GP Flashcards
What is angina pectoris?
Central chest tightness or heaviness, brought on by exertion and relieved by rest
Cause of angina? (6)
Myocardial ischaemia - mostly atheroma (atherosclerosis)
Anaemia
Aortic stenosis
Tachyarrhythmias
Hypertrophic cardiomyopathy
Small vessel disease - microvascular angina
Symptoms of angina? (7)
Chest pain - tight/heavy Worse on exertion Radiation to arms, neck, jaw, teeth Dyspnoea Nausea Sweatiness Syncope
What can trigger angina?
Exercise
Emotion
Cold weather
Heavy meal
Types of angina?
Stable angina - relieved by rest
Unstable - increasing frequency/severity, on minimal exertion or at rest, high risk of MI
Decubitus - precipitated by lying flat
Variant (Prinzmetals) angina - caused by coronary artery spasm, no usual CAD RFs
Risk factors for angina? (6)
Smoking Lack of exercise Obesity Hypertension Diabetes Hypercholesterolaemia
Tests for angina?
ECG - may show signs of past MI, ST depression, flat/inverted T waves
Stratify likelihood of CAD:
If >90% likelihood of CAD treat as known CAD
60-90 angiography
30-60 functional imaging
10-39 artery calcification score with CT
Management of modifiable risk factors of angina?
Modify risk factors - stop smoking, exercise, lose weight
Control hypertension, diabetes
Statin!
Secondary prevention of angina?
ASPIRIN 75mg or clopidogrel
Statin
ACEi
Medical management of angina?
Sublingual glyceryl trinitrate (GTN) spray Beta blocker (atenolol) OR calcium channel blocker (amlodipine) 2nd line - long acting nitrate (isosorbide mononitrate), or nicorandil, or ivabradine, or ranolazine
Contraindications to beta blockers?
Asthma, COPD
2nd/3rd degree heart block
Worsening unstable heart failure
Mechanism of beta blockers? 3 side effects
Reduce heart rate and force of ventricular contraction by blocking beta-adrenoreceptors
Bronchospasm, cold peripheries, sleep disturbance
Mechanism of nitrates? 3 side effects
Dilates arteries - relaxes vascular smooth muscle
headache, postural hypotension, tachycardia
Mechanism of calcium channel blockers? 3 side effects
Reduce calcium influx to reduce force of contraction of heart
Flushing, ankle oedema, headache
What type of beta adrenergic receptors are in the heart? Where are the other type?
Type 1
Type 2 are in the lung bronchioles
When is surgery indicated in angina?
Poor response or intolerance to medical therapy
What surgery is indicated in angina?
Percutaneous transluminal coronary angioplasty PTCA - balloon dilation of stenotic vessels
What is ACS?
Acute coronary syndrome, comprising of unstable angina and MI (STEMI/NSTEMI)
What is the pathology of ACS?
Atherosclerotic plaque in coronary artery
Forms a thrombus
Breaks off and occludes artery
Leads to ischaemia of heart, eventual infarction
Types of ACS?
ACS with ST elevation
ACS without ST elevation (ST depression, T wave inversion)
Risk factors for ACS?
Non-mod: age, male, family history
Mod: smoking, hypertension, diabetes, hyperlipidaemia, obesity, lack of exercise
Diagnosis of ACS?
Increase then decrease in cardiac markers i.e. troponin Symptoms of ischaemia ECG changes of ischaemia Pathological Q waves Loss of myocardium on imaging
Symptoms of MI?
Central chest pain lasting >20min, radiating to arm Nausea Sweatiness Dyspnoea Palpitations
When may a silent infarct be more likely and what are the symptoms?
The elderly, diabetics No pain Syncope Pulmonary oedema Abdo pain, vomiting Confusion
Signs of MI?
Distress Anxiety Pallor Sweatiness Fast/slow pulse Hyper/hypotension
Heart sounds in MI?
3rd/4th heart sounds
Pansystolic murmur
Tests for suspected MI?
ECG
Bloods
Cardiac enzymes
CXR
What is seen on ECG in STEMI initially?
ST elevation
Tall T waves
What is seen on ECG in STEMI after hours/days?
T wave inversion
Pathological Q wave
What is seen on ECG in other ACS?
ST depression
T wave inversion
May be non specific/normal
What is seen on CXR in ACS?
Cardiomegaly
Pulmonary oedema
Widened mediastinum
What bloods do you do in ACS?
FBC
U+E
Glucose
Lipids
What cardiac enzymes would you test for in ACS?
Cardiac troponin T and I - increased within 3-12 hours peak at 24-48 then fall
Creatine kinase - increased within 3-12 hour, peak within 24 then fall
Myoglobin - rise within 1-4
Changes in which ECG leads suggest anterior MI?
V1-V4
What is an anterior MI?
Blockage of left anterior descending LAD artery
Changes in what ECG leads suggest inferior MI?
II, III, aVF
What is an inferior MI?
Blockage of the right coronary artery
Changes in which ECG leads would suggest a lateral MI?
I, V5-V6
What is a lateral MI?
Blockage of the left circumflex artery
Initial management of STEMI?
Morphine
Oxygen if <95%
Nitrates
Aspirin 300mg
How is reperfusion done in STEMI?
Percutaneous coronary intervention if within 2hrs
If not, fibrinolysis
Other medications given in STEMI?
Clopidogrel
Beta blockers/CCB
ACEi
LMWH
What is the difference between NSTEMI and unstable angina?
NSTEMI has a rise in cardiac enzymes
Initial management for NSTEMI?
Morphine Oxygen Nitrates Aspirin Clopidogrel
Other medications given in NSTEMI?
Beta blocker/CCB LMWH IV nitrate Glycoprotein IIb/IIIa inhibitors ACEi
Long term management (secondary prevention) of ACS?
Aspirin and clopidogrel
Beta blocker or CCB
ACEi
Statin
What is PCI?
Balloon dilatation of stenotic vessels and stent insertion usually
What is CABG?
Coronary artery bypass graft
Internal mammary artery or saphenous vein grafted on the bypass stenosed coronary artery
Indications for CABG?
Left main stem disease
Triple vessel disease
Unresponsive to PCI or medical management
Complications after MI?
Bradycardias/heart block Tachyarrhythmias Right ventricular failure Pericarditis VTE Cardiac tamponade Mitral regurg
How does a statin work? 3 side effects
HMG-CoA reductase inhibitor - stops the enzyme that is needed to produce cholesterol, so reduces cholesterol
Muscle pain, hyperglycaemia/increased diabetes risk, memory loss
Contraindications for statins?
Liver disease
High alcohol intake
Previous history of muscle toxicity
Contraindications for beta blockers?
Asthma
2nd/3rd degree heart block
Worsening unstable heart failure
Contraindications of nitrates?
Aortic stenosis
Cardiac tamponade/constrictive pericarditis
Hypotension
Types of calcium channel blockers? Examples
Dihydropyridines (amlodipine, nifedipine)
Non-dihydropyridines (dilitiazem, verapamil)
How do the two classes of calcium channel blockers differ?
Both relax/widen arteries
Dilitiazem/verapamil also affect heart conduction i.e. for arrhythmias
Contraindications of calcium channel blockers?
Dilitiazem/verapamil avoid in heart failure, avoid concurrent use with beta blockers!
How does clopidogrel work? 3 side effects
Irreversibly inhibits platelet aggregation
Haemorrhage, GI upset, dizziness
ANTIPLATELET
Contraindications of clopidogrel?
Active bleeding
Caution with increased risk of bleeding i.e. surgery, conditions
Mechanism of ace inhibitors? 3 side effects
Inhibit conversion of angiotensin I to angiotensin II by ace to relax blood vessels, lower blood pressure
Cough (accumulation of bradykinin), chest pain, dizziness
Contraindications of ace inhibitors?
Use with aliskiren - direct renin inhibitor
Concomitant diuretics
Examples of and mechanism of glycoprotein IIb/IIIa inhibitors?
Tirofiban, bivalirudin
Inhibition of GPIIb/IIIa receptor on platelets so prevent platelet formation
Side effects of GPIIb/IIIA inhibitors? Contraindications
SE: haemorrhage, headache, nausea
CI: abnormal bleeding in last month, aneurysm history, history of haemorrhagic stroke
Mechanism of aspirin?
Irreversibly inhibits cyclooxygenase enzyme, stopping prostaglandin and thromboxane synthesis, reducing platelet aggregation
ANTIPLATELET
Side effects of aspirin? Contraindications
SE: dyspepsia, haemorrhage, skin reactions
CI: children under 16 (Reye’s syndrome), active peptic ulcer, bleeding disorders
When are alternative drug treatments used in angina?
As monotherapy if BBs or CCBs aren’t used
In combination with 1 1st line agent if symptoms are not controlled and other 1st line agent isn’t used
As a 3rd agent if symptoms aren’t controlled with 2 drugs and unsuitable/awaiting CABG/PCI
Ivabradine - symptomatic relief of angina in patients with a heart rate >70, as an alternative to first line therapies
What is isosorbide mononitrate?
Long acting nitrate
What is nicorandil? SE, CI
Potassium channel activator
SE: headache
CI: left ventricular failure, hypotension
What is ivabradine? SE, CI
Acts on sinoatrial node to lower heart rate
SE: dizzy, vision changes
CI: bradycardia, heart block, heart failure
What is ranolazine? SE, CI
Affects sodium dependent calcium channels
SE: dizzy, headache, nausea
CI: renal/liver failure
What is hypertension?
Persistently elevated blood pressure in vessels - symptomless until causes organ damage, risk factor for other CV disease/diabetes/stroke/kidney disease/PAD
What are the stages of hypertension?
1 - 140/90, ambulatory 135/85
2 - 160/100, ambulatory 150/95
Severe - systolic >180 or diastolic >110
Causes of hypertension?
Essential (unknown) - may be alcohol, obesity
Renal disease
Endocrine disease - Cushings, Conns, acromegaly
Coarctation of aorta
Pregnancy
Lifestyle advice for hypertension?
Stop smoking Lose weight, exercise Reduce alcohol Reduce salt intake, healthy diet Decrease caffeine intake Encourage relaxation
When are statins given in hypertension?
STATIN if CVD or everyone over 40 and 10yr CV risk >20%
When to treat stage 1 hypertension?
<80 yrs and 1 of: Target organ damage Renal disease CVD Diabetes 10yr CVD risk >20%
When to treat stage 2 hypertension?
All patients
What if <40 with stage 1 hypertension and no associated features?
Refer for evaluation of secondary causes of hypertension and detailed assessment of CV risk
Step 1 hypertension treatment?
If under 55 years - ACEi (ramipril) or ARB if not tolerated
If over 55, or black African/Caribbean any age - CCB (amlodipine) or thiazide like diuretic if not tolerated
Step 2 hypertension treatment?
Offer ACE inhibitor (or ARB if not tolerated or of AfroCaribbean origin) PLUS CCB (or thiazide like diuretic if not tolerated)
Step 3 hypertension treatment?
Ensurestep 2 is at optimal doses Offer ACEi (ARB if not tolerated) PLUS CCB PLUS thiazide like diuretic
Step 4 hypertension treatment? If BP still >140/90
4th drug:
Spironolactone
OR higher dose thiazide like diuretic
If diuretic CI, add alpha or beta blocker
When is a beta blocker used as step 1 treatment for hypertension?
Younger people if intolerant to ACEi/ARB
Women of childbearing potential
People with increased sympathetic drive
NB: add CCB if second drug required
What are the target BP for non diabetic patients with no CKD?
<140/90, ambulatory <135/85
<150/90 if over 80, ambulatory <145/85
What are the target BP for diabetic patients?
<140/80 uncomplicated type 2
<135/85 uncomplicated type 1
<130/80 if complications
What is the target BP for paitents with CKD?
<130/80
How is hypertension treated in patients with diabetes?
1 - ACEi (ARB if not tolerated), if AfroCaribbean ACEi+CCB
2 - add CCB
3 - add diuretic
4 - alpha/beta blocker, spironolactone
What is an ARB? Mechanism, give 2
Angiotensin II receptor antagonist
Block angiotensin II by preventing binding, blood vessels dilate reducing BP
Candesartan, irbesartan
ARB SEs, CI?
SE: abdo pain, cough, dizzy
CI: Combo with aliskiren, caution with afrocaribbean, people with LV hypertrophy, valve stenosis
How do alpha blockers work? Give 2
Alpha adrenergic antagonists - bind to alpha receptors in arteries/smooth muscle, relaxing vessels
Doxazosin, terazosin
Alpha blockers SE, CI?
SE: arrhythmias, chest pain, dizzy
CI: postural hypotension, careful in heart failure, pulmonary oedema
What thiazide like diuretics are used in hypertension and how do they work?
Chlortalidone, indapamide
Decrease cardiac output, reduce extracellular fluid volume, reduce peripheral vascular resistance - vasodilate
Thiazide like diuretics CI, SEs?
CI: addisons, hypercalcaemia, hyponatraemia, hypokalaemia, hyperuricaemia
SE: constipation, electrolyte imbalance, headache, hypotension
What is AF?
Atrial fibrillation, common disturbance of cardiac rhythm that may be episodic, associated with risk of stroke
What is seen on ECG in AF?
Rapid irregularly irregular narrow QRS complex tachycardia with the absence of P waves
Causes of AF?
No cause Coronary heart disease Hypertension Cardiomyopathy Valvular heart disease - esp. mitral
Causes of acute AF?
Infection
High alcohol
Surgery
MI, PE
Symptoms of AF?
Often asymptomatic Palpitations Chest pain Stroke/TIA Dyspnoea Light headedness/syncope Fatigue
Investigations of AF?
ECG CXR Bloods - TFTs, FBC, U+E Ambulatory ECG echo if <50
Management of recent onset AF?
Treat precipitating cause - infection
Direct current cardioversion or chemical cardioversion
Admit if fast rate/patient compromise
Management of not recent onset AF?
Address RFs i.e. alcohol, caffeine, hypertension, thyroid disease
Refer for echo and cardio assessment
Treatment of paroxysmal not recent onset AF?
No drugs if can avoid triggers
Pill in pocket - beta blocker as needed
Anticoagulate - low risk give aspirin, high risk give warfarin or NOAC
Treatment of chronic not recent onset AF?
Rhythm control - DC/chemical cardioversion
Beta blocker to maintain rhythm or rate limiting CCB i.e. verapamil
If ineffective, beta blocker + digoxin
If ineffective, verapamil + digoxin
If ineffective, refer
Anticoagulate - low risk give aspirin, high risk give warfarin or NOAC
Mechanism of atrial fibrillation?
Irregular atrial rhythm 300-600bpm which leads to an irregular ventricular rate due to AV node only sometimes responding
What system is used to measure stroke risk in AF?
CHA2D2-VASc
Risk assessment tool for someone starting anticoagulation?
HASBLED
What is atrial flutter?
ECG shows regular sawtooth baseline at 300bpm, with narrow complex QRS tachycardia superimposed at 150bpm
What is used for rate control in AF?
Beta blocker or rate limiting CCB
Can add digoxin
What is used for rhythm control in AF?
Electrical cardioversion
Dronedarone (with beta blocker)
Amiodarone if LV impairment/heart failure
How is acute medical cardioversion done in AF?
Fleicainide
Amiodarone if structural heart disease
How does digoxin work?
Increases the force of contraction of the heart muscle but reduces heart rate - inhibits Na/K ATPase
Side effects of digoxin? CIs?
SE: arrhythmias, dizzy, vision disorders
CI: intermittent complete heart block, myocarditis, 2nd degree AV block, V fib
How does amiodarone work?
Class III antiarrhythmic - prolongs the refractory period of SA and AV nodes, slowing conduction rate
Side effects of amiodarone? CIs?
SE: arrhythmias, liver damage, hyperthyroid
CI: severe conduction disturbances, sinus node disease, thyroid dysfunction
What are guidelines on returning to normal life after MI?
Sedentary work 4-6 weeks, light 6-8, heavy 12
Sex after 6 weeks
Fly - after 2 weeks if can climb stairs
Driving - car angioplasty 1 week, other 1 month, lorry licence revoked assess at 6 weeks
What is heart failure?
Output of the heart is inadequate to meet the needs of the body, end stage of all diseases of the heart
Causes of chronic heart failure?
High output - needs of the body are more than what heart can give
Low output - increased preload, pump failure, chronic excessive afterload
Causes of high output heart failure?
Hyperthyroidism
Anaemia
Paget’s disease
Causes of increased preload?
Mitral regurgitation
Fluid overload
Causes of pump failure?
IHD
Cardiomyopathy
Restrictive cardiomyopathy, constrictive pericarditis
Inadequate rate - beta blockers, heart block
Arrhythmia - AF
Negatively inotropic drugs - verapamil
Causes of chronic excessive afterload?
Hypertension
Aortic stenosis
Classification of heart failure?
Left ventricular systolic dysfunction - decreased left ventricular ejection fraction (LVEF) on echo
Heart failure with preserved ejection fracture - normal LVEF but signs/symptoms of heart failure
Tests for heart failure?
Echo Blood - FBC, U+E, TFT, eGFR, creatinine, HbA1C, glucose ECG CXR PEFR/spirometry Serum natriuretic peptides
What is the NY heart association grading of heart failure severity?
I - no limitation
II - slight limitation, ordinary activity causes fatigue/palpitations/dyspnoea
III - marked limitation, less than ordinary activities causes symptoms
IV - unable to carry out any physical activity without discomfort, symptoms present at rest
Symptoms of heart failure? (8)
SoB - on exertion, orthopnoea, paroxysmal nocturnal dyspnoea Decreased exercise tolerance Nocturnal cough Ankle oedema Abdo discomfort - liver distension Confusion, dizziness Gain or lose weight Wheeze
Signs of heart failure? (11)
Increased RR Cyanosis Increased pulse Increased JVP Displaced apex beat - cardiomegaly 3rd heart sound Hepatomegaly Right ventricular heave Crepitations, pleural effusions Pitting oedema ankles Ascites Cachexia, wasting
Features of PMH that may indicate heart failure?
MI, AF, hypertension
What serum natriuretic peptides are tested for in heart failure?
BNP - B-type natriuretic peptide
NTproBNP - N-terminal prohormone of BNP
If high SNPs, or previous MI what is next management?
Refer in <2wks for specialist and doppler echo
If low SNPs what is next management?
If medium, refer in 6wks for doppler echo
If low, heart failure unlikely
How often is review needed in heart failure? What is checked?
6 months - check functional capacity, fluid status, heart rhythm, cognition and nutrition Depression Co-morbidities Medication compliance/SEs Bloods - U+E, creatinine, eGFR
Non medical management of heart failure? (6)
Educate - discuss prognosis Ease - benefits, mobility, blue badge Diet - low salt, lose weight if obese, low alcohol Lifestyle - smoking, exercise Restrict fluid intake if severe Vaccination - pneumococcal and influenza
What is given in all types of heart failure?
Diuretics.
1st - loop i.e. furosemide
2nd - thiazide i.e. bendroflumethiazide if oedema/hypertension continue
What is first line treatment in LV systolic dysfunction?
(Diuretics)
ACE inhibitor (or ARB) and beta blocker
If ACEi/ARB not tolerated, use hydralazine with a nitrate
Add mineralocorticoid receptor antagonist (spironolactone)
What is treatment of heart failure with preserved ejection fraction?
(Diuretics)
No specific treatment
Treat diabetes, hypertension, IHD…
When is anticoagulation given in heart failure?
If AF or history of thromboembolism, LV aneurysm, intrathoracic thrombus
When is aspirin used in heart failure?
If concurrent with atherosclerotic arterial disease
When to refer heart failure?
Severe failure, not controlled by first line medication, concurrent with angina/arrhythmia
What 2nd line treatments for heart failure are given?
Digoxin Ivabradine Amiodarone Implantable cardioverter defibrillator Surgery - valve replacement, coronary angioplasty
How does spironolactone work?
Aldosterone antagonist - increases sodium and water excretion in DCT, spares potassium
(aldosterone normally increases resorption of sodium and water)
CI and SE of spironolactone?
CI: addisons, anuria, high potassium
SE: AKI, dizzy, electrolyte imbalance
How do loop diuretics (furosemide) work?
Inhibit reabsorption of sodium and water from the ascending loop of loop of Henle, increasing excretion
CI and SE of furosemide?
CI: anuria, renal failure, severe hypokalaemia or hyponatraemia
SE: Dehydration, dizzy, electrolyte imbalance
How do thiazide diuretics (bendroflumethiazide) work?
Inhibits sodium reabsorption at beginning of the distal convoluted tubule, increasing excretion
CI and SE of bendroflumethiazide:
CI: addisons, hypercalcaemia, hyponatraemia, hypokalaemia
SE: constipation, electrolyte imbalance, headache
What causes systolic failure?
MI, IHD, cardiomyopathy
What causes diastolic heart failure?
Inability of ventricle to relax and fill - constrictive pericarditis, tamponade, restrictive cardiomyopathy
Compensatory mechanisms when cardiac output compromised?
Sinus tachycardia
Increased venous pressure
Myocardial dilation/hypertrophy
Why does decreased CO lead to fluid retention?
Poor renal perfusion activates RAAS
What is positive inotropism and chronotropism?
Inotrope - Increase in force of contractility
Chronotrope - Increase in rate of contractions
3 cardinal symptoms of heart failure?
SOB
Ankle swelling
Fatigue
What are 3 major and 4 minor criteria in Framingham criteria?
Major - nocturnal SOB, crepitations, S3 gallop third heart sound
Minor - ankle oedema, SOB, tachycardia, nocturnal cough
Which 2 investigations if normal exclude heart failure?
ECG, BNP
Features on CXR in heart failure? (5)
Alveolar oedema (batwing) Kerley B lines (interstitial oedema) Cardiomegaly Dilated pulmonary vessels Pleural effusion
Features on echo of heart failure?
Dilated chambers, valve incompetence, cardiomyopathy,LV dysfunction
What is cor pulmonale?
Right sided heart failure due to chronic pulmonary hypertension - COPD, asthma, fibrosis
What is preload and afterload?
Preload - initial stretching of cardiac myocytes prior to contraction
Afterload - load against which the heart has to contract to eject blood
What is CKD?
Chronic kidney disease
Impaired renal function for >3months based on abnormal structure or function, or GFR <60mL persistently
What are the stages of CKD?
1 - eGFR>90, kidney damage normal GFR
2 - eGFR 60-89, kidney damage mildly low GFR
3a - 45-49, 3b - 30-44, moderately low GFR
4 - 15-29 severely low GFR
5 - <15 renal failure
Causes of CKD?
Diabetes Hypertension Urinary tract obstruction Polycystic kidneys Glomerulonephtritis Renovascular disease SLE
Who should be screened for CKD?
Diabetics Hypertension CV disease Chronic stones BPH Recurrent UTI Multisystem i.e. SLE FHx
How may CKD present?
Often asymptomatic until ~stage 4 Nausea Anorexia/lethargy Itch Nocturia Impotence Oedema Dyspnoea
Signs of CKD?
Pallor Lemon tinge to skin - uraemic Pulm/peripheral oedema Pericarditis Pleural effusions Metabolic flap Retinopathy Hypertension
Investigations of CKD?
Bloods - U+E, creatinine, eGFR, glucose, protein, FBC
Urinalysis - MC+S, albumin:creatinine
Renal tract USS - usually small kidneys
What would be on bloods in CKD?
Anaemia
High calcium
High phosphate
Raised alkaline phosphatase
General management of CKD?
Treat reversible cause i.e. nephrotoxic drugs (NSAIDs)
Manage CVD risk i.e. statin, antihypertensives, antiplatelet
Treat diabetes
Stop smoking
Treat anaemia, renal bone disease
When to refer?
Stage 4 or 5 Significant proteinuria Sudden drop in eGFR Persistent haematuria if under 50yo Bone disease, anaemia
How to treat CKD?
ACEi (lisinopril) or ARB (losartan) Statin Loop diuretics for oedema, restrict fluid/salt VitD/calcium supplements Sodium bicarb supplements Replace iron/B12/folate/EPO if anaemia Gabapentin for restless legs
When to start dialysis?
eGFR 8-10
What are types of RRT?
Haemodialysis, haemofiltration (if critically ill), peritoneal dialysis (ambulatory)
How does haemodialysis work?
Blood flows opposite dialysis fluid and substances cleared along a concentration gradient across semi permeable membrane
Complications of dialysis?
Pulmonary oedema
Infection
Hypotension
End stage treatment of CKD?
Transplant
What is COPD?
Chronic obstructive pulmonary disease
Progressive disorder characterised by airway obstruction with little or no reversibility
Includes emphysema and chronic bronchitis
What is the FEV1 and FEV1/FVC needed to diagnose COPD?
FEV1 <80%
FEV1/FVC <0.7
Difference between obstructive and restrictive airways disease?
Obstructive - conditions that hinder ability to exhale all the air from lungs
Restrictive - difficulty fully expanding lungs
What are the obstructive lung diseases?
Chronic bronchitis
Emphysema
Asthma
Bronchiectasis
What would indicate COPD instead of asthma? (6)
Increasing age History of smoking/smoke Chronic sob Sputum Little diurnal FEV1 variation Irreversible
What is chronic bronchitis?
CLINICAL diagnosis
Cough, sputum production on most days for 3 months of 2 successive years
What is emphysema?
HISTOLOGICAL diagnosis
Enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls
What causes COPD?
Smoking
What inherited trait can cause COPD?
Alpha1 antitrypsin deficiency on chromosome 14
Inhibits neutrophil elastase - enzyme that disrupts connective tissue, so develop emphysema at young age
Pathological features seen in COPD? (4)
Goblet cell hyperplasia Inflammatory infiltration Squamous epithelium replaced with columnar Fibrosis Loss of elasticity - emphysema
What is a pink puffer?
Breathless NOT cyanosed
Normal Co2 from increased ventilation
Pursed lips and barrel chest
From emphysema
What is a blue bloater?
Cyanosed NOT breathless
High Co2 due to insensitivity, rely on hypoxic drive
Bloat due to right heart failure
From chronic bronchitis
Symptoms of COPD? (4)
Cough
Sputum
Dyspnoea
Wheeze
Signs of COPD? (8)
Tachypnoea Use of accessory muscles Hyperinflation Decreased chest expansion Hyperresonant percussion Quiet breath sounds Cyanosis Cor pulmonale
Complications of COPD? (4)
Acute exacerbations/infections
Polycythaemia - more RBCs
Resp failure
Cor pulmonale - oedema
Triggers for COPD exacerbations? (3)
Cold weather
Pollution/smoke
Exertion
Investigations for COPD? (6)
FBC - high circulating RBCs ABG - hypoxia, possible hypercapnia Lung function CXR ECG Steroid trial
What is seen on CXR in COPD? (4)
Bullae - air filled spaces
Hyperinflation (>6 ribs above diaphragm), flat hemidiaphragms, large pulmonary arteries, decreased peripheral vascular markings
What is seen on ECG in COPD?
Right atrial and ventricular hypertrophy
What is FEV1 and FVC?
Forced expiratory volume in 1 second into a spirometer
Forced vital capacity into a spirometer - until no more can be exhaled
Steroid trial in COPD?
Oral prednisolone for 2 weeks
If FEV1 > by 15% COPD is steroid responsive
Not done much
How is severity of COPD tested?
1 mild - FEV1 >80% predicted
2 moderate - 50-79% predicted
3 severe - 30-49% predicted
4 very severe - <30% predicted
General management of COPD? (7)
Stop smoking Exercise Nutrition/lose weight Flu and pneumoccocal vaccine Pulmonary rehabilitation Mucolytics Diuretics for oedema
What is first line for COPD?
Short acting beta 2 agonist as needed - salbutamol
OR short acting muscarinic antagonist as needed - ipatropium bromide
What is second line for COPD if persistent sob?
FEV1 >50%:
Long acting beta 2 agonist - formoterol
OR Long acting muscarinic antagonist - tiotropium (discontinue ipatropium)
FEV <50%:
Long acting beta 2 agonist - formoterol AND inhaled corticosteroid - budesonide
OR Long acting muscarinic antagonist - tiotropium (discontinue ipatropium)
What is third line for COPD if remain symptomatic?
Long acting beta 2 agonist - formoterol PLUS inhaled corticosteroid - budesonide PLUS long acting muscarinic antagonist (tiotropium)
Treatments for more advanced COPD?
Theophylline PLUS inhaled corticosteroid - budesonide PLUS long acting beta 2 agonist - formoterol
Pulmonary rehabilitation
LTOT if oxygen <7.3kPa
What is ipatropium and tiotropium, how do they work?
Short and long acting antimuscarinics
Decrease bronchial secretions by antagonising M3 muscarinic receptors, cause bronchodilation
SE/CI for antimuscarinics
SE: arrhythmias, cough, dizziness
CI: parodoxical bronchospasm, susceptible to angle closure glaucoma
What is salbutamol and formoterol, how do they work?
Short and long acting beta 2 agonists
Activates beta 2 receptors which relax bronchial smooth muscle
SE/CI for S/LABAs
SE: fine tremor, headache, hypokalaemia
CI: severe pre-eclampsia
How does budesonide work? SE, CI
Glucocorticoid agonist, prevents inflammation
SE: headache, oral candidiasis, taste change
CI: acute exacerbations
How does theophylline work? SE, CI
Phosphodiesterase inhibitor causing bronchodilation of airway smooth muscle
SE: anxiety, arrhytmias, dizzy
CI: arrhythmias, hypokalaemia risk
Surgery available for COPD?
Bullectomy, lung transplant
Treatment of acute COPD exacerbations? (4)
Nebulised salbutamol and ipratropium
Oxygen
Steroids - prednisolone
Antibiotics - amoxicillin
What is asthma?
Recurrent episodes of dyspnoea, cough, wheeze caused by REVERSIBLE airways obstruction
What factors contribute to asthma pathogenesis?
Bronchial muscle contraction
Mucosal inflammation - mast cell and basophil degranulation
Increased mucous production
Symptoms of asthma?
Intermittent dyspnoea Wheeze Cough - often nocturnal Sputum Disturbed sleep - indicates severe Acid reflux Eczema, hayfever
Precipitants of asthma?
Cold air Exercise emotion Allergens - dust, pollen, fur Infection Smoke inhalation/pollution Job - if better at weekends
What drugs can precipitate asthma?
NSAIDs
Beta blockers
What is diurnal variation seen in asthma?
In symptoms OR peak flow - worse in morning
Signs of asthma?
Tachypnoea Audible wheeze - widespread, polyphonic Hyperinflated chest Hyperresonant percussion Decreased air entry
Signs of a severe asthma attack?
Inability to complete sentences
Pulse >110bpm
Resp rate >25
PEF 33-50% expected
Signs of a life threatening asthma attack?
Silent chest Confusion Exhaustion Cyanosis - oxygen <8kPa (low), <92%, co2 4.6-6 (normal) Bradycardia PEF <33% predicted
Sign of a near fatal asthma attack?
Increased PaCO2 - shows failing respiratory effort
Tests for asthma? (4)
Peak expiratory flow monitoring - diurnal variation >20% for 3 days a week for 2 weeks
Spirometry - obstructive, FEV1/FVC <0.7 FEV1 <80%
Steroid/b2 agonist trial - 15% increase in FEV1
CXR - hyperinflation
General management of asthma?
Stop smoking
Avoid precipitants
CHECK INHALER TECHNIQUE
Teach peak flow technique for 2x daily monitoring
Step 1 of asthma treatment?
Inhaled short acting beta 2 agonist - salbutamol
Step 2 of asthma treatment?
If using SABA/having symptoms more than 3 times a week or woken at night
ADD inhaled corticosteroid - beclometasone
Step 3 of asthma treatment?
Offer leukotriene receptor antagonist (montelukast) in addition to SABA and ICS
Step 4 of asthma treatment?
Add a long acting beta 2 agonist (formoterol) with the SABA, ICS, LTRA
What if uncontrolled asthma on SABA, ICS, LABA, LTRA?
Change ICS and LABA therapy to maintenance and reliever (MART) with fast acting LABA
Then increase ICS to moderate
What if uncontrolled with moderate ICS dose?
Trial of high ICS
OR theophylline
OR muscarinic receptor antagonist (ipratropium)
What are leukotriene receptor antagonists?
Block the effects of cysteinyl leukotrienes in the airways which normally cause narrowing/swelling of the airways
SE/CI of LTRAs
SE: diarrhoea, GI upset, headache, URTI
CI: pregnancy. none really - may be linked to depression/suicide
