Oxford summary 2 Flashcards
1
Q
Abnormal ABPM
A
Average day time ≥135/85
Average night-time ≥120/70
2
Q
HTN causes
A
- Essential/ unknown- alcohol, obesity
- Renal disease
- Endocrine disease- cushings, conns, Phaeochromocytoma, acromegaly, hyperparathyroidism
- Pregnancy
- Coaractation of aorta
3
Q
HTN assessment
A
Examination: heart size, Heart Sound, heart failure examine fundi for silver wiring, AV nipping, flame haemorrhage, cotton wool spots
Blood tests: creatinine, U&E, eGFR, HbA1c, lipid profile
Urine: RBC and protein and albumin: creatine ratio
Cardiovascular risk estimation
ECG ± echo if LVH
4
Q
HTN Dx stages
A
Stage 1: clinic ≥140/90 and av daytime ≥135/85
Stage 2: clinic ≥160/100 and av daytime ≥150/95
Severe: clinic systolic ≥180 or diastolic ≥110
5
Q
HTN Tx
step 1
if under 55
A
ACEi
ARBs
6
Q
HTN Tx
step 1
if over 55 or AA
A
Ca Channel blocker
Thiazide
7
Q
HTN Tx
step 2
A
ACEI
ARB
Ca channel blocker
thiazide
8
Q
HTN Tx
step 3
A
ACEI + CCB + Thiazide
9
Q
HTN Tx
step 4
Resistant HTN
A
Spironolactone 25mg od if K under 4.5 mmol/L
Thiazide if K over 4.5 mmol/
A or B blocker
10
Q
Hyperlipidemia drug causes
A
- Steroids
- BB, thiazides
- OCP, Tamoxifen
- Isotretinonin
- Antipsychotics
- Antiretrovirals
11
Q
Before starting statins
A
Bloods
Fasting total cholesterol, LDL, HDL, TG
Fasting blood glucose
LFT, renal function, TSH
12
Q
statin doses hyperlipidemia
A
Simvastatin 40mg
or
atorvastatin 20mg
13
Q
Statin SE:
A
Myositis: muscle pain/ weakness
Peripheral neuropathy
Abnormal LF
14
Q
Statins contraindicated in
A
pregnancy, breastfeeding, acute liver disease (AST/ALT >3x normal)
15
Q
Statin drug interactions
A
increased warfarin effect
increased mysositis when with lipid- lowering drugs,
Erythromycin, CCB, ciclopsorin
16
Q
Polygenic hypercholesterolaemia:
A
FH premature CHD + total cholesterol >6.5mmol/L
17
Q
Familial combined hyperlipidemia:
A
a/w obesity, IR, FM, HT, xanthelasma, corneal arcus, premature IHD.
Total cholesterol 6.5-10, TG 2.3- 12
18
Q
Familial hypercholesterolemia type IIa: AD
A
o Tendon xanthomata and FH premature IHD
o LDL >4.9, total >7.5 and normal TG
19
Q
Familial hypertriglyceridemia type IV/V: AD
A
A/w obesity, DM, gout, eruptive xanthomas, pancreatitis
Normal/ slightly total cholesterol, TG 2-3->10
20
Q
Angina causes
A
CAD HOCM valve disease hypoperfusion during arrhythmia arteritis anaemia thyrotoxicosis
21
Q
stable angina investigations
A
- Bloods: FBC, lipids, fasting blood glucose, ESR, TFT
* 12- lead ECG
22
Q
stable angina drug tx
A
As required: GTN spray. SE- flushing, headache, lightheadedness
Regular treatment:
1. Β-blocker or CCB
2. Long- acting nitrates, ivabradine, nicrorandil, ranolazine
• Monotherapy or in combination with first-line
Secondary prevention
• Aspirin 75mg or clopidogrel 75mg
• Statin
ACEI
23
Q
stable angina surgical tx
A
• CABG or PCI
• If not controlled with 2 drugs
CABG better if DM, >65, LAD, 3 vessel disease
24
Q
unstable angina Management:
A
refer to cardiology,
admission if severe,
at rest or >10min even with GTN
25
Dihydropyridine CCB:
eg
Contraindications:
amlodipine, delodipine
AS,
<1month post MI, uncontrolled HF
26
Rate- limiting CCB:
eg
Contraindications:
diltiazem, verapamil
HB or HF
Don’t combine with BB
27
Cardiac syndrome X
what is it
tx
angina despite normal angiogram = microvascular angina
BB ± CCB
28
Β-blocker:
can accumulate in renal disease
Monitor HR- resting ≤65, post-exercise ≤90 (indicates successful beta blockade)
Warn to not stop suddenly-taper off over 4 weeks
Asthma/ COPD: use atenolol, bisoprolol, metoprolol, nebivolol- cardio-selective (usually start from A-M)
LVH: start at low dose and increase
29
Long acting nirates: isosorbide mononitrate (ISMO)
Oral and patch ≥10mg/24hrs
SE
Tolerance
Contraindications
SE: headache, postural hypotension, dizziness, reflex tachy= decrease coronary BF worsen angina
Tolerance develops rapidly- nitrate- free period 4-8hrs overnight by removing patch or give 2nd dose at 4pm
HOCM, AS, constrictive pericarditis, MS, severe anemia, closed- angle glaucoma
30
Potassium channel activator: nicorandil (venous vasodilator)
SE:
Contraindications:
headache
| LVF, hypotension
31
Ivabradine
Lower HR by acting at sinus node
Contraindications:
HR <60, HB, HF
32
Ranolazine: sodium-dependent calcium channels
Contraindications:
RenalF, LiverF, caution with CCF and weight <60kg
33
Drugs after an MI
ACEI: decrease myocardial work
Antiplatelet: aspirin 75mg od for life
Add clopidogrel 75mg od:
• For 12 months if NSTEMI/ unstable
• For 1 month STEMI with no stenting
• For 3 months STEMI w/ bare metal stenting
• For 12 months STEMI with drug- eluting stenting
Anticoagulation: if AF, LV aneurysm or if cant use antiplatelet
HF/ LV dysfunction: spironolactone 25mg od
34
when can you return to work after an MI?
sedentary 4-6wks later,
light 6-8 wks,
heavy 3mo
35
Dressler syndrome:
2-10wks post MI or heart surgery
Autoantibodies to myocytes
Presentation?
Tx:
recurrent fever, chest pain ± pleural/ pericardial effusion
steroids and NSAIDS
36
Causes of high output HF:
hyperthyroidism,
anemia,
Pagets,
AV malformation
37
Causes of low output:
increased preload: MR, fluid overload
Pump failure
i. Cardiac muscle disease- IHD, cardiomyopathy
ii. decreased heart expansion/restricted filling: restrictive CM, constrictive pericarditis, tamponade
iii. Inadequate HR: BB, HB, post-MI
iv. Arrhythmia- AF
v. decreased power: negative inotropes- verapamil- diltiazem
Chronic excessive afterload: HT, AS
38
causes of Falsely elevated ANP:
```
Structural/ functional cardiac disease (including MI)
Baseline high in males and >70
Lung disease- COPD, PE
Renal and liver impairment
DM
Sepsis
```
39
HF Severity- New York heart association (NYHA)
| 1-4
1. No limitation, ordinary exercise doesn’t cause SOB, palpitations, fatigue
2. Slight limitation: comfortable at rest but ordinary activity causes symptoms
3. Marked limitation: comfortable at rest but less than ordinary activity causes symptoms
4. Symptoms at rest and worse with any activity
40
Prognosis HF
50% die suddenly- due to arrhythmia
Mild/ moderate: 20-30% 1year mortality
Severe: >50% 1 year
41
HF meds
3 main meds
diuretics
ACEi
BB
42
HF meds
| diuretics
* Loop: furosemide 20-40mg or bumetanide 1-2mg od
* + thiazide if continued problems with odema or HT
* Monitor for hypokalemia treat with amiloride or K+ supplements
43
HF meds
| LV systolic dysfunction:
ACEI (repipril 1.25mg od) + BB (bisoprolol 1.25mg mane)
44
HF other meds
* Anticoagulation if HF+ AF or history of thromboembolism, LV aneurysm, Intrathoracic thrombus
* Aspirin 75- 150 mg if HF + atherosclerotic arterial disease
* Statins
* Amlodipine: angina and HT
45
Atrial Fibrillation chronic causes
isolated,
HT,
coronary heart disease, cardiomyopathy,
Valvular heart disease
46
Atrial Fibrillation acute causes
```
infection,
high alcohol intake,
surgery,
electrocution,
MI,
pericarditis,
PE
hyperthyroidism
```
47
AF investigations
• Routine: ECG, CXR, bloods- TFT, FBC, U&E
• Ambulatory ECG or cadiac memo if paroxysmal
• ECHO if <50 or murmur/ HF present
Exercise tolerance test if exercise related
48
AF TX aims
B blocker
rhythm control - DC or chemical cardioversion
rate control - verapamil 40-120mg tds
49
Intermittent claudication investigations
* Bloods: FBC, U&E, Cr, eGFR, FBC/ HbA1c, lipids
* ABPI <0.95
* Duplex USS
50
Intermittent claudication tx
* Exercise: ideally 2h/ week for 3 months
* Decrease risk factors
* Aspirin 75mg od or clopidogrel 75mg od
* Foot care
51
Intermittent claudication exam
* Cool, white, atrophic changes, absent pulses
* Superficial femoral A: no popliteal and foot- calf pain
* Aorta or ilia A: weak or no femoral pulse ± femoral bruit. Calf, thigh, buttock pain
52
Critical limb ischaemia presentation
deteriorating claudication and nocturnal rest pain. Ulceration/ gangrene from minor trauma
53
Critical limb ischaemia exam
* Atrophic changes: cold, pallor, hairless, shiny
* Elevated= pallor + venous guttering, lowered= blue- red
* Ulceration
* Swelling suggests sleeping on chair to avoid rest pain
* No pulses, ABPI <0.5
54
Chronic Peripheral Ischaemia vascular surgeon tricks
• Angiography: to assess extent and position of diease
• Percutaneous transluminal angioplasty ± stenting: if short occlusions/ stenoses of iliac and superficial femoral vessels
Surgery: longer occlusions/ multiple stenosis
55
Chronic Peripheral Ischaemia drug tx
Naftidrofuryl
56
Varicose Veins Complications
* Haemorrhage
* Varicose eczema, skin pigmentation, ulcerations, oedema
* Atrophie blanche- white lacy scars
* Thrombophelebitis
* Lipodermatosclerosis- fibrosis of dermis and subcutis --> firm
57
Saphena varix
* Dilation of saphenous vein at confluence with femoral vein
* Transmits a cough impulse
* Blue tinge and gone when lying flat, lump in groin
* No tx unless symptomatic
58
Thrombophlebitis
Px
Causes
Tx
Px: severe pain, erythema, pigmentation + hardening of vein
Due to stasis, malignancy, thrombophilia if in normal veins
Tx
o Crepe bandaging to compress vein and minimize propagation of thrombus if ABPI >0.8
o Analgesia- NSAID>
o Ice pack + elevation
o Aspirin 75-150mg od
If in long saphenous toward SFJ- uregent duplex bc may cause ligation
59
Thrombophlebitis migrans
Recurrent tender nodules affecting veins throughout body
| A/w pancreatic carcinoma
60
DVT presentation
Unilateral leg pain, swelling, tenderness, ± fever, pitting oedema, warmth, distended collateral superficial veins
61
DVT considerations
with no cause found
• If <45y: thrombophilia
• If >45y: undiagnosed cancer
62
DVT Immediate action
if there is delay in dx
tx with LMWH
Well’s diagnostic algorithm
o Low probability: do D-Dimer, if +ve assess as med/high
o Med/ high: compression USS ± D-dimer, repeat in 1 wk
D-dimer
o Degradation product of fresh venous thrombus
o Normal = high negative predictive value
o Causes of DD: malignancy, pregnancy, trauma, inflammation, sepsis, liver impairment
63
DVT Management if confirmed DVT
Initially LMWH then warfarin or other oral anticoagulant
Continue LMWH for 4 days until INR is 2-3 for ≥2 days
Continue oral anticoagulants for 3-6months
Wear elastic compression stockings for >2 y to reduce post- thrombotic leg syndrome
64
DVT complications
• PE
• Post- thrombotic syndrome: chronic venous HT pain, swelling, hyperpigmentation, dermatitis, ulcers, gangrene, lipodermatosclerosis
Recurrent venous thromboembolism
65
cause of falls in elderly
```
• Physical:
o Neurological: stroke, visual loss
o Cardiac- arrhythmia, postural hypotension
o Muscular: steroid- induced myopathy
o Skeletal: OA
o Infection: pneumonia, UTI
Environmental
```
66
Falls Assessment
* Frequency and causes
* Medications: hypnotics, sedatices, diuretics, antihypertensives
* Gait and balance
* Neurological function: vision, mental status, muscle strength, LE peripheral nerves, proprioception, reflexes
* CV status: BP, HR, rhythm
* Assessment of environmental risks
67
Incontinence Hx
```
• How long
• Urgency, frequency, nocturia, volume
• Stress- cough, sneezing, standing
• Past obstetric and medical hx
Medications
```
68
Incontinence Dx
Intake/ out put diary
Urinalysis
Bloods: U&E, eGFR, FBC, HbA1c
69
Incontinence medication causes
```
diuretics
antihistamines
anxiolytics
α-blockers
sedatives
hypnotics
anticholinergics
TCA
```
70
Stress incontinence
Loss with cough/ exercise
Causes:
Tx
prostatectomy, childbirth, pelvic floor muscles
pelvic floor exercises >3months, vaginal cones, electrical stimulation
71
Functional incontinency
No urological problem
Caused by
immobility,
| inaccessible toilets, behavioral
72
Overflow
Dribbling is constant
Causes:
Tx:
BPH, prostate ca, urethral stricture, faecal impaction, neuro- LMN, SE of meds
Tx: relieve obstruction
73
Urge incontinence: detrusor instability or hyperreflexia
Sx
Causes:
Tx:
Sx Frequency, urgency, large loss, nocturia
Causes: idiopathic, neurological, local irritation, obstruction, surgery
Tx: bladder retaining , oxybutynin
74
Urinary fistula: communication between bladder and outside
Constant dribbling
Causes:
congenital,
malignancy,
complication of surgery
Refer to gynecology/ urology
75
GP management of incontinence
• Fluid intake- amount, timing, type- avoid coffee/tea/caffeine
• Promote weight loss
• Alter medications, treat UTI and chronic respiratory conditions
• Avoid constipation
HRT if estrogen deficiency
76
Dementia definition:
Generalized impairment of intellect, memory, and personality without impairment of consciousness
77
Dementia Investigations
* FBC, U&E, eGFR, LFTs, TFT, Ca2+, B12, folate, glucose
| * MSU, CXR, ECG
78
Dementia DDx
* Acute delirium
* Depression
* Communication probz- deaf, dysphagia, language difficulties
79
Alzheimers drug tx
Mild/ moderate: anticholinesterase inhibitors- donepezil, galantamine, rivastigmine
Moderate/ severe: memantine
80
Vascular dementia
Multiple lacunar infarcts or larger strokes
Generalized intellectual impairment
Clinically: dementia, pseudobulbar palsy, shuffling gait
Tx: secondary prevention of TIA/ stoke
81
Picks dementia
* Personality change a/w frontal lobe signs (gross tactlessness)
* Lack of restraint stealing, practical jokes, unusual sexual adventures
* Tx: supportive
82
Lewy body dementia
* Fluctuating but persistant cognitive impairement, parkinsonism, and hallucinations
* No tx, can use benzodiazepines as tranquillization
* Avoid antipsychotics- can be fatal
