Paper II — Heart and lungs

Appendix — Rapid Revision Grid

Consolidated examinable numbers, named trials and Indian context lines from all 54 questions A. Numbers worth memorising Topic Number Heart failure HFrEF ≤ 40%, HFmrEF 41–49%, HFpEF ≥ 50%; > 75% of overt HF in the old is due to hypertension or coronary disease; spironolactone 12.5–50 mg reduced mortality by 30% in NYHA III–IV; digoxin over 70 — 0.125 mg/day, level 0.5–0.9 ng/mL Refractory heart Stage D one-year mortality approaches 50%; acceptable creatinine rise during decongestion up to 30% failure Beta blockers Only 4 agents proven: bisoprolol, carvedilol, metoprolol succinate, nebivolol; double dose no sooner than every 2 weeks; SENIORS studied age ≥ 70 Cardiogenic Systolic BP < 90 mmHg for > 30 min with hypoperfusion; MAP target ≥ 65 mmHg; fluid in 250 mL aliquots shock ACS / unstable ECG within 10 min; troponin at 0 and 1–3 h; immediate invasive < 2 h, high risk < 24 h, GRACE > 140; prasugrel angina contraindicated > 75 y, < 60 kg; DAPT 12 months (1–3 if HBR)

STEMI ECG ≥ 1 mm in 2 contiguous leads; ≥ 2 mm in V2–V3 men ≥ 40, ≥ 2.5 mm men < 40, ≥ 1.5 mm women; PCI within 120 criteria min of diagnosis Secondary LDL < 55 mg/dL with ≥ 50% reduction; BP < 130/80; HbA1c ~7%; weight loss 5–10%; exercise 150 min/week prevention targets JNC 8 Age ≥ 60 — treat at ≥ 150/90, goal < 150/90; < 60, diabetes and CKD — < 140/90; beta-blockers not first-line Hypertension Stage 1 140–159/90–99; Stage 2 ≥ 160/100; ISH ≥ 140 systolic with < 90 diastolic; 2025 AHA/ACC target < classification 130/80 Accelerated Usually diastolic > 120–130; grade III retinopathy (accelerated) vs grade IV papilloedema (malignant); reduce MAP by hypertension ≤ 20–25% in the first hour; dissection — systolic < 120 and HR < 60 within 20 min Postural Fall of ≥ 20 mmHg systolic or ≥ 10 mmHg diastolic within 3 min; present in ~30% of elderly (> 40 mmHg in hypotension 10%); fludrocortisone 100–200 µg; ephedrine 15–30 mg tds; head-up tilt of bed ~10° Aortic stenosis Prevalence 2.8% at ≥ 75; sclerosis in 26–29% over 65; symptomatic AS untreated — 20% three-year survival; severe = area < 1.0 cm², velocity ≥ 4 m/s, mean gradient ≥ 40 mmHg; octogenarian SAVR five-year survival ~65%; valvuloplasty — mortality 3–10%, stroke 10–25%, restenosis 66% at 6 months Mitral disease Mucoid degeneration in ~1% of autopsies > 65; mitral annular calcification in 9% of autopsies > 50, and 44% of women > 90; two-thirds of MAC present with an apical systolic murmur; surgery when EF ≤ 60% or ESD ≥ 40 mm ABI and toe ABI ≤ 0.90 = PAD; < 0.40 = severe; > 1.40 = non-compressible; exercise fall > 20%; TBI < 0.70 = PAD; toe pressure pressures > 55 heals, < 30 mmHg = CLTI Atrial fibrillation 43 million worldwide; lifetime risk at 55 ~35%; 1.5× commoner in men; up to 30% of ischaemic strokes; 20–30% develop heart failure; up to 60% relative increase in cognitive decline; 3.5-fold increase in mortality; each 10 mmHg systolic rise increases AF risk 11–16%; rate target < 110 lenient Tachyarrhythmias Rate > 100/min; QRS ≥ 120 ms = broad; ectopy in up to 100% of older people; ventricular arrhythmia in 70–80% over 60; adenosine 6 then 12 mg; amiodarone 300 mg then 900 mg/24 h; magnesium 2 g; post-MI ectopy > 10/hour is adverse Tilt test Tilt to 60–70° for 20–45 min; GTN 400 µg; cardioinhibitory type 2B = asystole > 3 s; sensitivity ~50–70%, specificity ~80–90% Polypill Wald & Law 2003 — 88% reduction in IHD, 80% in stroke (theoretical); aspirin 75–100 mg Cardiorenal 5 Ronco types; IV diuretic at 1–2.5× the home oral dose; creatinine rise up to 30% acceptable; acetazolamide 500 mg syndrome IV daily Infective Incidence 4×, mortality 2× that of younger patients; antibiotics 4–6 weeks; 3 sets of blood cultures endocarditis in the elderly Complete heart Ventricular escape 30–40 bpm; PR > 200 ms = first degree; PR > 240 ms + LBBB with lamin A/C = pace block Pacemaker Pneumothorax 1–2% (subclavian) vs <0.1% (cephalic/axillary); tamponade <0.2%; infection <1%; early complications complications ~7% at 2 weeks; CRT/His if EF < 50% and pacing > 40% CHA2DS2-VASc Max 9; anticoagulate men ≥ 2, women ≥ 3; CHA2DS2-VA max 7, threshold ≥ 2 (2024 ESC) HAS-BLED Max 9; ≥ 3 = high risk (modify, do not withhold); falls — need ~295 falls/year to outweigh benefit Apixaban dose 2 of 3: age ≥ 80, weight ≤ 60 kg, creatinine ≥ 1.5 mg/dL → 2.5 mg BD reduction DOAC reversal Idarucizumab 5 g IV; 4F-PCC 50 U/kg; charcoal if < 2–4 h; dabigatran dialysable Stents BMS restenosis 20–30%; DES TLR < 5%; ISR = ≥ 50% renarrowing; DAPT 6 months elective, 12 months post-ACS, 1–3 months if HBR Statins in the old Time to benefit ~2.5 years; NLA/AGS 2025 LDL-C 70–189 mg/dL; prasugrel contraindicated > 75 y, < 60 kg DVT D-dimer age-adjusted cut-off = age × 10 µg/L if > 50; enoxaparin 40 mg OD; extended prophylaxis 28–35 days post hip surgery; provoked = 3 months; PTS up to 40% LTOT ≥ 15 h/day; PaO2 < 7.3 kPa (55 mmHg), or 7.3–8.0 kPa with cor pulmonale/polycythaemia; refer if SpO2 < 93%; target SpO2 88–92%; ~50% survive 3 years NIV Acute NIV if pH < 7.35; home NIV if PaCO2 > 7 kPa at 2–4 weeks post-exacerbation Lung cancer NSCLC ~85%, SCLC ~15%; median age at diagnosis ~70; TNM 9th edition (2024) Inhalers Difficulty in ~20%; MMSE < 24 predicts failure; breath-hold 10 s; inhale over 4–5 s; wait 30 s between puffs Pneumonia in the 2 of 3 pneumonia admissions are aged > 70; fever and cough absent in 30–40%; viruses cause 10–30% of CAP; RR > elderly 30/min, HR > 110/min as severity signs; review at 48 hours; persistent shadow at 12 weeks → suspect cancer CURB-65 Confusion, Urea > 7 mmol/L, RR ≥ 30, BP < 90/60, age ≥ 65 HAP Onset ≥ 48 h after admission; VAP > 48 h after intubation; late-onset from day 5; treat 7 days; head-up 30–45° DPLD / IPF IPF median age 65–70, median survival 3–5 years; acute exacerbation mortality > 50%; progression = FVC ↓ ≥ 5% or DLCO ↓ ≥ 10% in 1 year; GAP index Pleural effusion Normal fluid 10–20 mL; 250–500 mL to blunt costophrenic angle; 50 mL detectable on USG; Light's — protein ratio > 0.5, LDH ratio > 0.6, LDH > ⅔ ULN; albumin gradient > 1.2 g/dL = transudate; drain if pH < 7.20 or glucose < 60 mg/dL; ADA > 40 U/L = TB; aspirate max 1.5 L at a sitting COPD Exacerbations = 10% of medical admissions; ⅓ readmitted at 30 days, 15% die at 3 months; ICS if eosinophils ≥ 300/µL; steroids 5–7 days; oxygen target 88–92% Senile lung RV and FRC ↑, FVC ↓, FEV1/FVC ↓ ("pseudo-obstructive"), TLC ~unchanged; use LLN not 0.70; PRISm = ratio ≥ 0.70 with FEV1 < 80% Respiratory PaO2 < 60 mmHg (8 kPa); PaCO2 > 50 mmHg (6.7 kPa); NIV if pH < 7.35; intubate if pH < 7.25; normal A–a failure gradient ≈ age/4 + 4 ARDS Tidal volume 4–6 mL/kg PBW, plateau < 30, driving pressure < 15 cmH2O; prone if P/F < 150 for ≥ 16 h/day; Berlin severity ≤ 100 / 100–200 / 200–300; new global definition SpO2/FiO2 ≤ 315, HFNO ≥ 30 L/min Pulmonary Age-adjusted D-dimer = age × 10 µg/L if > 50; high-risk mortality > 15%; alteplase 100 mg over 2 h; sPESI includes embolism age > 80; provoked 3 months CTEPH Occurs in 2–4% after PE; up to 25% have no prior PE; mPAP > 20 mmHg with PVR > 2 WU; screen after 3 months anticoagulation; V/Q scan is the screening test of choice OSA AHI > 5 + symptoms = OSA; elderly — 50% have AHI > 5, 20% have AHI > 15 (vs 10% young); severity 5–15 / 15– 30 / > 30; non-snorers increase after age 50 Sleep / insomnia > 50% of over-65s have a sleep problem; insomnia prevalence 40–50%; 50–80% nap in the day; RLS in 20% of over-80s; limit naps to < 30 min RBD Phenoconversion ~6% per year; > 70–80% at 12–15 years; melatonin 3–12 mg; clonazepam 0.25–1 mg; α-synuclein SAA positive in > 90% of isolated RBD Solitary Nodule ≤ 3 cm (> 3 cm = mass); stability 2 years excludes malignancy (solid); PET useful > 8 mm; pneumothorax after pulmonary nodule CT biopsy 20–25%; screening age 50–80, ≥ 20 pack-years B. Trials and guidelines to name Name One-line message RALES / EMPHASIS-HF Spironolactone reduces mortality 30% in NYHA III–IV; eplerenone benefits mild symptoms — equal benefit at all ages PARADIGM-HF / DIG / SHIFT Sacubitril–valsartan beats enalapril; digoxin reduces hospitalisation but not mortality; ivabradine for HR ≥ 70 EMPEROR-Preserved / SGLT2 inhibitors reduce events across the whole ejection fraction spectrum, including HFpEF DELIVER FINEARTS-HF (NEJM 2024) Finerenone reduces worsening HF and CV death in HFmrEF and HFpEF STEP-HFpEF (NEJM 2023) Semaglutide improves symptoms and exercise capacity in obesity-related HFpEF STRONG-HF Rapid uptitration to full dose within 2 weeks of discharge reduces death and readmission ADVOR / CLOROTIC Acetazolamide and thiazide added to loop diuretics improve decongestion CIBIS-II / MERIT-HF / The four evidence-based beta-blockers; SENIORS specifically in age ≥ 70 COPERNICUS / SENIORS REDUCE-AMI / ABYSS (2024) No benefit of long-term beta-blockade after MI with preserved EF — a deprescribing opportunity DanGer Shock (NEJM 2024) Microaxial flow pump reduces mortality in STEMI-related cardiogenic shock, at the cost of more complications CULPRIT-SHOCK / IABP- Culprit-lesion-only PCI is superior in shock; balloon pump is neutral SHOCK II SENIOR-RITA (NEJM 2024) Invasive strategy in NSTE-ACS over 75 reduces recurrent MI but not death — individualise by frailty 2023 ESC ACS guideline No routine P2Y12 pre-treatment in NSTE-ACS; 24-h invasive timing downgraded to IIa; abbreviated DAPT if HBR SELECT (NEJM 2023) Semaglutide reduces MACE by 20% in obesity with established CVD without diabetes SPRINT / STEP / ESPRIT / Intensive systolic lowering benefits older adults; HYVET showed mortality benefit even over 80 BPROAD / HYVET 2025 AHA/ACC hypertension Retires 2017 guideline; universal target < 130/80 with encouragement toward < 120 systolic; PREVENT guideline calculator; single-pill combinations; renal denervation IIb 2024 ESC hypertension New "Elevated BP" category 120–139/70–89; systolic target 120–129 where tolerated; mandatory guideline orthostatic screening JNC 8 (JAMA 2014) Age ≥ 60 — treat at ≥ 150/90 to a goal of < 150/90; now superseded SHEP / Syst-Eur Treating isolated systolic hypertension reduces stroke by 36–42%; Syst-Eur also reduced dementia PATHWAY-2 Spironolactone is the drug of choice for resistant hypertension EARLY TAVR (NEJM 2024) Early TAVI beats surveillance in asymptomatic severe aortic stenosis COAPT / RESHAPE-HF2 / Transcatheter edge-to-edge repair reduces HF hospitalisation in secondary MR; non-inferior to surgery MATTERHORN (2024) with fewer adverse events SAFE PACE Carotid sinus syndrome is a modifiable cause of non-accidental falls; pacing reduces falls BIOSync CLS Closed-loop stimulation pacing reduces recurrence in tilt-documented asystolic vasovagal syncope 2024 ESC AF guideline CHA2DS2-VA replaces CHA2DS2-VASc; AF-CARE replaces ABC; early rhythm control favoured EAST-AFNET 4 / CASTLE-AF Early rhythm control improves outcomes; ablation benefits AF with heart failure NOAH-AFNET 6 / ARTESiA Device-detected subclinical AF — anticoagulation gives little net benefit; do not treat it as clinical AF (NEJM 2023)

2024 ACC/AHA PAD guideline Toe brachial index when ABI > 1.40; WIfI staging; supervised exercise first-line; rivaroxaban 2.5 mg bd plus aspirin SECURE (NEJM 2022) / TIPS- Polypill improves adherence and reduces events; WHO added it to the Essential Medicines List in 2023 3 / PolyIran FIDELIO-DKD / FIGARO-DKD Finerenone protects kidney and heart in CKD with type 2 diabetes, with less hyperkalaemia 2022 World Falls Guidelines Stratified falls pathway; unexplained falls require cardiovascular assessment for syncope 2023 ESC IE guideline / Duke– Cardiac CT and FDG-PET/CT as major criteria; partial oral therapy accepted ISCVID POET Partial oral antibiotics non-inferior to full IV course in stabilised left-sided endocarditis 2023 ESC Cardiomyopathy First standalone guideline; phenotype-based approach guideline ATTR-ACT / ATTRibute-CM / Tafamidis, acoramidis, vutrisiran — disease-modifying therapy in ATTR cardiac amyloidosis HELIOS-B EXPLORER-HCM Mavacamten (cardiac myosin inhibitor) for symptomatic obstructive HCM 2023 HRS/APHRS/LAHRS Conduction system pacing (LBBAP) when high ventricular pacing burden expected; minimise RV pacing physiologic pacing in sinus node disease ANNEXA-I (2024) Andexanet alfa better haemostasis than usual care in Xa-inhibitor ICH, but more thrombotic events AGENT IDE (2024) Paclitaxel-coated balloon superior to plain balloon for coronary in-stent restenosis; first US coronary DCB approval NLA/AGS consensus (JAGS Statin reasonable > 75 y for primary prevention if LDL-C 70–189 mg/dL and no life-limiting illness; CAC 2025) to refine; deprescribe when life-limited STAREE Atorvastatin 40 mg vs placebo, age ≥ 70, disability-free survival — results awaited PROSPER / ALLHAT-LLT Older evidence: modest or no benefit of statins for primary prevention in the old API-CAT (NEJM 2025) Extended apixaban 2.5 mg BD non-inferior to 5 mg BD in cancer-associated VTE with less bleeding CLOTS-1 Graduated compression stockings of no benefit and harmful after stroke NOTT / MRC Established the survival benefit of LTOT ≥ 15 hours per day LOTT No benefit of oxygen for moderate resting or exercise-induced desaturation HOT-HMV Home NIV plus oxygen prolongs time to readmission or death in persistently hypercapnic COPD ADRIATIC (2024) Consolidation durvalumab improves overall survival in limited-stage SCLC LAURA (2024) Osimertinib after chemoradiotherapy in unresectable stage III EGFR-mutant NSCLC DeLLphi-301 / 304 Tarlatamab (DLL3 bispecific) in relapsed small cell lung cancer GOLD 2025/2026 Check inhaler technique at every visit before escalating; consider low-GWP propellants CAPE COD (NEJM 2023) Hydrocortisone reduces 28-day mortality in severe CAP ACIP 2024 (pneumococcal) Routine vaccination age lowered to 50; single dose PCV20 or PCV21 ACIP 2024 (RSV) Single lifetime RSV vaccine dose for all ≥ 75, and 50–74 with risk factors ATS/IDSA 2019 CAP β-lactam + macrolide/doxycycline, or respiratory fluoroquinolone alone IDSA AMR guidance 2023–24 Ceftazidime-avibactam, cefiderocol, sulbactam-durlobactam for resistant HAP/VAP; 7-day courses 2022 ATS/ERS/JRS/ALAT Defined progressive pulmonary fibrosis (PPF); nintedanib recommended INBUILD Nintedanib slows FVC decline in progressive fibrosing ILD of any cause PANTHER-IPF Prednisolone + azathioprine + NAC increases mortality in IPF — steroids are harmful FIBRONEER-IPF / -ILD (NEJM Nerandomilast (oral PDE4B inhibitor) reduces FVC decline in IPF and PPF, alone or added to 2025) antifibrotics BTS Pleural Disease 2023 Ultrasound for all procedures; thoracoscopy for undiagnosed exudate; IPC or talc equally acceptable; RAPID score MIST-2 Intrapleural alteplase + DNase improves drainage in pleural infection AMPLE / IPC-PLUS Indwelling pleural catheter reduces hospital days; talc via IPC achieves pleurodesis BOREAS / NOTUS (NEJM Dupilumab reduces exacerbations in eosinophilic COPD on triple therapy 2023, 2024)

GINA 2024–2025 No SABA-alone at any step; ICS-formoterol (AIR/MART) is the preferred track GOLD 2023–2026 Pre-COPD and PRISm defined; LLN preferred over fixed 0.70 ratio; check inhaler technique before escalating ARMA / ARDSNet Low tidal volume 4–6 mL/kg PBW reduces mortality in ARDS PROSEVA Prone positioning ≥ 16 h/day reduces mortality in severe ARDS ROSE / ART / FACTT / EOLIA Routine paralysis neutral; aggressive recruitment harmful; conservative fluids beneficial; ECMO for refractory ARDS New Global Definition of Adds non-intubated ARDS on HFNO ≥ 30 L/min, SpO2/FiO2 ≤ 315, lung ultrasound ARDS (2023)

PEITHO Thrombolysis in intermediate-risk PE prevents decompensation but causes excess bleeding, especially > 75 years PEERLESS (Circulation 2025) Large-bore mechanical thrombectomy better than catheter-directed thrombolysis, and better than / STORM-PE anticoagulation alone for RV recovery CHEST-1 / RACE / MACiTEPH Riociguat is the only licensed CTEPH drug; riociguat pre-treatment makes BPA safer; macitentan trial (2025) stopped for futility SURMOUNT-OSA (NEJM Tirzepatide markedly reduces AHI — first drug approved for OSA 2024)

SAVE CPAP improves symptoms but did not reduce cardiovascular events (adherence-limited) AGS Beers 2023 Avoid benzodiazepines and Z-drugs in older adults; DORAs are the preferred hypnotic if one is needed NSD-ISS 2024 / SynNeurGe Isolated RBD with a positive α-synuclein seed amplification assay = biologically defined prodromal synuclein disease ACS 2023 / Lung-RADS 2022 LDCT screening 50–80 with ≥ 20 pack-years, no quit-time limit; standardised nodule categories C. Indian context lines worth adding Topic Line to write Heart failure and Rheumatic valvular heart disease remains an important cause of heart failure and of mitral and aortic disease in valve disease Indian older adults Anticoagulation in Rheumatic mitral stenosis and mechanical valves require warfarin, not a DOAC — a common examination trap AF in the Indian setting Hypertension High dietary salt with low potassium intake, a large treatment gap, and API and Lipid Association of India consensus favouring early combination therapy and intensive LDL targets Atherosclerosis Indians develop ASCVD a decade earlier, with more small dense LDL, higher Lp(a) and a higher prevalence of diabetes at lower BMI Polypill India led this field through the TIPS/Polycap programme; WHO HEARTS and the national NCD programme promote standardised fixed-dose regimens Cardiorenal Consider NSAID and traditional/herbal remedy nephrotoxicity and late presentation with advanced CKD as syndrome common contributors Infective Rheumatic valvular disease remains an important substrate in India, with viridans streptococci still prominent endocarditis Cardiomyopathy Endomyocardial fibrosis is a regionally important cause of restrictive cardiomyopathy in India DOACs Rheumatic mitral stenosis is common in India — these patients need warfarin, not a DOAC; idarucizumab and andexanet have limited availability, so 4F-PCC is the practical reversal option Lung cancer Biomass fuel smoke and indoor air pollution are major risks in never-smoking Indian women; post-tubercular scarring is a recognised substrate Statins / Indians develop ASCVD at a younger age with a higher burden of small dense LDL; API and Lipid Association of India prevention consensus recommend lower LDL-C targets in high-risk groups Pneumonia Always consider tuberculosis in subacute pneumonia and send sputum for AFB/CBNAAT; aspergillosis complicates old TB cavities HAP Carbapenem-resistant Klebsiella and Acinetobacter dominate Indian ICUs — empirical therapy must follow the local antibiogram DPLD Hypersensitivity pneumonitis (birds, mould, biomass) and CTD-ILD form a larger share than in Western registries; exclude post-tubercular fibrosis Pleural effusion Tuberculosis is often the commonest exudative effusion; ADA > 40 U/L with lymphocytic predominance is the key test; ATT for 6 months COPD / senile lung Biomass fuel smoke and indoor air pollution are major non-smoking causes of airflow obstruction, especially in rural women Solitary nodule Tuberculoma is the commonest benign SPN, and granulomatous disease causes false-positive PET-CT — always obtain tissue before declaring malignancy