GP Flashcards
AF risk factors
HTN CCF Coronary artery disease Valvular disease Arrhythmias
Age DM Alcohol Male Smoking
AF presenting features
Palpitations Tachycardia Irregular pulse Stroke Dyspnoea Fatigue Chest pain Dizziness
AF investigations
ECG
TFTs
Echo
Before starting medication:
U+Es
CHA2DS2-VASc
AF ECG findings
Absent P waves
Irregularly irregular rate
AF echo findings
Valvular regurgitation or stenosis
LV or LA enlargement
PHTN
LV thickening and dysfunction
CHA2DS2-VASc
CHF - 1 HTN - 1 Age > 75 - 2 DM - 1 Stroke/TIA - 2 Vascular disease - 1 Age 65-74 - 1 Sex - Female
AF management
Anticoagulation - DOAC
- Factor 10a inhibitor
- CI in mitral stenosis or prosthetic valves
- Maintain INR 2-3
?Warfarin - HASBLED
Rate control - B-blocker
HASBLED
HTN - 1 Abnormal renal/liver function - 2 Stroke - 1 Bleeding history - 1 Labile INRs - 1 Elderly > 65 - 1 Drugs predisposing bleeding - 1
HTN definition
Clinical reading > 140/90
Ambulatory reading > 135/85
Primary hypertension = 90-95% of cases
Secondary HTN causes
Renal
- Glomerulonephritis
- Chronic pyelonephritis
- PKD
- Renal artery stenosis
Endocrine
- Primary hyperaldosteronism
- Phaeochromocytoma
- Cushing’s
- CAH
- Acromegaly
Other causes
- Glucocorticoids
- NSAIDs
- Pregnancy
- CoA
- COCP
HTN features
Usually asymptomatic
Headaches
Visual disturbances
Seizures
HTN investigations
24-hour BP monitoring
U+E - Check for cause or consequence HbA1c Lipids ECG Urine dip
HTN management
< 55 or DM2
- A
- A + D
- A + C + D
K+ < 4.5 - Spironolactone
K+ > 4.5 - A/B-blocker
HTN management
> 55 or Afro-Caribbean
- C
- C + A
- C + A + D
K+ < 4.5 - Spironolactone
K+ > 4.5 - A/B-blocker
ACE
Inhibits conversion of AT1 to AT2
Side effects
- Cough
- Angioedema
- Hyperkalaemia
Considerations
- CI in pregnancy
- Check renal function 2/3 weeks after starting
CCB
Block voltage-gated Ca channels
- Causes smooth muscle relaxation
- Reduces force of myocardial contraction
Side effects
- Flushing
- Ankle swelling
- Headache
Thiazide diuretics
Inhibit sodium absorption at the beginning of the DCT
Side effects
- Hyponatraemia
- Hypokalaemia
- Dehydration
A2RB
Block the effects of AT2 at the AT1 receptor
Side effects - Hyperkalaemia
Used if ACE is not tolerated
Adrenal cortex layers
Great Friday routines
Salt, sugar, sex
The deeper you go, the sweeter it gets
GFR-ACD
Glomerulosa - Mineralocorticoids - Aldosterone
Fasciculata - Glucocorticoids - Cortisol
Reticularis - Androgens - DHEA
R-A-S
Low BP detected by baroreceptors in aortic arch…
Stimulates SNS…
- Vasoconstriction
- Increased water and sodium reabsorption
- Increased potassium excretion
Renin
Released by renal juxtaglomerular cells…
In response to…
- Reduced renal perfusion
- Hyponatraemia
- SNS
Hydrolyses angiotensinogen to AT1
AT2
ACE converts AT1 to AT2
AT2 acts to increase BP…
- Vasoconstriction of efferent arteriole
- Increased filtration fraction to preserve GFR
- Stimulates thirst via hypothalamus
- Stimulates aldosterone and ADH release
- Increases proximal tubule Na+/H+ activity
Aldosterone
Released by zona glomerulosa in response to raised AT2, K+ and ACTH
Acts on DCT and collecting ducts
Stimulates…
- Na+ reabsorption
- K+ excretion
- H2O reabsorption
ADH
Increases BP
- Synthesised by hypothalamus
- Secreted by PP in response to decreased BP
- Acts on collecting ducts
- Increases water reabsorption
ANP
Atrial natriuretic peptide
Decreases BP
Released by atrial myocytes in response to…
- Cardiac distension
- SNS stimulation
- AT2
Inhibits RAS and causes vasodilation
CKD definition and staging
GFR < 60
Stage 1 - GFR > 90 + Evidence of kidney damage on investigation Stage 2 - GFR 60-89 Stage 3a - GFR 45-59 Stage 3b - GFR 30-44 Stage 4 - GFR 15-29 Stage 5 - GFR < 15
CKD risk factors
Age > 50
DM
HTN
Childhood kidney disease
Long-term steroid use Male Black/Hispanic FH Smoking Obesity AI disorders
CKD signs and symptoms
Anaemia Oedema Nausea Pruritus Arthralgia Enlarged prostate
CKD investigations
Creatinine-based estimate of GFR Albumin:Creatinine ratio Creatinine ^ Urinalysis - Haematuria and proteinuria Microalbuminaemia Renal USS Biopsy
Complications
Anaemia
Renal osteodystrophy
CVD
Protein malnutrition
Metabolic acidosis
Hyperkalaemia
Pulmonary oedema
CKD stage 1-2
Management
- ACE-I or ARB
Measure serum K+ and GFR before starting and 1/2 weeks after
K+ > 5 - Do not offer RAS inhibitor
- CCB - Verapamil
+++ Statin
CKD stage 3-4
Management
- ACE-I or ARB
Measure serum K+ before starting and 1/2 weeks after
K+ > 5 - Do not offer RAS inhibitor
- CCB - Verapamil
+++ Statin
+++ B-blocker
CKD additional treatments
CONSIDER ANTICOAGULATION
EPO stimulating agent Ferrous sulphate Calcium carbonate Ergocalciferol Calcitriol Sodium bicarbonate
CKD stage 5
Management
Dialysis
Kidney transplant
Calcium carbonate
Calcitriol
Ergocalciferol
HF risk factors
MI DM Dyslipidaemia Age ^ Male HTN Valvular heart disease FH AF Thyroid disease
HF symptoms
Dyspnoea Chest pain Fatigue Orthopnoea Tachycardia
HF signs
Raised JVP S3 gallop Cardiomegaly Hepatojugular reflux Rales Hepatosplenomegaly Pitting oedema
HF diagnosis
Framingham criteria
1 major + 2 minor
Framingham criteria
Major - Acute pulmonary oedema, cardiomegaly, hepatojugular reflux, neck vein distension , orthopnoea, pulmonary rales, S3 gallop
Minor - Ankle oedema, dyspnoea on exertion, hepatomegaly, nocturnal cough, pleural effusion, tachycardia > 120
HF investigations
Echo CXR BNP ^^^ FBC Serum electrolytes - Sodium LOW Creatinine and urea ^ BM - Check for DM LFTs ^ TFTs Lipids ^ Ferritin or transferrin saturation
HF management
ACE-I or ARB B-blocker Loop diuretic or thiazide diuretic Digoxin Aldosterone antagonist - Spironolactone
