P&T June 2023

Question 1

AAA

Answer 1

focal weakening & dilation of the abdominal aorta, with a diameter of more than 3cm. Mortality of a ruptured AAA is around 80% and risk increases if diameter >5cm (large aneurysm). 90% found below renal artery and around 50% involve the iliac arteries. Most AAAs are fusiform (circumferential widening of the artery). AAAs typically enlarge at a rate of 10%/year, but some enlarge exponentially; about 20% remain the same size indefinitely

Question 2

Aetiology AAA

Answer 2

Atherosclerosis
Trauma
Vasculitis
Cystic medial necrosis
Infections (syphilis, Escherichia coli, salmonella)

Question 3

Risk factors AAA

Answer 3

 Older age (peak 70-80)- 5% of population over 60
 Smoking
 Hypertension
 Family history
 Male
 Race (white ancestry>African ancestry)
 COPD
 Marfan’s syndrome and Ehlers-Danlos syndrome

Question 4

Pathophysiology AAA

Answer 4

 Atherosclerosis is a contributing factor
 Weakening of the tunica media due to decrease in collagen & elastin
 Local inflammatory & immune response further weaken the vessel wall
 Leading to an aneurysm
 90% found below renal artery

Question 5

Clinical presentation AAA

Answer 5

 Mostly asymptomatic until rupture (50-75%)
 Epigastric pain which radiates to back (felt most prominently in the lumbosacral region)
 Pulsatile and expansive mass in the abdomen when palpated with both hands
 As an incidental finding on an abdominal x-ray, ultrasound or CT scan
 Syncope
 Vomiting
 Hypotension
 Complications:
If rupture onto peritoneal cavity is fatal, if does on retroperitoneal less dangerous
 Renal failure
 Lower extremity ischemia

Question 6

Clinical presentation AAA

Answer 6

 Mostly asymptomatic until rupture (50-75%)
 Epigastric pain which radiates to back (felt most prominently in the lumbosacral region)
 Pulsatile and expansive mass in the abdomen when palpated with both hands
 As an incidental finding on an abdominal x-ray, ultrasound or CT scan
 Syncope

If ruptures:
 Vomiting
 Hypotension
 If rupture onto peritoneal cavity is fatal, if does on retroperitoneal less dangerous
 Tachycardia
 Profound anaemia

Complications:
 Renal failure
 Lower extremity ischemia

Question 7

Scanning findings AAA

Answer 7

All men in England are offered a screening ultrasound scan at age 65 to detect asymptomatic AAA. Early detection of an AAA means preventative measures can stop it from expanding further or rupturing

 Usually found as an incidental finding on an abdominal x-ray, ultrasound or CT scan
 Ultrasound is the usual initial investigation for establishing the diagnosis.
 CT angiogram gives a more detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm

Question 8

Management AAA

Answer 8

Lifestyle changes
-Stop smoking
-Healthy diet
-Exercise
-Optimal management of hypertension or diabetes

Elective surgery:
-Symptomatic aneurysm
-Diameter growing more than 1cm per year
-Diameter above 5.5cm

Question 9

Beta blockers

Answer 9

Beta blockers are part of a group of drugs known as sympathetic nervous system antagonists

Question 10

BB Patho

Answer 10

The primary function of these BBs is to block B1receptor mediated vasoconstriction and decrease heart rate.

They also increase blood flow to the kidneys which results in a decrease in the release of renin.

Use the lock and key mechanism by blocking the adrenalin receptors that will compete with adrenaline to attach to them which effectively reduces the BP

Question 11

BB uses

Answer 11

Hypertension
Heart failure
Anxiety
Angina
Arrhythmias
thyotoxicosis

Question 12

Cautions and contradictions BB

Answer 12

Cautions:
1)Diabetics
Sympathetically mediated reductions in blood glucose may aggravate symptomology
2)Asthmatics
The bronchospasm effect of beta blockers may aggravate symptomology

Contraindications:
1) Printzmetals angina
2) Uncontrolled heart failure
3) Bad Hypotension and marked bradycardia
4) Sick sinus syndrome-2nd or 3rd AV block

Question 13

BB side effects

Answer 13

Nausea
Diahorrea
Bronchospasm
Dizziness
Dysponea
Orthostatic hypotension (getting up too quickly)
Fatigue
Cold extremities/ exacerbation of raynauds
Heart failure!

Question 14

ACE inhibitors

Answer 14

Angiotensin-converting enzyme (ACE) inhibitors are medications that help relax the veins and arteries to lower blood pressure.

Question 15

ACE Patho

Answer 15

ACE inhibitors block the conversion of angiotensin 1 to angiotensin 2 in the lungs

As angiotensin 2 is a powerful vasoconstrictor this drugs stop the renin-angiotensin system

This prevents vasoconstriction (which aggravates hypertension)

Stops ACE 1 from being converted to ACE 2 and ACE 1 can’t affect the medullary cortex to produce adrenaline and increase blood pressure so the blood pressure decreases

Question 16

ACE Uses

Answer 16

Heart failure
Hypertension
Diabetic nephropathy
Prophylaxis of cardiovascular events

Question 17

ACE Cautions and contraindications

Answer 17

Cautions:
1) Hyperkalemia (medicine causes increase of calcium in the blood)
2) Breast feeding (can cross the placenta and affect its system)
3) Hypersensitivity reactions
4) Concomitant diuretics

Contrindications:
1) Hepatic impairment
2) Renal impairment
3) Pregnancy—unless essential

Question 18

ACE side effects

Answer 18

Renal problems
Persistent dry cough
Nausea
Vomiting
Diahorrea
Constipation
Headache
Fatique