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Dan's Copy > GP Peer Teaching > Flashcards

GP Peer Teaching Flashcards

1
Q

Describe the NICE pathway on Hypertension.

A
  • First interaction >140/90
  • To avoid white coat syndrome:
    > ABPM
    > Home BP monitoring
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2
Q

What are the parameters for stage 1 HTN?

A

ABPM / HBPM BP >135/85

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3
Q

What are the parameters for stage 2 HTN?

A

ABPM / HBPM BP > 150/95

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4
Q

What are the parameters for Severe HTN?

A

Systolic > 180

Diastolic > 110

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5
Q

Any patient with Stage 1 HTN plus comorbidities should be treated as Stage 2 HTN.
List some examples of these comorbidities.

A
  • End organ damage (ECG, U+Es, Haematuria, Fundoscopy)
  • Established CVD
  • Diabetes
  • Renal pathology
  • 10 year CVD risk >20% (according to QRISK-2)
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6
Q

How should Stage 1 HTN be managed?

A

LIFESTYLE MODIFICATIONS!!!

  • Smoking cessation
  • Exercise
  • Improve diet
  • Reduce alcohol intake
  • Engage in relaxation
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7
Q

What is the 1st line treatment for Stage 2 HTN in a person under 55 years?

A

ACEi

eg. Ramipril, Lisinopril

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8
Q

What is the 1st line treatment for Stage 2 HTN in a person over 55 years OR Afro-Caribbean origin?

A

Calcium Channel Blocker

eg. Amlodipine, Verapamil

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9
Q

What is the 2nd line treatment for Stage 2 HTN if a person is under 55y and already on an ACEi?

A

Add Calcium Channel Blocker (Amlodipine, Verapamil)

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10
Q

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?

A

ACEi

eg. Ramipril, Lisinopril

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11
Q

What is the 3rd line treatment for Stage 2 HTN?

this is the same for under and over 55s and for Afro-Caribbeans

A

Add a thiazide-like diuretic

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12
Q

What is the 4th line treatment for Stage 2 HTN if a pt’s Potassium is below 4.5mmol/l?

A

Spironolactone

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13
Q

What is the 4th line treatment for Stage 2 HTN if a pt’s Potassium is above 4.5mmol/l?

A

Increase dose of thiazide-like diuretic

eg. Indapamide

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14
Q

What is the 5th line treatment for Stage 2 HTN?

A

“Refer for expert advice” (!)

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15
Q

List 2 conditions which can give an irregular pulse.

A
  • Atrial Fibrillation
  • Ventricular ectopics
  • Sinus arrhythmia
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16
Q

What would you see on an ECG which would indicate AF?

A
  • Absent P waves

- Irregularly irregular QRS

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17
Q

List some risk factors for AF.

A
  • HTN
  • Coronary artery disease
  • Valvular heart disease
  • Sepsis
  • Alcohol
  • PE
  • Thyrotoxicosis
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18
Q

How common is AF in the over 80s?

A

1 in 4 over 80yo have AF.

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19
Q

Define ‘Persistent AF’.

A
  • Not self terminating
  • Lasting longer than 7 days, or prior cardioversion
  • Persistent AF may degenerate into permanent AF
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20
Q

Define ‘Acute AF’.

A

Onset within 48hours.

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21
Q

How would you manage a haemodynamically stable patient who is in AF?

A
  • 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
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22
Q

When treating AF, what is the aim of rate control?

Which medications might be used?

A

To reduce the myocardial metabolic demands

Meds:
> B blocker (Atenolol)
> Rate limiting CCB (Diltiazem)

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23
Q

When treating AF, what is the aim of rhythm control?

Which medications might be used?

A

To regain sinus rhythm

Meds:
> IV Amiodarone or PO/IV Fleicanide
> Digoxin for sedentary elderly patients as rate control

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24
Q

What ‘worrying features’ should you look out for in a patient with AF?

A
  • Heart failure
  • Decreased BP
  • Chest pain
  • Decreased GCS
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25
Q

If a patient with AF is haemodynamically unstable, what treatment should you commence?

A
  • Oxygen

- DCCV (Direct Current Cardioversion)

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26
Q

When should you consider anticoagulation in AF?

How do you decide?

A

Consider anticoagulation to reduce risk of CVA in:

  • All rate control strategies
  • Rhythm control prior to cardioversion

Decision: CHADs-VASc score

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27
Q

Why should you consider anticoagulation in the treatment of AF?

A

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.

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28
Q

What does the CHAD-VASc score predict?

A

The risk of stroke in a patient with AF.

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29
Q

What are the components of the CHADs-VASc Score?

A 
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)
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30
Q

A male patient scores 1 on the CHADs-VASc risk score. What should you do?

A

Consider anticoagulation

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31
Q

A patient scores 2+ on the CHADs-VASc risk score. What should you do?

A
  • Offer anticoagulation (NOAC / Warfarin)
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32
Q

What is the therapeutic range for an INR of a pt on Warfarin?

A

2- 3

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33
Q

List some examples of NOACs.

A
  • Apixaban
  • Dabigatran
  • Rivaroxaban
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34
Q

What is the HAS-BLED score?

A

1 year risk of major bleeding in patients taking anticoagulants with AF.

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35
Q

What are the components of the HAS-BLED score?

A 
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)
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36
Q

How do people with heart failure present?

A
  • Breathlessness
  • Ankle swelling
  • Fatigue
    > progressive + worsening
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37
Q

What is the NICE pathway for Heart Failure?

A
  • 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
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38
Q

You suspect a patient is in heart failure. What investigations should you do?

A
  • 12 lead ECG
  • CXR
  • Bloods
  • Urinalysis
  • Peak flow / spirometry
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39
Q

What would you look for on an ECG if a patient was in ?heart failure?

A
  • Ischaemia

- Hypertrophy

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40
Q

What would you see on a CXR if a patient had heart failure?

A
  • Alveolar oedema (Bat’s wings)
  • Kerley B lines
  • Cardiomegaly
  • Upper lobe diversion
  • Pleural effusion
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41
Q

Which bloods should you order if you suspect Heart Failure?

A
  • FBC
  • U+Es
  • LFTs
  • TFTs
  • eGFR
  • Lipid profile
  • Glucose
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42
Q

When should a person with heart failure be referred to the MDT?

A
  • 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
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43
Q

Describe Stage 1 of the NYHA classification of Heart Failure.

A

No symptoms or limitation to daily activities

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44
Q

Describe Stage 2 of the NYHA classification of Heart Failure.

A

Mild symptoms and slight limitation of daily activities

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45
Q

Describe Stage 3 of the NYHA classification of Heart Failure.

A

Marked symptoms, limitation on daily activities, only comfortable at rest

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46
Q

Describe Stage 4 of the NYHA classification of Heart Failure.

A

Severe symptoms, uncomfortable at rest.

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47
Q

What is the 1st line management for Heart Failure?

A

ACEi + Beta blocker

> When starting ACEi, measure U+Es, eGFR

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48
Q

What is the 2nd line management for Heart Failure?

A
  • 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
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49
Q

What is the 3rd line management for Heart Failure?

A
  • Digoxin

- Ivabradine

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50
Q

Beyond the initial medical management of Heart Failure, what else should you consider?

A
  • Yearly flu vaccine, pneumococcal vaccine
  • Manage ischaemic / valvular co-morbidity
  • Consider defibrillator if arrhythmic
  • Advance care planning
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51
Q

Who is involved in the management of a patient with Heart failure in the community?

A
  • GP
  • ANPs
  • District Nurses
  • Third sector (BHF)
  • Family
  • Counselling
  • Palliative services
  • Community Mental Health Teams
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52
Q

Describe the presentation of (stable) angina pectoris.

A
  • 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
53
Q

A pt has Angina Pectoris. What should you consider?

A
  • Identify cardiovascular risk factors
  • Look for signs of other cardiovascular disease
  • Exclude non-coronary causes of angina / other causes of chest pain
54
Q

List some factors which make anginal chest pain a less likely diagnosis.

A
  • Continuous or very prolonged pain
  • Unrelated to activity
  • Brought on by breathing in
  • Associated with dizziness, palpitations, tingling or difficulty swallowing
55
Q

What are the 2 aspects of treatment for angina pectoris?

A
  1. 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)

56
Q

Why should beta blockers not be prescribed concurrently with verapamil?

A

Risk of complete heart block

57
Q

What is the 1st line treatment for Angina relief?

A
  • Short acting Nitrates plus:

- B-blockers or CCB

58
Q

What is the 2nd line treatment for Angina relief?

A
  • Long acting nitrates
  • Nicorandil
  • Ranolazine
  • Trimetazidine
59
Q

What 1st line advice should you give patients with Angina?

A
  • Lifestyle management
  • Control of risk factors
  • Educate the patient
60
Q

How does Ivabradine work?

A
  • 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.

61
Q

List the symptoms of COPD.

A
  • SOBOE
  • Chronic cough with sputum
  • Wheeze
  • Bronchitis
  • Apnoea
  • Fatigue
  • Weight loss
  • Haemoptysis
  • Recurrent infections
62
Q

How is COPD diagnosed?

A 
Spirometry.
Perform spirometry if:
- Older than 35yrs 
- Current or ex-smoker
- Chronic cough
63
Q

What is the key measure in diagnosis of COPD?

A

FEV1 to FVC ratio

64
Q

A person with COPD is ‘GOLD Scale = 1’. What is their FEV1 to FVC ratio?

(GOLD = global initiative for obstructive lung disease)

A

Greater than 0.8 (Mild)

65
Q

A person with COPD is ‘GOLD Scale = 2’. What is their FEV1 to FVC ratio?

A

0.5 - 0.79 (Moderate)

66
Q

A person with COPD is ‘GOLD Scale = 3’. What is their FEV1 to FVC ratio?

A

0.3 - 0.49 (Severe)

67
Q

A person with COPD is ‘GOLD Scale = 4’. What is their FEV1 to FVC ratio?

A

<0.3 (Very severe)

68
Q

Describe the Medical Research Council Scale for SOB (1 - 5)

A 
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
69
Q

What are the 4 steps for early management of COPD?

A
  • Pulmonary rehab
  • Aim for BMI 20 -25
  • Stop smoking
  • Vaccinations (Yearly flu and pneumococcal)
70
Q

Describe the management of Acute exacerbations of COPD.

A
  • Increase bronchodilator use
  • Steroid (no Abx unless positive sputum sample)
    > common organisms: H. influenzae, S. pneumoniae, Maroxella catarrhalis
71
Q

Describe the management of chronic COPD.

A
  • SABA +/- short acting anti-muscarinic
  • LABA +/- long acting anti-muscarinic
  • Long term oxygen therapy
72
Q

Describe the pathophysiology of T1DM

A

Autoimmune destruction of insulin-producing beta cells of pancreatic Islets of Langerhans -> absolute insulin deficiency

73
Q

Describe the pathophysiology of T2DM.

A

Diminished effectiveness of endogenous insulin / insulin resistance

74
Q

How do patients with T1DM present?

A
  • Weight loss
  • Polydipsia
  • Polyuria
  • Acutely unwell -> DKA
75
Q

How do patients with T2DM present?

A
  • Incidental finding
  • Polydipsia
  • Polyuria
76
Q

How might a patient in DKA present?

A
  • Abdominal pain
  • Vomiting
  • Reduced consciousness level
77
Q

How is diabetes mellitus diagnosed?

A

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.

78
Q

If HbA1c is under 6.5%, it does not exclude DM. Why?

A
  • Not as sensitive a test as FBG

- Results can be misleading in conditions where there is increased RBC turnover

79
Q

What are the blood sugar levels of someone with pre-diabetes?

A
  1. 1 - 6.9 mmol/l

- Pts should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes.

80
Q

What are the blood sugar levels of someone with Impaired Glucose Tolerance?

A
  1. 8 - 11.0 mmol/l

- > indicates the person doesn’t have diabetes, but does have impaired glucose tolerance.

81
Q

Describe Type 1 diabetes management.

A
  • 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
82
Q

Describe Type 2 diabetes management.

A
  1. Blood glucose control
  2. Monitor + treat microvascular complications
  3. Modify RF for CVD - BP, lipids
83
Q

What is the target BP for someone with T2DM?

A

140/80
or 130/80 if end organ damage
Use ACEi

84
Q

If a diabetic has a QRISK greater than 10%, what medication should they commence?

A

20mg Atorvastatin ON

-> If known IHD/CVD, Atorvastatin 80mg

85
Q

List some examples of lifestyle interventions for type 2 diabetes.

A
  • Dietary advice
  • Smoking cessation
  • 5-10% initial weight loss (if overweight)
86
Q

What dietary advice should you give to a T2DM patient?

A
  • High fibre
  • Low GI carbohydrates
  • Control saturated fats intake
  • Include low-fat dairy products and oily fish in diet
87
Q

A T2DM patient’s HbA1c is above 48. Which drug should you start? What class of drug is this?

A

Metformin -> drug class = biguanide

88
Q

What are the side effects of Metformin?

A
  • GI upset

- Risk of lactic acidosis if impaired renal function

89
Q

What are the benefits of Metformin?

A
  • Weight neutral

- No risk of hypoglycaemia

90
Q

What is the mechanism of action of Metformin?

A
  • Increases insulin sensitivity, hepatic gluconeogenesis and GI absorption of carbohydrates
91
Q

Give a contraindication to using Metformin.

A

Recent tissue hypoxia -> CT contrast within 48hrs

92
Q

What is the HbA1c target if a patient is on dual therapy?

A

53

93
Q

What medications are used for ‘dual therapy’ for T2DM?

A

Metformin + Sulfonylurea / DPP4 / SGLT2 / Pioglitazone

94
Q

Sulfonylureas (eg. gliclazide) can be used in the treatment of T2DM. List some side effects.

A
  • Weight gain
  • Hypoglycaemia
  • SIADH
  • Peripheral neuropathy
95
Q

Sulfonylureas (eg. gliclazide) can be used in the treatment of T2DM. What is the criterion to sulfonylureas being effective treatment?

A

Sulfonylureas are only effective if some functioning beta cells are present.
-> bind to beta cell receptors and stimulate insulin release

96
Q

Sulfonylureas (eg. gliclazide) can be used in T2DM treatment. List 2 contraindications.

A
  • Pregnancy

- Breastfeeding

97
Q

Pioglitazone can be used in T2DM. List 3 side effects.

A
  • Weight gain
  • Fracture risk
  • Bladder cancer
98
Q

If a patient is taking Pioglitazone for T2DM, what monitoring do they require?

A

LFT monitoring

99
Q

When is Pioglitazone (for T2DM) contraindicated?

A

Heart failure (fluid retention)

100
Q

What is the mechanism of Pioglitazone in T2DM treatment?

A
  • PPARgamma receptor agonist

- increases adipogenesis and improves insulin sensitivity

101
Q

Give examples of the SGLT2 inhibitors used in T2DM.

A

‘Flozins’

  • Dapagliflozin
  • Canagliflozin
102
Q

List 3 side effects of SGLT2 inhibitors (used to treat T2DM).

A
  • UTI
  • Thrush
  • Euglycaemic ketoacidosis
103
Q

Do SGLT2 inhibitors (T2DM treatment) causes the patient to lose weight or to gain weight?

A

Lose weight

104
Q

Explain the mechanism of SGLT2 inhibitors in T2DM.

A

SGLT2 inhibitors block renal absorption of glucose.

105
Q

Give 2 examples of the DPP4 inhibitors (for T2DM treatment).

A

‘Gliptins’

  • Sitagliptin
  • Vildagliptin
106
Q

Describe the mechanism of DPP4 inhibitors in the treatment of T2DM.

A

DPP4 inhibitors prevents GLP1 degradation and therefore inhibits glucagon secretion.

107
Q

What happens to your weight when you’re on a DPP4 inhibitor (eg. Sitagliptin) for T2DM?

A

Weight stays the same

108
Q

Is there a risk of hypoglycaemia when taking DPP4 inhibitors (Sitagliptin) for T2DM?

A

No

109
Q

When should you consider insulin therapy in a T2DM patient?

A

When triple therapy is not tolerated or is ineffective.

110
Q

What should you do if triple therapy is ineffective / not tolerated in a T2DM patient?

A

If BMI is above 35: Insulin therapy

If BMI is below 35: GLP1 agonist eg. Exenatide

111
Q

Exenatide is used for T2DM. What class of drug is it?

A

GLP1 mimetics

112
Q

Explain the mechanism of action of Exenatide (GLP1 mimetic used for T2DM).

A
  • Preserves beta cells
  • Increases insulin secretion
  • Inhibits glucagon
113
Q

Exenatide is a GLP1 mimetic used for T2DM. List some:

i. Side effects
ii. Contraindications

A

i. SE: Nausea / vomiting; severe pancreatitis

ii. CI: Breastfeeding, pregnancy

114
Q

Exenatide is a GLP1 mimetic used for T2DM. Does it cause weight loss or weight gain?

A

Weight loss

115
Q

List 3 side effects of insulin.

A
  • Weight gain
  • Hypoglycaemia
  • Lipodystrophy
116
Q

Describe possible insulin regimes.

A
  • Basal

- Overnight NPH insulin eg. Humulin 1

117
Q

List some risk factors for CKD.

A
  • HTN
  • Diabetes Mellitus
  • RAS (Renal Artery Stenosis)
  • Glomerulonephritis
  • SLE
  • Adult PKD (polycystic kidney disease)
118
Q

When can you diagnose CKD in Stages 1 + 2?

A

If abnormal U+E, proteinuria, or haematuria

-> evidence of renal damage

119
Q

What should you consider when managing CKD?

A
  • Treat reversible causes (eg. obstruction)
  • Limit progression / complications -> target BP = 130/80
  • Symptom control -> anaemia, oedema, restless legs
  • Refer to nephrology when eGFR < 30
120
Q

Decreased eGFR is an independent risk factor for CVD. What meds should you offer to patients with CKD?

A
  • Statin

- Antiplatelet

121
Q

What dietary advice should you give to a patient with CKD?

A

Avoid foods with high potassium and phosphate

122
Q

A 73yo lade is currently on Lisinopril and Felodipine. Her clinic and ABPM are consistently >150/90. What should be added next?

A

Thiazide-like diuretic

eg. Indapamide

123
Q

Name 2 groups of medications that can be used for rate control in AF and an example of each?

A
  • Beta blocker (any apart from Sotalol).
  • Rate limiting CCB (diltiazem)
  • Cardiac glycoside (digoxin)
124
Q

What agent reverses the actions of Warfarin?

A

Vitamin K

125
Q

What agent reverses the actions of a NOAC?

A

Beriplex

126
Q 
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
A

Type 2 respiratory failure

  • > chronic
  • > because the bicarbonate has increased.
127
Q

What oxygen saturations are the target for COPD patients on Oxygen therapy?

A

88 - 92%

128
Q

Three things that require an annual review in a diabetic patient?

A
  • Renal function
  • HbA1c
  • BP
  • Eyes
  • Feet
129
Q

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?

A

> 11.1

Dan's Copy (19 decks)

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