Cardiology
Cardiology questions cluster around acute coronary syndromes, heart failure with reduced ejection fraction, atrial fibrillation, hypertension and valvular disease. The exam favours time-critical decisions and mortality-reducing therapy over descriptive cardiology.
Acute coronary syndromes
- STEMI: primary PCI within 120 minutes of first medical contact; fibrinolysis only if PCI is unavailable within that window, symptoms are under 12 hours and there is no contraindication.
- NSTE-ACS: risk stratify with GRACE; an early invasive strategy within 24 hours for high-risk features (dynamic ST change, rising troponin, haemodynamic instability).
- Dual antiplatelet therapy plus parenteral anticoagulation is standard; avoid fibrinolysis in NSTEMI.
Heart failure: the four pillars
For HFrEF, four drug classes reduce mortality and should be started early, at low dose, and titrated: an ARNI (or ACE inhibitor/ARB), an evidence-based beta-blocker (bisoprolol, carvedilol, metoprolol succinate), a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor. Loop diuretics relieve congestion but do not improve survival.
Atrial fibrillation
Anticoagulate when CHA2DS2-VASc is 2 or more in men and 3 or more in women; DOACs are preferred over warfarin except with mechanical valves or moderate-to-severe mitral stenosis.
Worked example
A 68-year-old with EF 30%, NYHA II symptoms, eGFR 55, potassium 4.4 and no diabetes should receive all four pillars, including an SGLT2 inhibitor - its benefit is independent of diabetes. Review potassium and creatinine at 1–2 weeks rather than withholding therapy.
Traps that cost marks
- Withholding an MRA at eGFR 30–50 when potassium is below 5.0.
- Using aspirin instead of anticoagulation for AF.
- Stopping a beta-blocker in decompensated heart failure without shock.
- Forgetting that fibrinolysis is contraindicated in aortic dissection and prior intracranial haemorrhage.