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Medicine year 4 ACE > Core conditions 2 > Flashcards

Core conditions 2 Flashcards

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1
Q

Ischaemic heart disease definition

A

Caused by atheromatous plaques that cause blocking/narrowing of the coronary arteries. Causes ischaemia and death of heart muscle. Can be temporary or permanent. Split into angina pectoris and ACS.

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2
Q

Angina

A

Occurs on exertion, due to narrowing of a coronary artery causing less oxygen to reach the heart muscle resulting in anaerobic respiration. Lactic acid builds up in the heart muscle causing pain, on rest pain stops

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3
Q

Angina clinical features

A
  • A syndrome of reversible myocardial ischaemia
  • 1= Constriction/heavy discomfort in the chest which may radiate to the jaw, neck, shoulders or arms
  • 2= Symptoms are present on exertion
  • 3= Symptoms are relieved within 5mins by rest or GT
  • All 3 features = typical angina, 2/3 features = atypical angina, 0-1 features = non-anginal chest pain
  • Associated symptoms: dyspnoea, nausea, sweatiness and faintness
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4
Q

Angina investigations

A
  • Bloods – FBC, U&Es, TFTs, lipids, HbA1c, Troponin (if unstable)
  • ECG – usually normal, but may show ST depression, flat or inverted T-waves or signs of a past MI
  • Echo or CXR
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5
Q

To confirm IHD diagnosis

A
  • Exercise ECG – assess for ischaemic ECG changes
  • Angiography – either using cardiac CT with contrast, or transcatheter angiography
  • Functional imaging: myocardial perfusion, scintigraphy, stress echo, cardiac MRI
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6
Q

Complications of angina

A
  • Main complication of angina is progression to ACS
  • Risk stratification is caried out using the QRISK 2 tool, calculates risk of stroke or MI within 10 years. If risk >10% take statin
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7
Q

Management of angina

A
  • Short acting nitrates: GTN spray
  • Beta blocker or calcium channel blocker
  • Information, lifestyle modification
  • Second line: long acting nitrates, Ivabradine, Nicorandil
  • Symptomatic: beta blocker and dihydropyridine
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8
Q

Investigations ACS

A
  • Bloods: FBC, U&E, glucose, lipids, troponin
  • CXR: look for cardiomegaly, pulmonary oedema or widened mediastinum
  • Echocardiogram: regional wall abnormalities
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9
Q

ACS treatment: STEMI and NSTEMI

A
  • STEMI patients and very high-risk NSTEMI patients (e.g. haemodynamically unstable) should receive immediate angiography with or without PCI (inserting a stent into the coronary artery to open it up)
  • NSTEMI patients who are high risk should have angiography within 24 hours; immediate risk within 3 days; low-risk patients may be considered for non-invasive testing
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10
Q

Treatment for ACS: symptoms and multivessel disease

A
  • Patients with multivessel disease may be considered for CABG (involves harvesting a vessel from elsewhere in the body and bypassing the blockage of the coronary artery) instead of PCI
  • Symptom control: PRN GTN and opiates, if insufficient give GTN infusion (monitor BP)
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11
Q

Post ACS cardioprotective treatment

A
  • Antiplatelets: aspirin (75mg OD) and a second antiplatelet agent (e.g. clopidogrel) for at least 12 months to decrease vascular events (e.g. MI, stroke). Consider adding a PPI (e.g. lansoprazole) for gastric protection
  • Anticoagulate, until discharge
  • Beta-blockers If contraindicated, consider verapamil or diltiazem
  • ACE-Iin patients with LV dysfunction, hypertension, or diabetes unless not tolerated (consider ARB). Titrate up slowly, monitoring renal function
  • High-dose statin, e.g. atorvastatin 80mg
  • Do an echo to assess LV function.Eplerenoneimproves outcomes in MI patients with heart failure (ejection fraction <40%)
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12
Q

Common co-morbidities with ACS

A
  • Stroke, TIA and peripheral vascular disease
  • Heart failure: diagnosis requires symptoms of HF and evidence of cardiac dysfunction at rest. For example: fatigue, breathlessness and oedema
  • Depression, stress, anxiety, PTSD: recommend CBT and yoga
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12
Q

Driving and ACS

A
  • The patient should stop for; 1 week if they have had a successful angioplasty, 4 weeks if they have an unsuccessful angioplasty and 4 weeks again if they didn’t have an angioplasty
  • Bus, coach or lorry: inform DVLA and stop driving for 6 weeks, must be assessed by doctor before they can start driving again
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13
Q

ACS investigations

A
  • Bloods: FBC, U&E, BNP
  • CXR
  • ECG: may show cause (MI, ischaemia or ventricular hypertrophy), rare to be normal
  • Echocardiogram: can indicate cause and confirm presence or absence of LV dysfunction. If either ECG or BNP is abnormal then echocardiography is required
  • Endomyocardial biopsy is rarely needed
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14
Q

Main physical symptoms of heart failure at end of life

A
  • Fatigue
  • Breathlessness: usually caused by pulmonary oedema. Management is sitting patient up and improving oxygen flow. Maintain good oral hygiene
  • Peripheral oedema: manage with diuretics i.e. furosemide
  • Pain: opiates
  • Nausea and vomiting: anti-emetics and changing position when eating
  • Cardiac cachexia or anorexia: loss of appetite and weight loss
  • Anxiety and depression
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15
Q

Ischaemic stroke

A

When blood flow to part of the brain is disrupted due to blockage in the blood vessel. Can be thrombotic where the blood clots forms within the artery or Embolic where the blood clots travels from another part of the body

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16
Q

Haemorrhagic stroke

A

When a blood vessel ruptures and bleeds into the brain tissue. Intracerebral haemorrhage is in the brain parenchyma and is due to hypertension, cerebral amyloid angiopathy or vascular malformation. A subarachnoid haemorrhage is due to a rupture of an intracranial aneurysm or arteriovenous malformation in the subarachnoid space

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17
Q

Bamford stroke classification rules

A
  1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  2. homonymous hemianopia
  3. higher cognitive dysfunction e.g.[dysphasia]
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18
Q

Total anterior circulation infarct (TACS)

A
  • involves middle and anterior cerebral arteries
  • all 3 of the above criteria are present: unilateral sensory loss of face, arms and legs, homonymous hemianopia, higher cognitive impairement i.e. dysphasia
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19
Q

Partial anterior circulation infarcts (PACI, c. 25%)

A
  • involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
  • 2 of the above criteria are present: unilateral sensory loss of face, arms and legs, homonymous hemianopia, higher cognitive impairement i.e. dysphagia
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20
Q

Lacunar infarcts (LACI 25%)

A
  • involves perforating arteries around the internal capsule, thalamus and basal ganglia
  • presents with 1 of the following:
    1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
    2. pure sensory stroke.
    3. ataxic hemiparesis
21
Q

Posterior circulation infarcts (POCI 25%)

A
  • involves vertebrobasilar arteries
  • presents with 1 of the following:
  1. cerebellar or brainstem syndromes
  2. loss of consciousness
  3. isolated homonymous hemianopia
22
Q

Stroke definition

A

A syndrome consisting of rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin. In contrast in a TIA the symptoms and signs resolve within 24 hours

23
Q

Stroke clinical features

A
  • Motor weakness (upper motor neurone), speech problems (dysphasia), swallowing problems, visual field defects (homonymous hemianopia), balance problems
  • Central hemisphere infarcts: contralateral hemiplegia, contralateral sensory loss, homonymous hemianopia, dysphasia
  • Brainstem: can cause more severe symptoms like quadriplegia and lock-in syndrome
24
Q

Stroke investigations

A
  • Exclude hypoglycaemia first then use Rosier score to detect risk
  • First line: Non contrast CT head- detects whether its ischaemic or haemorrhagic
  • If uncertain use an MRI
  • ECG: to test for A-fib
  • Blood tests: FBC, LFT, U&E, full lipid profile and glucose
  • Imaging of the carotids with doppler ultrasound: detects carotid stenosis
25
Q

Stroke management

A
  • Aspirin 300mg orally or rectally as soon as haemorrhagic stroke is excluded
  • In ischaemic stroke anticoagulants can be given after 14 days
  • If cholesterol is >3.5mmol/l start statin after 48 hours
26
Q

Thrombolysis for ischaemic stroke

A
  • With alteplase should be given within 4.5 hours of onset of symptoms and haemorrhage has been excluded
  • Contraindications: Previous intracranial haemorrhage, seizure at onset of stroke, intracranial neoplasm, suspected subarachnoid haemorrhage, active bleeding, pregnancy, varices, uncontrolled hypertension
27
Q

Stroke thrombectomy

A
  • A pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS)
  • Within 6 hours of symptoms onset and/or with thrombolysis
28
Q

Stroke: secondary prevention

A
  • Clopidogrel (75mg) recommended over aspirin. Take Asprin for the first two weeks. Take PPI at some time
  • Carotid endarterectomy: in patients who have a >50% stenosis in the internal coronary artery and are not severely disabled
  • Statins: even if there cholesterol is not high, main side effect is muscle aches
  • Antihypertensives i.e. ACEi to keep blood pressure lower than 130/80
  • Anticoagulants i.e. Apixaban: help reduce risk of ischaemic stroke in A-fib. Use CHADS1VASC and HASBLED score
  • Improve nutrients and exercise
29
Q

Stroke differentials

A
  • Brain tumour, cerebral abscess or demyelination: can cause identical symptoms to a stroke
  • Delirium: cognitive symptoms of stroke are more specific i.e. aphasia and onset of delirium is hours to days but stroke is more sudden
  • Bell’s palsy: causes unilateral facial weakness but is a lower motor neurone lesion, slower onset then stroke
  • Migraine, generalised seizure, functional neurological symptoms
30
Q

Common persistent effects of stroke

A
  • Cognitive impairment
  • Disordered visuospatial abilities
  • Communication problems: aphasia
  • Impaired swallowing
  • Visual problems: homonymous hemianopia
  • Weakness or paralysis: often one sided
  • Sensory problems: one sided
  • Pain, fatigue, continence problems
31
Q

Complications post stroke

A
  • Respiratory tract complications especially bronchopneumonia
  • Deep venous thrombosis and pulmonary embolism
  • Myocardial infarction
  • Falls, trauma and fractures
  • Further and increasingly severe stroke
  • Depression
  • Seizure: can occur immediately after or as a later complication
  • Decompensation of previous stroke: when patient is tired/unwell the initial stroke symptoms can emerge, tends to resolve when patient is back to baseline
32
Q

Therapies used by stroke patients

A
  • Physiotherapy – aimed at assisting in the recovery of motor function.
  • Occupational Therapy – aimed at improving functional abilities (initially personal care)
  • Speech and Language Therapy – aimed at improving swallowing and communication. May recommend changes to consistency of food or use of a gastrostomy tube
33
Q

Long term complications post stroke

A
  • Cognitive impairment and vascular dementia
  • Epilepsy
  • Swallowing impairments
  • Venous thromboses and PE
  • Pressure sores due to immobility
34
Q

Stroke: end of life

A
  • Stroke is not painful
  • Discussions around continuing nutrition and hydration: may not want to continue life, often not needed to feel comfortable
  • Important to moisten lips and maintain oral hygiene
35
Q

Common causes of CKD

A
  • diabetic nephropathy
  • chronic glomerulonephritis
  • chronic pyelonephritis
  • hypertension
  • adult polycystic kidney disease: hereditary condition
  • Medication: NSAID’s or lithium
  • Following sepsis or T2D
36
Q

Clinical features of CKD

A
  • Early clinical manifestations: fatigue, polyuria or nocturia, hypertension, puffiness or swelling
  • Later clinical manifestations: decreased urine output, fluid overload symptoms (SOB due to pulmonary oedema), fatigue, weight loss, nausea, muscle cramps
37
Q

CKD investigations ACR

A
  • Better to use albumin: creatinine (ACR) ratio instead pf protein:creatinine (PCR) to identify patients with proteinuria
  • Use first pass morning urine. If between 3-70mg/mmol use another sample, if above 70 dont need repeat
  • A confirmed ACR of 3 mg/mmol or more is clinically important proteinuria’
  • Refer to nephrologist: if ACR >70mg/mmol, if ACR >30 with persistent haematuria
38
Q

CKD: measuring eGFR

A
  • The formula is the Modification of Diet in Renal Disease (MDRD) which considers serum creatinine, age, gender and ethnicity
  • Factors that may affect result: pregnancy, muscle mass, eating red meat before sample taken
39
Q

CKD stage classified according to GFR

A
  • 1= Greater than 90 ml/min, with some sign of kidney damage on other tests (if all the kidney tests are normal, there is no CKD)
  • 2= 60-90 ml/min with some sign of kidney damage (if kidney tests are normal, there is no CKD)
  • 3a= 45-59 ml/min, a mild to moderate reduction in kidney function
  • 3b= 30-44 ml/min, a moderate to severe reduction in kidney function
  • 4= 15-29 ml/min, a severe reduction in kidney function
  • 5= Less than 15 ml/min, established kidney failure - dialysis or a kidney transplant may be needed
40
Q

CKD complications

A
  • Anaemia: due to reduced erythropoietin levels, normally normochromic normocytic anaemia, occurs when GFR is less than 35ml/min, can predispose to left ventricular hypertrophy
  • Mineral bone disease: management is to reduce dietary intake of phosphate, use phosphate binders and vitamin D
  • Hypertension: ACEi is first line
  • Most common cause of death is cardiovascular disease
41
Q

CKD investigations

A
  • eGFR
  • Proteinuria is quantified with urine albumin: creatinine ratio
  • Haematuria is identified with urine dipstick
  • Renal ultrasound to identify obstruction and polycystic kidney disease
  • Other investigation: Blood pressure, HbA1c, lipid profile
  • CTKUB
  • Bedside: BP, heart rate, BM monitoring
42
Q

CKD: a diagnosis can be made when there are consistent results over 3 months of either:

A
  • Estimated glomerular filtration rate(eGFR) is sustainedbelow 60 mL/min/1.73 m2
  • Urine albumin:creatinine ratio(ACR) is sustainedabove 3 mg/mmol
43
Q

CKD: refer to renal specialists when

A
  • eGFRless than30 mL/min/1.73 m2
  • Urine ACRmore than70 mg/mmol
  • Accelerated progression(a decrease in eGFR of25%or15 mL/min/1.73 m2within12 months)
  • 5-year riskof requiring dialysisover 5%
  • Uncontrolled hypertensiondespite four or more antihypertensives
44
Q

CKD: management of complications involve

A
  • Oralsodium bicarbonateto treatmetabolic acidosis
  • Ironanderythropoietin (including EPO injections)to treatanaemia
  • Vitamin D,low phosphate dietandphosphate bindersto treatrenal bone disease
45
Q

CKD: medication

A
  • Slow disease progression: ACE inhibitors, SGLT-2 inhibitors (dapagliflozin) if acr >30
  • To reduce complications: exercise, maintain healthy weight, stop smoking. Avoid NSAIDs, take vaccines
  • Diet to avoid excess salt, potassium and phsophate
  • End stage renal disease: special dietary advice, dialysis, renal transplant. Avoid blood transfusions as reduces chances of finding transplant match
  • Renally excreted opioids (codeine, morphine, oxycodone) should be avoided in ESRD
  • All adults with CKD are offered a statin
46
Q

Who is offered a statin

A
  • All patients who have had a stroke, heart attack, peripheral artery disease
  • All patients with CKD
  • All patients with QRISK >10%
  • Have high cholesterol
47
Q

Screening and monitoring for CKD

A

What patients fall into the screening category for CKD: hypertension, diabetes and structural kidney abnormalities

Monitoring kidney disease progression: urinalysis, blood pressure, U&E

48
Q

Haemodialysis

A
  • Typically 4 hours a day, 3 days per week
  • Blood passes along a semipermeable membrane solutes filter out of the blood. Anticoagulation with citrate or heparin stops blood clotting in the machine
  • For longer term access use a: Tunnelled cuffed catheter or Arteriovenous fistula. Never take blood from a fistula for testing
  • Complications: aneurysm, infection, thrombosis
  • Done in hospital
49
Q

Peritoneal dialysis

A
  • A dialysis solution containing dextrose is added to the peritoneal cavity, ultrafiltration occurs across the peritoneal membrane
  • Tenckhoff catheter: tube inserted in the peritoneal cavity with one end outside allowing access
  • Complications: bacterial peritonitis, weight gain, peritoneal sclerosis
  • Can be done at home

Medicine year 4 ACE (9 decks)

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