Question 1#

You are looking after a 75-year-old man who was admitted 3 days previously with an anterior STEMI and underwent primary PCI to his LAD. He has made a good recovery and his echocardiogram shows that he has only mild LV impairment. He is asking about safe levels of physical activity once he goes home.

What should you advise him?

A. To return immediately to his previous (pre-admission) level of activity

Following an acute MI patients should be referred to the CR team for assessment, and in the meantime they are advised to be physically active for 20–30 minutes a day to the point of slight breathlessness. A warm-up period of 6–0 minutes should be encouraged as it allows the body to adjust to increasing demand. The main 20–30 minutes of activity should be at a moderate level of exertion and is best followed by a cool-down period which is often similar to the warm-up. Patients who are not achieving this should be advised to increase their activity in a gradual step-by-step way. After completion of their CR programme patients should be given long-term advice to continue with at least 20–60 minutes of moderate aerobic exercise three to five times a week.

Question 2#

One of your patients is about to be discharged following an NSTEMI. They ask you for some dietary advice to help to try and reduce their risk of having a further heart attack. 

What advice should you give?

A. To eat a Mediterranean-style diet with less meat and more bread, fruit, vegetables, and fish, and to replace butter and cheese with products based on vegetable and plant oils

Patients should be encouraged to eat a Mediterranean-style diet (more bread, fruit, vegetables, and fish; less meat; replace butter and cheese with products based on vegetable and plant oils). A healthy diet should include five portions of fruit and vegetables per day and patients should reduce the intake of salt and saturated fats. Post-MI patients should eat at least 7 g of omega-3 fatty acids per week (two to four portions of oily fish), and if they are not achieving this you should consider providing at least 1 g of omega-3-acid ethyl esters daily (as per the current NICE guidance, although this may be reviewed with the results of the Alpha Omega trial that shows a less clear benefit from omega-3 fatty acids). Patients should be advised not to take supplements containing beta-carotene, antioxidant supplements (vitamin E and/or C), or folic acid to reduce cardiovascular risk.

Question 3#

You are reviewing a 60-year-old patient in clinic after a recent NSTEMI. They have not yet completed their cardiac rehabilitation programme and are asking for advice about ongoing physical activity. They have been looking online and have come across articles that say they should exercise at about 6 ‘METs’. 

They ask you to explain what a MET is and if it means that they have to jog to keep healthy.

A. 1 MET, or metabolic equivalent of task, is equivalent to the resting metabolic rate when sitting quietly, and has a conventional reference value of 3.5 mL O2/kg/min which is equal to 1 kcal/kg/h

A metabolic equivalent is a way of expressing the metabolic energy requirements of a task as multiples of the resting metabolic rate (RMR). 1 MET is equivalent to the RMR when sitting quietly, and has a conventional reference value of 3.5 mL O2/kg/min which is equal to 1 kcal/kg/h.

Question 4#

When advising patients about the DVLA regulations governing the entitlement to drive a private car or motorcycle,

which one of the following statements is correct?

A. After an ACS successfully treated by PCI, patients can drive after  week providing that their ejection fraction is >15%

Patients with angina should stop driving if symptoms occur at rest, with emotion, or at the wheel. Following an ACS, patients who have undergone successful PCI may drive after 1 week provided that no other urgent revascularization is planned and that their LVEF is >40% pre-discharge. Patients with an ACS who have not successfully been treated by PCI can drive after 4 weeks. Patients can drive 1 week after an elective PCI and 4 weeks after a CABG.

Question 5#

Whilst you are working in your local cardiology ward, one of the nursing staff approaches you and asks, in general, which patients are very high risk and will need specialist assessment prior to referral for the exercise component of your local cardiac rehabilitation (CR) programme. 

Which one of the following statements is correct?

A. Patients with cyanotic congenital heart disease or those who have received an implantable cardiac defibrillator should never be referred for cardiac rehabilitation

CR should be offered to all patients following an acute MI and those undergoing a CABG or angioplasty. CR should also be offered to patients with chronic heart failure and unstable angina with disabling symptoms. Increasingly there is also evidence to support the benefit for other patient groups including those with congenital heart disease, post cardiac transplantation, and those with implantable cardiac defibrillators. High-risk patients should participate in exercise sessions based in a safe environment with access to a defibrillator and staff trained in advanced life support. High-risk patients include those with:

1. a myocardial infarction complicated by heart failure, cardiogenic shock, and/or complex ventricular arrhythmias
2. angina or breathlessness occurring at a low level of exercise (inability to complete the first 4 minutes of the shuttle walking test)
3. ST segment depression ≥ mm on resting ECG

exercise testing with marked ST depression ≥2 mm or angina at <5 METs (3 minutes of a Bruce protocol).

Patients unsuitable for exercise training include those with:

1. decompensated heart failure
2. severe valvular stenosis or regurgitation
3. refractory arrhythmias
4. other clinical conditions which worsen with exertion.