GP Peer Teaching Flashcards
Describe the NICE pathway on Hypertension.
- First interaction >140/90
- To avoid white coat syndrome:
> ABPM
> Home BP monitoring
What are the parameters for stage 1 HTN?
ABPM / HBPM BP >135/85
What are the parameters for stage 2 HTN?
ABPM / HBPM BP > 150/95
What are the parameters for Severe HTN?
Systolic > 180
Diastolic > 110
Any patient with Stage 1 HTN plus comorbidities should be treated as Stage 2 HTN.
List some examples of these comorbidities.
- End organ damage (ECG, U+Es, Haematuria, Fundoscopy)
- Established CVD
- Diabetes
- Renal pathology
- 10 year CVD risk >20% (according to QRISK-2)
How should Stage 1 HTN be managed?
LIFESTYLE MODIFICATIONS!!!
- Smoking cessation
- Exercise
- Improve diet
- Reduce alcohol intake
- Engage in relaxation
What is the 1st line treatment for Stage 2 HTN in a person under 55 years?
ACEi
eg. Ramipril, Lisinopril
What is the 1st line treatment for Stage 2 HTN in a person over 55 years OR Afro-Caribbean origin?
Calcium Channel Blocker
eg. Amlodipine, Verapamil
What is the 2nd line treatment for Stage 2 HTN if a person is under 55y and already on an ACEi?
Add Calcium Channel Blocker (Amlodipine, Verapamil)
What is the 2nd line treatment for Stage 2 HTN if a person is over 55 or of Afro-Caribbean origin and is already on a CCB?
ACEi
eg. Ramipril, Lisinopril
What is the 3rd line treatment for Stage 2 HTN?
this is the same for under and over 55s and for Afro-Caribbeans
Add a thiazide-like diuretic
What is the 4th line treatment for Stage 2 HTN if a pt’s Potassium is below 4.5mmol/l?
Spironolactone
What is the 4th line treatment for Stage 2 HTN if a pt’s Potassium is above 4.5mmol/l?
Increase dose of thiazide-like diuretic
eg. Indapamide
What is the 5th line treatment for Stage 2 HTN?
“Refer for expert advice” (!)
List 2 conditions which can give an irregular pulse.
- Atrial Fibrillation
- Ventricular ectopics
- Sinus arrhythmia
What would you see on an ECG which would indicate AF?
- Absent P waves
- Irregularly irregular QRS
List some risk factors for AF.
- HTN
- Coronary artery disease
- Valvular heart disease
- Sepsis
- Alcohol
- PE
- Thyrotoxicosis
How common is AF in the over 80s?
1 in 4 over 80yo have AF.
Define ‘Persistent AF’.
- Not self terminating
- Lasting longer than 7 days, or prior cardioversion
- Persistent AF may degenerate into permanent AF
Define ‘Acute AF’.
Onset within 48hours.
How would you manage a haemodynamically stable patient who is in AF?
- Conservative: treat the cause
- Rate control: B-blockers or Rate-limiting Calcium Channel blocker
- Rhythm control
> Cardioversion (for younger patients)
> IV Amiodarone or PO/IV Fleicanide
When treating AF, what is the aim of rate control?
Which medications might be used?
To reduce the myocardial metabolic demands
Meds:
> B blocker (Atenolol)
> Rate limiting CCB (Diltiazem)
When treating AF, what is the aim of rhythm control?
Which medications might be used?
To regain sinus rhythm
Meds:
> IV Amiodarone or PO/IV Fleicanide
> Digoxin for sedentary elderly patients as rate control
What ‘worrying features’ should you look out for in a patient with AF?
- Heart failure
- Decreased BP
- Chest pain
- Decreased GCS
If a patient with AF is haemodynamically unstable, what treatment should you commence?
- Oxygen
- DCCV (Direct Current Cardioversion)
When should you consider anticoagulation in AF?
How do you decide?
Consider anticoagulation to reduce risk of CVA in:
- All rate control strategies
- Rhythm control prior to cardioversion
Decision: CHADs-VASc score
Why should you consider anticoagulation in the treatment of AF?
In all rate control strategies (and prior to cardioversion), switches from AF to sinus rhythm presents the highest risk for embolism.
> Patients must either have had a short duration of symptoms (less than 48 hours) or be anti coagulated for a period of time prior to attempting cardioversion.
What does the CHAD-VASc score predict?
The risk of stroke in a patient with AF.
What are the components of the CHADs-VASc Score?
Congestive Heart Failure Hypertension (>140/90) Age > 75 Diabetes Mellitus Prior TIA or Stroke Vascular disease (MI, Aortic plaque) Age 65-74 Sex category (Female = 1 point)
A male patient scores 1 on the CHADs-VASc risk score. What should you do?
Consider anticoagulation
A patient scores 2+ on the CHADs-VASc risk score. What should you do?
- Offer anticoagulation (NOAC / Warfarin)
What is the therapeutic range for an INR of a pt on Warfarin?
2- 3
List some examples of NOACs.
- Apixaban
- Dabigatran
- Rivaroxaban
What is the HAS-BLED score?
1 year risk of major bleeding in patients taking anticoagulants with AF.
What are the components of the HAS-BLED score?
H: HTN A: Abnormal renal / liver function S: Stroke, Hx of B: Bleeding, Hx of L: Labile INRs E: Elderly (>65y) D: Drugs predisposing to bleeding (anti platelet agents, NSAIDs)
How do people with heart failure present?
- Breathlessness
- Ankle swelling
- Fatigue
> progressive + worsening
What is the NICE pathway for Heart Failure?
- Has the patient had a previous MI?
- Yes -> Urgent Transthoracic Echo (TTE)
- No -> measure serum BNP
> Above 4000pg/ml -> urgent TTE
> 100 - 4000pg/ml -> TTE within 6 weeks
You suspect a patient is in heart failure. What investigations should you do?
- 12 lead ECG
- CXR
- Bloods
- Urinalysis
- Peak flow / spirometry
What would you look for on an ECG if a patient was in ?heart failure?
- Ischaemia
- Hypertrophy
What would you see on a CXR if a patient had heart failure?
- Alveolar oedema (Bat’s wings)
- Kerley B lines
- Cardiomegaly
- Upper lobe diversion
- Pleural effusion
Which bloods should you order if you suspect Heart Failure?
- FBC
- U+Es
- LFTs
- TFTs
- eGFR
- Lipid profile
- Glucose
When should a person with heart failure be referred to the MDT?
- First diagnosis
- Severe cases
- Failure to manage in primary care
- Co-morbid valvular disease
- Consider referral to palliative services -> prognosis worse than most cancers
- Screen for depression at diagnosis
Describe Stage 1 of the NYHA classification of Heart Failure.
No symptoms or limitation to daily activities
Describe Stage 2 of the NYHA classification of Heart Failure.
Mild symptoms and slight limitation of daily activities
Describe Stage 3 of the NYHA classification of Heart Failure.
Marked symptoms, limitation on daily activities, only comfortable at rest
Describe Stage 4 of the NYHA classification of Heart Failure.
Severe symptoms, uncomfortable at rest.
What is the 1st line management for Heart Failure?
ACEi + Beta blocker
> When starting ACEi, measure U+Es, eGFR
What is the 2nd line management for Heart Failure?
- Refer!
- If NYHA 3/4 in the last month, begin Spironolactone
- ARB may be used in unresponsive cases
- Hydralazine with Nitrate may be of particular use in Afro-Caribbean patients
What is the 3rd line management for Heart Failure?
- Digoxin
- Ivabradine
Beyond the initial medical management of Heart Failure, what else should you consider?
- Yearly flu vaccine, pneumococcal vaccine
- Manage ischaemic / valvular co-morbidity
- Consider defibrillator if arrhythmic
- Advance care planning
Who is involved in the management of a patient with Heart failure in the community?
- GP
- ANPs
- District Nurses
- Third sector (BHF)
- Family
- Counselling
- Palliative services
- Community Mental Health Teams
Describe the presentation of (stable) angina pectoris.
- Constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
- Precipitated by physical exertion
- Relieved by rest on GTN in about 5 minutes
3/3 = typical anginal pain 2/3 = atypical anginal pain 1/3 = non-anginal chest pain
A pt has Angina Pectoris. What should you consider?
- Identify cardiovascular risk factors
- Look for signs of other cardiovascular disease
- Exclude non-coronary causes of angina / other causes of chest pain
List some factors which make anginal chest pain a less likely diagnosis.
- Continuous or very prolonged pain
- Unrelated to activity
- Brought on by breathing in
- Associated with dizziness, palpitations, tingling or difficulty swallowing
What are the 2 aspects of treatment for angina pectoris?
- Symptom control (eg. GTN, b-blockers, rate-limiting CCB)
2. Prevention of ACS (all patients should receive aspirin and a statin in the absence of any contraindication)
Why should beta blockers not be prescribed concurrently with verapamil?
Risk of complete heart block
What is the 1st line treatment for Angina relief?
- Short acting Nitrates plus:
- B-blockers or CCB
What is the 2nd line treatment for Angina relief?
- Long acting nitrates
- Nicorandil
- Ranolazine
- Trimetazidine
What 1st line advice should you give patients with Angina?
- Lifestyle management
- Control of risk factors
- Educate the patient
How does Ivabradine work?
- New class of anti-anginal drug; works by reducing the heart rate
- Acts on the ‘funny’ ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity adverse effects
> luminous phenomena
> visual effects
Headache + bradycardia may be seen, due to the mechanism of action.
List the symptoms of COPD.
- SOBOE
- Chronic cough with sputum
- Wheeze
- Bronchitis
- Apnoea
- Fatigue
- Weight loss
- Haemoptysis
- Recurrent infections
How is COPD diagnosed?
Spirometry. Perform spirometry if: - Older than 35yrs - Current or ex-smoker - Chronic cough
What is the key measure in diagnosis of COPD?
FEV1 to FVC ratio
A person with COPD is ‘GOLD Scale = 1’. What is their FEV1 to FVC ratio?
(GOLD = global initiative for obstructive lung disease)
Greater than 0.8 (Mild)
A person with COPD is ‘GOLD Scale = 2’. What is their FEV1 to FVC ratio?
0.5 - 0.79 (Moderate)
A person with COPD is ‘GOLD Scale = 3’. What is their FEV1 to FVC ratio?
0.3 - 0.49 (Severe)
A person with COPD is ‘GOLD Scale = 4’. What is their FEV1 to FVC ratio?
<0.3 (Very severe)
Describe the Medical Research Council Scale for SOB (1 - 5)
1 - With strenuous activity 2 - With vigorous walking 3 - With normal walking (level at which NICE recommends rehab) 4 - After walking for several minutes 5 - On changing clothing
What are the 4 steps for early management of COPD?
- Pulmonary rehab
- Aim for BMI 20 -25
- Stop smoking
- Vaccinations (Yearly flu and pneumococcal)
Describe the management of Acute exacerbations of COPD.
- Increase bronchodilator use
- Steroid (no Abx unless positive sputum sample)
> common organisms: H. influenzae, S. pneumoniae, Maroxella catarrhalis
Describe the management of chronic COPD.
- SABA +/- short acting anti-muscarinic
- LABA +/- long acting anti-muscarinic
- Long term oxygen therapy
Describe the pathophysiology of T1DM
Autoimmune destruction of insulin-producing beta cells of pancreatic Islets of Langerhans -> absolute insulin deficiency
Describe the pathophysiology of T2DM.
Diminished effectiveness of endogenous insulin / insulin resistance
How do patients with T1DM present?
- Weight loss
- Polydipsia
- Polyuria
- Acutely unwell -> DKA
How do patients with T2DM present?
- Incidental finding
- Polydipsia
- Polyuria
How might a patient in DKA present?
- Abdominal pain
- Vomiting
- Reduced consciousness level
How is diabetes mellitus diagnosed?
Symptomatic patient:
- Fasting glucose > 7.0 mmol/l
- Random blood glucose > 11.1 mmol/l (or after 75g OGTT)
- HbA1c >48 (6.5%)
Asymptomatic patient:
- one of the above must be demonstrated on 2 separate occasions.
If HbA1c is under 6.5%, it does not exclude DM. Why?
- Not as sensitive a test as FBG
- Results can be misleading in conditions where there is increased RBC turnover
What are the blood sugar levels of someone with pre-diabetes?
- 1 - 6.9 mmol/l
- Pts should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes.
What are the blood sugar levels of someone with Impaired Glucose Tolerance?
- 8 - 11.0 mmol/l
- > indicates the person doesn’t have diabetes, but does have impaired glucose tolerance.
Describe Type 1 diabetes management.
- Individual care plan
- Insulin: short and long acting insulin (Novorapid boluses + Detemir BD)
- Annual reviews: BP, renal function, eye check, foot check
- Target HbA1c <48mmol/mol
Describe Type 2 diabetes management.
- Blood glucose control
- Monitor + treat microvascular complications
- Modify RF for CVD - BP, lipids
What is the target BP for someone with T2DM?
140/80
or 130/80 if end organ damage
Use ACEi
If a diabetic has a QRISK greater than 10%, what medication should they commence?
20mg Atorvastatin ON
-> If known IHD/CVD, Atorvastatin 80mg
List some examples of lifestyle interventions for type 2 diabetes.
- Dietary advice
- Smoking cessation
- 5-10% initial weight loss (if overweight)
What dietary advice should you give to a T2DM patient?
- High fibre
- Low GI carbohydrates
- Control saturated fats intake
- Include low-fat dairy products and oily fish in diet
A T2DM patient’s HbA1c is above 48. Which drug should you start? What class of drug is this?
Metformin -> drug class = biguanide
What are the side effects of Metformin?
- GI upset
- Risk of lactic acidosis if impaired renal function
What are the benefits of Metformin?
- Weight neutral
- No risk of hypoglycaemia
What is the mechanism of action of Metformin?
- Increases insulin sensitivity, hepatic gluconeogenesis and GI absorption of carbohydrates
Give a contraindication to using Metformin.
Recent tissue hypoxia -> CT contrast within 48hrs
What is the HbA1c target if a patient is on dual therapy?
53
What medications are used for ‘dual therapy’ for T2DM?
Metformin + Sulfonylurea / DPP4 / SGLT2 / Pioglitazone
Sulfonylureas (eg. gliclazide) can be used in the treatment of T2DM. List some side effects.
- Weight gain
- Hypoglycaemia
- SIADH
- Peripheral neuropathy
Sulfonylureas (eg. gliclazide) can be used in the treatment of T2DM. What is the criterion to sulfonylureas being effective treatment?
Sulfonylureas are only effective if some functioning beta cells are present.
-> bind to beta cell receptors and stimulate insulin release
Sulfonylureas (eg. gliclazide) can be used in T2DM treatment. List 2 contraindications.
- Pregnancy
- Breastfeeding
Pioglitazone can be used in T2DM. List 3 side effects.
- Weight gain
- Fracture risk
- Bladder cancer
If a patient is taking Pioglitazone for T2DM, what monitoring do they require?
LFT monitoring
When is Pioglitazone (for T2DM) contraindicated?
Heart failure (fluid retention)
What is the mechanism of Pioglitazone in T2DM treatment?
- PPARgamma receptor agonist
- increases adipogenesis and improves insulin sensitivity
Give examples of the SGLT2 inhibitors used in T2DM.
‘Flozins’
- Dapagliflozin
- Canagliflozin
List 3 side effects of SGLT2 inhibitors (used to treat T2DM).
- UTI
- Thrush
- Euglycaemic ketoacidosis
Do SGLT2 inhibitors (T2DM treatment) causes the patient to lose weight or to gain weight?
Lose weight
Explain the mechanism of SGLT2 inhibitors in T2DM.
SGLT2 inhibitors block renal absorption of glucose.
Give 2 examples of the DPP4 inhibitors (for T2DM treatment).
‘Gliptins’
- Sitagliptin
- Vildagliptin
Describe the mechanism of DPP4 inhibitors in the treatment of T2DM.
DPP4 inhibitors prevents GLP1 degradation and therefore inhibits glucagon secretion.
What happens to your weight when you’re on a DPP4 inhibitor (eg. Sitagliptin) for T2DM?
Weight stays the same
Is there a risk of hypoglycaemia when taking DPP4 inhibitors (Sitagliptin) for T2DM?
No
When should you consider insulin therapy in a T2DM patient?
When triple therapy is not tolerated or is ineffective.
What should you do if triple therapy is ineffective / not tolerated in a T2DM patient?
If BMI is above 35: Insulin therapy
If BMI is below 35: GLP1 agonist eg. Exenatide
Exenatide is used for T2DM. What class of drug is it?
GLP1 mimetics
Explain the mechanism of action of Exenatide (GLP1 mimetic used for T2DM).
- Preserves beta cells
- Increases insulin secretion
- Inhibits glucagon
Exenatide is a GLP1 mimetic used for T2DM. List some:
i. Side effects
ii. Contraindications
i. SE: Nausea / vomiting; severe pancreatitis
ii. CI: Breastfeeding, pregnancy
Exenatide is a GLP1 mimetic used for T2DM. Does it cause weight loss or weight gain?
Weight loss
List 3 side effects of insulin.
- Weight gain
- Hypoglycaemia
- Lipodystrophy
Describe possible insulin regimes.
- Basal
- Overnight NPH insulin eg. Humulin 1
List some risk factors for CKD.
- HTN
- Diabetes Mellitus
- RAS (Renal Artery Stenosis)
- Glomerulonephritis
- SLE
- Adult PKD (polycystic kidney disease)
When can you diagnose CKD in Stages 1 + 2?
If abnormal U+E, proteinuria, or haematuria
-> evidence of renal damage
What should you consider when managing CKD?
- Treat reversible causes (eg. obstruction)
- Limit progression / complications -> target BP = 130/80
- Symptom control -> anaemia, oedema, restless legs
- Refer to nephrology when eGFR < 30
Decreased eGFR is an independent risk factor for CVD. What meds should you offer to patients with CKD?
- Statin
- Antiplatelet
What dietary advice should you give to a patient with CKD?
Avoid foods with high potassium and phosphate
A 73yo lade is currently on Lisinopril and Felodipine. Her clinic and ABPM are consistently >150/90. What should be added next?
Thiazide-like diuretic
eg. Indapamide
Name 2 groups of medications that can be used for rate control in AF and an example of each?
- Beta blocker (any apart from Sotalol).
- Rate limiting CCB (diltiazem)
- Cardiac glycoside (digoxin)
What agent reverses the actions of Warfarin?
Vitamin K
What agent reverses the actions of a NOAC?
Beriplex
Interpret this ABG: 65yo male, brought into A+E with an exacerbation of COPD. On 28% Oxygen via a simple face mask. pH = 7.35 PaO2 = 7.3 PaCO2 = 11.2 HCO3 = 36.0
Type 2 respiratory failure
- > chronic
- > because the bicarbonate has increased.
What oxygen saturations are the target for COPD patients on Oxygen therapy?
88 - 92%
Three things that require an annual review in a diabetic patient?
- Renal function
- HbA1c
- BP
- Eyes
- Feet
If an asymptomatic patient has an incidental random plasma glucose test done with a result of 12, what does the result of his GTT have to be to be diagnosed as diabetic?
> 11.1
