortic regurgitation	Early diastolic; collapsing pulse, wide pulse pressure
Mitral stenosis	Mid-diastolic + opening snap; AF, malar flush, haemoptysis
Mitral regurgitation	Pansystolic → axilla
HOCM	Ejection systolic, ↑ with Valsalva; jerky pulse, S4
Tricuspid regurgitation	Pansystolic + giant CV waves; IVDU

Manoeuvres

↑ Afterload (handgrip): Louder in AR and MR.
↑ Preload (squatting): Louder in AS.
↓ Preload (Valsalva/standing): Louder in HOCM.

Congenital clues

ASD: Fixed wide split S2; pulmonary flow murmur (Marfan link).
VSD: Pansystolic, left lower sternal edge.
PDA: Continuous ‘machinery’ murmur; bounding pulse.
Coarctation: BP higher in arms than legs; weak femoral pulses.

Clinical pearlCollapse or severe hypotension after starting an ACE inhibitor should make you think of undiagnosed aortic stenosis — moderate-to-severe AS is a contraindication to ACE inhibitors.

Red flag / must-knowInfective endocarditis antibiotic prophylaxis for dental procedures is NOT routinely recommended in the UK — emphasise oral hygiene instead.

🎯 SBA Test Bank (2)

An elderly man has exertional syncope and angina, a slow-rising pulse, narrow pulse pressure and an ejection systolic murmur radiating to the carotids. What is the diagnosis?

AAortic regurgitation
BAortic stenosis
CMitral regurgitation
DMitral stenosis
EHOCM

Correct answer: B — Aortic stenosis

Why it’s right: The triad of syncope, angina and dyspnoea with a slow-rising pulse and an ejection systolic murmur to the carotids is aortic stenosis. It is a contraindication to ACE inhibitors when moderate-to-severe.

Options:

AR gives a collapsing pulse and diastolic murmur.
(correct)
MR radiates to the axilla.
MS is mid-diastolic with an opening snap.
HOCM increases with Valsalva.

A 33-year-old with Marfan’s has fixed wide splitting of S2 and a pulmonary flow murmur; ECG shows partial RBBB and right axis deviation. What is the diagnosis?

AVentricular septal defect
BAtrial septal defect
CPatent ductus arteriosus
DCoarctation
ETetralogy of Fallot

Correct answer: B — Atrial septal defect

Why it’s right: Fixed wide splitting of S2 with a pulmonary flow murmur and right-sided ECG changes is an atrial septal defect. Fixed splitting is the classic exam signature.

Options:

VSD gives a pansystolic murmur.
(correct)
PDA is a continuous murmur.
Coarctation gives arm–leg BP difference.
Fallot’s is cyanotic with a boot-shaped heart.

Cardiac Drugs

⚡ High-Yield Core Teaching

ACE inhibitors — the rules

Stop thresholds: Creatinine rises >30% or eGFR falls >25% → stop. Potassium ≥6 → stop; ≥5.5 → stop/seek advice.
Renal artery stenosis: Marked worsening of renal function after starting suggests bilateral renal artery stenosis.
Adverse effects: Cough, hyperkalaemia, angioedema, first-dose hypotension (worse with furosemide).

Amiodarone monitoring

When	Tests
Baseline	TFT, LFT, U&E, chest X-ray
Every 6 months	TFT, LFT

High-yield drug effects

Amiodarone: Thyroid (hypo- or hyper-), pneumonitis, slate-grey skin, photosensitivity, corneal deposits.
Nicorandil: Anal (and other mucosal) ulceration.
Ivabradine: Headache, visual (‘luminous phenomena’), heart block.
Digoxin: Nausea, xanthopsia (yellow vision); toxicity worse with hypokalaemia.
Clopidogrel + omeprazole: Omeprazole/esomeprazole reduce efficacy — use lansoprazole.

Warfarin & INR

Situation	Action
INR >8, no bleeding	Stop warfarin; oral vitamin K 1–5 mg; restart when INR <5
INR 5–8, no bleeding	Withhold 1–2 doses; reduce maintenance
Enzyme inhibitor (e.g. fluconazole)	INR rises
Enzyme inducer	INR falls

Clinical pearlAmiodarone-induced HYPOthyroidism: continue amiodarone and add levothyroxine. HYPERthyroidism: stop amiodarone and seek cardiology advice.

Red flag / must-knowDabigatran is contraindicated in mechanical heart valves. Statins are contraindicated in pregnancy.

🎯 SBA Test Bank (3)

A 56-year-old started ramipril 6 months ago. Today: sodium 121, potassium 5.6, creatinine risen 35% from baseline. What is the most appropriate action?

AContinue and recheck in 3 months
BStop the ACE inhibitor
CIncrease the dose
DAdd a potassium supplement
EAdd spironolactone

Correct answer: B — Stop the ACE inhibitor

Why it’s right: A creatinine rise over 30% or potassium of 5.5 or more warrants stopping the ACE inhibitor. Continuing risks worsening renal function and hyperkalaemia.

Options:

Continuing is unsafe.
(correct)
Increasing worsens it.
Potassium is already high.
MRA raises potassium further.

A patient on amiodarone develops a raised TSH with low free T4 (hypothyroidism). What is the correct management?

AStop amiodarone
BContinue amiodarone and start levothyroxine
CStart carbimazole
DRefer for thyroidectomy
EHalve the amiodarone dose

Correct answer: B — Continue amiodarone and start levothyroxine

Why it’s right: Amiodarone-induced hypothyroidism is managed by continuing the amiodarone and adding levothyroxine, monitoring TFTs. Hyperthyroidism, by contrast, requires stopping the drug.

Options:

Stopping is for hyperthyroidism.
(correct)
Carbimazole treats hyperthyroidism.
Surgery is not indicated.
Dose change is not the answer.

Which proton-pump inhibitor should be avoided with clopidogrel because it reduces its efficacy?

ALansoprazole
BOmeprazole
CPantoprazole
DRanitidine
EFamotidine

Correct answer: B — Omeprazole

Why it’s right: Omeprazole (and esomeprazole) inhibit CYP2C19 and reduce clopidogrel activation; lansoprazole is the safer PPI choice.

Options:

Lansoprazole is acceptable.
(correct)
Pantoprazole has less interaction.
Ranitidine is an H2 blocker.
Famotidine is an H2 blocker.

DVLA & Fitness to Fly

⚡ High-Yield Core Teaching

DVLA Group 1 (car)

Event	Off driving
Angioplasty (elective) / ACS treated with PCI / pacemaker	1 week
CABG / ACS not treated with PCI / prophylactic ICD	4 weeks
ICD for arrhythmia	6 months
Heart transplant	6 weeks
AAA >6.5 cm	Permanent bar

DVLA Group 2 (HGV/PSV)

Event	Rule
ACS / PCI / pacemaker	6 weeks off
CABG / heart transplant	3 months
ICD (any)	Permanent bar
AAA >5.5 cm	Permanent bar
HF with EF <40%	Cannot drive

Fitness to fly

Uncomplicated MI: Fly after 7–10 days.
Complicated MI: After 4–6 weeks.
PCI: After 3 days.
CABG: After 10–14 days.
Stroke: Wait 10 days (3 days if stable).

Clinical pearlAn ICD means permanent loss of an HGV (Group 2) licence, regardless of the indication.

🎯 SBA Test Bank (2)

A car driver (Group 1) has an ACS treated with primary PCI and makes a good recovery. How long must he stop driving, and must he notify the DVLA?

A1 week; no need to notify
B4 weeks; must notify
C6 months; must notify
D1 day; no need to notify
EPermanent bar

Correct answer: A — 1 week; no need to notify

Why it’s right: After ACS treated with successful angioplasty, a Group 1 driver stops for 1 week and need not notify the DVLA. ACS not treated with PCI requires 4 weeks off.

Options:

(correct)
4 weeks applies to ACS without PCI.
6 months is for an arrhythmia ICD.
1 day is too short.
Not a permanent bar.

A Group 2 (HGV) driver receives an implantable cardioverter-defibrillator. What is the DVLA consequence?

A6 weeks off then resume
BPermanent loss of the HGV licence
C3 months off
D6 months off
ENo restriction

Correct answer: B — Permanent loss of the HGV licence

Why it’s right: An ICD causes permanent disqualification from Group 2 (HGV/PSV) driving, irrespective of the reason for implantation.

Options:

Not a temporary restriction.
(correct)
Not 3 months.
6 months is a Group 1 rule.
There is a restriction.

Aorta, PAD & Vascular

⚡ High-Yield Core Teaching

Peripheral arterial disease

ABPI: Normal 0.9–1.2; PAD 0.5–0.9; **critical ischaemia <0.5** → refer urgently.
Best medical therapy: Stop smoking, atorvastatin 80 mg, clopidogrel 75 mg (aspirin if intolerant), treat comorbidities.
Active treatment: Supervised exercise first; then angioplasty/stent/bypass. Amputation for critical ischaemia.
Declines surgery, exercise fails: Naftidrofuryl oxalate first-line.

Aortic emergencies & screening

Aortic dissection: Tearing chest pain to the back, unequal pulses, widened mediastinum — investigate with CT/MRI.
AAA screening: Single abdominal ultrasound for men at 65.
Coarctation: Radio-femoral delay; BP higher in arms than legs.

Varicose veins management

Line	Treatment
First	Endothermal ablation / endovenous laser
Second	Ultrasound-guided foam sclerotherapy
Third	Surgery

Clinical pearlRefer varicose veins to vascular services for skin changes (pigmentation/eczema), superficial thrombophlebitis with incompetence, or a venous leg ulcer (healed or not).

🎯 SBA Test Bank (2)

A 68-year-old man with calf claudication has an ABPI of 0.7. Besides supervised exercise and risk-factor control, what is the appropriate antiplatelet and statin?

AAspirin 75 mg + atorvastatin 20 mg
BClopidogrel 75 mg + atorvastatin 80 mg
CWarfarin + simvastatin
DTicagrelor + rosuvastatin
ENo drug therapy

Correct answer: B — Clopidogrel 75 mg + atorvastatin 80 mg

Why it’s right: In peripheral arterial disease, clopidogrel 75 mg is the first-line antiplatelet and atorvastatin 80 mg the statin, alongside supervised exercise and smoking cessation.

Options:

Aspirin is second-line if clopidogrel intolerant; statin dose too low.
(correct)
Anticoagulation is not standard PAD therapy.
Not the standard PAD regimen.
Medical therapy is essential.

A patient with PAD has rest pain, an ulcer and an ABPI of 0.3. What does this indicate and what is the action?

AIntermittent claudication — supervised exercise
BCritical limb ischaemia — urgent vascular referral
CNormal — reassure
DVenous insufficiency — compression
EDeep vein thrombosis — anticoagulate

Correct answer: B — Critical limb ischaemia — urgent vascular referral

Why it’s right: Rest pain, tissue loss and an ABPI below 0.5 define critical limb ischaemia, a limb emergency needing urgent vascular referral for revascularisation.

Options:

This is beyond claudication.
(correct)
0.3 is severely abnormal.
This is arterial, not venous.
Not a DVT picture.