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GP common conditions key info Flashcards

1
Q

What are the non-modifiable RFs of CVD?

A

-older age
-family history
-male

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2
Q

What are the modifiable RFs of CVD?

A

-smoking
-alcohol consumption
-poor diet (high sugar, trans-fat and reduced fruit and veg)
-low exercise
-obesity
-poor sleep
-stress

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3
Q

What conditions can increase risk of CVD?

A

-Diabetes
-Hypertension
-CKD
-inflammatory conditions, such as RA
-atypical antipsychotic medications

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4
Q

What can atherosclerosis lead to?

A

-MI
-angina
-TIA
-Stroke
-PVD
-mesenteric ischaemia

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5
Q

Who is CVD primary prevention offered to?

A

-patients who have no past history of CVD

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6
Q

Who is CVD secondary prevention offered to?

A

-patients who have history of CVD

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7
Q

What do both primary and secondary prevention include?

A

-Optimising modifiable risk factors:
>advice on diet, exercise and weight loss
>stop smoking
>stop drinking alcohol
>tightly treat co-morbidities like diabetes

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8
Q

What tool is used in the primary prevention of CVD?

A

QRISK 3 score -> will calculate the percentage risk of a pt having a stroke/mi in the next 10 years

-If >10% then you should offer a statin -> (atorvastatin 20mg at night)

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9
Q

Who should be offered a statin in primary prevention of CKD?

A

-pts that score a QRISK3 > 10% and all patients who have had CKD or diabetes for over 10 years

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10
Q

When should lipids be checked after being commenced on statins?

A

-NICE recommends checking lipids at 3 months and increasing the dose to aim for >40% reduction in non-HDL cholesterol
*always check adherence before increasing the dose

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11
Q

What else should be checked after being commenced on statins?

A

-NICE also recommend checking LFTs within 3 months of starting a statin and again at 12 months. No need to check after that if normal
-this is because statins can cause a mild rise in ALT and AST in the first few weeks of use and they often don’t need stopping if the rise is < 3 times the upper limit of normal

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12
Q

What does secondary prevention of CVD involve?

A

4 As:
-Aspirin (plus clopidogrel for 12 months)
-Atorvastatin 80mg
-Atenolol (or other beta-blocker - commonly bisoprolol) titrated to max tolerated dose
-ACE inhibitor (commonly ramipril) titrated to max tolerated dose

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13
Q

What are the side effects of statins?

A

-Myopathy (check creatine kinase in pts with muscle pain or weakness)
-Type 2 diabetes
-Haemorrhagic strokes (very rarely)

Usually, the benefits of statins far outweigh the risks and newer statins (such as atorvastatin) are mostly very well tolerated.

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14
Q

What is Angina?

A

-chest pain as a result of insufficient supply of blood to meet demand

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15
Q

What is stable and unstable angina?

A

-Angina is stable when symptoms come during exertion and it is relieved by rest or GTN spray
-Angina is unstable when symptoms come on randomly at rest, considered as an ACS

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16
Q

What is the gold standard diagnostic investigation for angina?

A

CT Coronary Angiography - involves injecting contrast and taking CT images timed with the heartbeat to give a detailed view of the coronary arteries, highlighting any narrowing

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17
Q

What other baseline investigations should all patients have for angina?

A

-Physical Examination (heart sounds, signs of heart failure, BMI)
-ECG
-FBC (check for anaemia)
-U&Es (prior to ACEi and other meds)
-LFTs (prior to statins)
-Lipid profile
-Thyroid function tests (check for hypo / hyper thyroid)
-HbA1C and fasting glucose (for diabetes)

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18
Q

What are the stages of management of angina?

A

RAMP

R – Refer to cardiology (urgently if unstable)
A – Advise them about the diagnosis, management, and when to call an ambulance
M – Medical treatment
P – Procedural or surgical interventions

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19
Q

What are the aims of medical management of angina?

A

-Immediate Symptomatic Relief
-Long-Term Symptomatic Relief
-Secondary prevention of cardiovascular disease

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20
Q

What is used for Immediate Symptomatic Relief in angina?

A

-GTN spray
-Take GTN, then repeat after 5 minutes. If there is still pain 5 minutes after the repeat dose – call an ambulance.

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21
Q

What is used for Long term Symptomatic Relief in angina?

A

First Line:
-beta blocker e.g bisprolol 5mg once daily
-CCB e.g amlodipine 5mg once daily

-these can then be used together if symptoms are not controlled by one. If still not controlled then:

-Long acting nitrates (e.g. isosorbide mononitrate)
-Ivabradine
-Nicorandil
-Ranolazine

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22
Q

What should be given as secondary prevention against CVD in angina?

A

Aspirin (i.e. 75mg once daily)
Atorvastatin 80mg once daily
ACE inhibitor
Already on a beta-blocker for symptomatic relief.

23
Q

What are the surgical interventions available for angina?

A

-PCI with coronary angioplasty
-CABG

24
Q

What are the three types of ACS?

A

Unstable Angina
ST Elevation Myocardial Infarction (STEMI)
Non-ST Elevation Myocardial Infarction (NSTEMI)

25
Q

How would you make a diagnosis of ACS?

A

-if pt presents with possible ACS symptoms (i.e. chest pain) perform an ECG:

If there is ST elevation or new left bundle branch block the diagnosis is STEMI.

-If there is no ST elevation then perform troponin blood tests:
-If there are raised troponin levels and other ECG changes (ST depression or T wave inversion or pathological Q waves) the diagnosis is NSTEMI
-If troponin levels are normal and the ECG does not show pathological changes the diagnosis is either unstable angina or another cause such as musculoskeletal chest pain

26
Q

What are the symptoms of ACS?

A

Symptoms should continue at rest for more than 20 minutes. If they settle with rest consider angina

-Nausea and vomiting
-Sweating and clamminess
-Feeling of impending doom
-Shortness of breath
-Palpitations
-Pain radiating to jaw or arms

27
Q

How can a MI present in a diabetic patient?

A

Diabetic patients may not experience typical chest pain during an acute coronary syndrome. This is often referred to as a “silent MI”.

28
Q

What are the ECG changes in STEMI?

A

-ST segment elevation in leads consistent with an area of ischaemia
-New Left Bundle Branch Block also diagnoses a “STEMI”

29
Q

What are the ECG changes in NSTEMI?

A

-ST segment depression in a region
-Deep T Wave Inversion
-Pathological Q Waves

30
Q

Which leads and heart area would be affected if MI in Left Coronary Artery?

A

Anterolateral

I, aVL, V3-6

31
Q

Which leads and heart area would be affected if MI in LAD?

A

Anterior

V1-4

32
Q

Which leads and heart area would be affected if MI in circumflex?

A

Lateral

I, aVL, V5-6

33
Q

Which leads and heart area would be affected if MI in RCA?

A

Inferior

II, III, aVF

34
Q

What imaging investigations would you do for ACS?

A

-Chest xray to investigate for other causes of chest pain and pulmonary oedema
-Echocardiogram after the event to assess the functional damage
-CT coronary angiogram to assess for coronary artery disease

35
Q

What is the acute treatment for a STEMI?

A

-Primary PCI (if available within 2 hours of presentation)
-Thrombolysis (if PCI not available within 2 hours)

36
Q

What is the acute treatment for an NSTEMI?

A

BATMAN
B – Beta-blockers unless contraindicated

A – Aspirin 300mg stat dose

T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)

M – Morphine titrated to control pain

A – Anticoagulant: Fondaparinux (unless high bleeding risk)

N – Nitrates (e.g. GTN) to relieve coronary artery spasm

Give oxygen only if their oxygen saturations are dropping (i.e. <95%).

37
Q

What tool is used to assess for a need for PCI in NSTEMI?

A

GRACE Score -gives a 6-month risk of death or repeat MI after having an NSTEMI:

<5% Low Risk
5-10% Medium Risk
>10% High Risk

If they are medium or high risk they are considered for early PCI (within 4 days of admission)

38
Q

What is the secondary prevention medical management for MIs (ACS)?

A

6As

-Aspirin 75mg once daily
-Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
-Atorvastatin 80mg once daily
-ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
-Atenolol (or other beta blocker titrated as high as tolerated)
-Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

Dual antiplatelet duration will vary following PCI procedures depending on the type of stent that was inserted. This is due to a higher risk of thrombus formation in different stents.

39
Q

What is the secondary prevention lifestyle for MIs (ACS)?

A

-Stop smoking
-Reduce alcohol consumption
-Mediterranean diet
-Cardiac rehabilitation (a specific exercise regime for patients post MI)
-Optimise treatment of other medical conditions (e.g. diabetes and hypertension)

40
Q

What is hypertension?

A

-high blood pressure - 140/90 in clinic or 135/85 with ambulatory or home readings

41
Q

What is essential hypertension?

A

-Essential hypertension accounts for 95% of hypertension
-also known as primary hypertension
-means that the hypertension has developed on its own and does not have a secondary cause.

42
Q

WHat are the secondary causes of hypertension?

A

ROPE
R
– Renal disease -> most common cause of secondary hypertension. If the blood pressure is very high or does not respond to treatment consider renal artery stenosis.
O – Obesity
P – Pregnancy-induced hypertension/pre-eclampsia
E – Endocrine. Most endocrine conditions can cause hypertension but primarily consider hyperaldosteronism (“Conns syndrome”) as this may represent 2.5% of new hypertension. A simple test for this is a renin: aldosterone ratio blood test.

43
Q

What are the complications of hypertension?

A

-Ischaemic heart disease
-Cerebrovascular accident (i.e. stroke or haemorrhage)
-Hypertensive retinopathy
-Hypertensive nephropathy
-Heart failure

44
Q

How is a diagnosis of hypertension confirmed?

A

-pts with a clinic blood pressure between 140/90 mmHg and 180/120 mmHg should have 24-hour ambulatory blood pressure or home readings to confirm the diagnosis

45
Q

What are the different stages of hypertension?

A

Stage 1 Hypertension

clinic reading >140/90

Ambulatory / Home Readings >135/85

Stage 2 Hypertension

clinic reading >160/100

Ambulatory / Home Readings >150/95

Stage 3 Hypertension

clinic reading >180/120

46
Q

What tests should all patients with newly diagnosed hypertension have?

A

-Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
-Bloods for HbA1c, renal function and lipids
-Fundus examination for hypertensive retinopathy
-ECG for cardiac abnormalities

47
Q

What are the medications to treat hypertension?

A

A – ACE inhibitor/ ARB (e.g. ramipril 1.25mg up to 10mg once daily/ candesartan 8mg to up 32mg once daily)
B – Beta blocker (e.g. bisoprolol 5mg up to 20mg once daily)
C – Calcium channel blocker (e.g. amlodipine 5mg up to 10mg once daily)
D – Thiazide-like diuretic (e.g. indapamide 2.5mg once daily)

48
Q

Why would you give a patient an ARB instead of an ACEi?

A

-if the person does not tolerate ACE inhibitors (commonly due to a dry cough)
-or the patient is black of African or African-Caribbean descent

49
Q

What does the initial management of hypertension involve?

A

-Establish a diagnosis
-Investigate for possible causes and end organ damage.
-Advise on lifestyle. This includes recommending a healthy diet, stopping smoking, reducing alcohol, caffeine and salt intake and taking regular exercise.

50
Q

Who is offered medical management for hypertension?

A

-All patients with stage 2 hypertension
-All patients under 80 years old with stage 1 hypertension that also have a Q-risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage.

51
Q

Describe the steps of prescribing anti-hypertensive medications

A

FIRST -> if <55 and non-black use ACEi/ARB, if >55 or black use CCB

SECOND -> ACEi + CCB, or ACEi+ thiazide like diuretic / CCB + thiazide like diuretic. If black then use ARB instead of ACEi

THIRD -> ACEi/ARB + CCB + thiazide like diuretic

FOURTH -> ACEi/ARB + CCB + Diuretic + potassium sparing diuretic (if serum K+ <4.5mmol/l), if higher - alpha blocker (doxazosin) or a beta blocker (e.g atenol)

If still uncontrolled seek specialist advice

52
Q

What are the treatment targets for hypertension?

A

if < 80 years - < 140 < 90
if > 80 years - <150 <90

53
Q

What are presenting symptoms of AF?

A

-Palpitations
-Shortness of breath
-Syncope (dizziness or fainting)
-Symptoms of associated conditions (e.g. stroke, sepsis or thyrotoxicosis)

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