General Practice Flashcards
(78 cards)
1
Q
List causes of chest pain?
A
- Cardiac: ACS (unstable angina & MI), stable angina, dissecting thoracic aneurysm, pericarditis, cardiac tamponade, myocarditis, acute CCF, arrhythmia
- Respiratory: PE, pneumothorax, CAP, asthma, pleural effusion
- GI: acute pancreatitis, oesophageal rupture, peptic ulcer disease, GORD, oesophageal spasm, or oesophagitis
- MSK: rib fracture, costochondritis, spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction), OA, RA, OP, fibromyalgia or polymyalgia rheumatica
- Other: lung cancer, herpes zoster, Bornholm’s disorder/ precordial catch (Texidor twinge), psychogenic/non-specific chest pain
2
Q
List the 6 chest pain clinical features which would lead to hospital admission from a GP?
A
- RR >30bpm
- Tachy >130bpm
- SBP <90mmHg / DBS <60mmHg (unless normal for them)
- O2 sats <92% / central cyanosis (if no Hx of chronic hypoxia)
- Altered LOC
- High temp (esp >38.5°C)
3
Q
List the 3 features of suspected ACS which would require hospital admission from a GP?
A
- Current chest pain
- Sx of complications (such as pulmonary oedema)
- Pain-free, but have had chest pain in the last 12 hours and have an abnormal ECG / ECG is not available
4
Q
What are 2 ways to classify chest pain?
A
- Cause (cardiac, non-cardiac)
2. Type (localised, poorly localised, pleuritic, non-pleuritic
5
Q
Describe what elements of a chest pain Hx indicate specific causes?
A
- Acute onset, with central/band-like pain which radiates to the person’s jaw, arms, or back –> cardiac
- Persistent, localised pain –> pulmonary / MSK
- Exertional chest pain –> angina
- Pleuritic chest pain –> pulmonary / MSK
- Breathlessness –> cardiac / pulmonary
- Associated with palpitations, dizziness, or difficulty swallowing is less likely to be angina
- Do not rule out stable angina on the basis of a normal resting 12-lead ECG
- An abnormal ECG makes the diagnosis of CAD more likely
- A recent normal coronary angiogram excludes CAD
- Stable angina or MI –> assess for CV risk factor (older age, male, smoking, HTN, DM, increased cholesterols, FHx CVD)
- Previous chest trauma- MSK, GI
- Anxiety/depression –> psychogenic or non-specific chest pain
6
Q
Describe the examination you’d preform for chest pain?
A
- CV exam: Heart sounds (murmurs/pericardial rub), BP both arms (aortic dissection), pulse rate and rhythm (shock / arrhythmias), JVP, carotid pulse, ankles (oedema –> HF)
- Chest wall: palpate for tenderness, assess whether movement of the chest wall reproduces the pain (MSK), listen to lung fields (infection),
RR and pulse oximetry (low O2 sat) - General appearance: pallor and sweating (shock)
- Abdomen: tenderness (gallstones, pancreatitis, or peptic ulceration)
- Neck: localised tenderness and stiffness (cervical spondylosis or OA)
- Legs: swelling or tenderness (DVT)
- Skin: rashes (shingles) and bruising (rib fracture)
- Temp: especially >38.5ºC (infection, pericarditis, or pancreatitis)
7
Q
List the investigations you’d perform if the patient did not require immediate admission/referral?
A
- ECG: vent hypertrophy/arrhythmia/PE/stable angina/ACS
- Blood glucose, lipid profiles, U&Es: CV risk profile
- FBC: anaemia which may exacerbate stable angina
- TFT: thyroid disease
- LFT & amylase: cholecystitis, pancreatitis
- CRP/ESR: infection/inflam (polymyalgia rheumatica, OA)
- CXR: HF/pleural effusion/lobar collapse/lung cancer
8
Q
Describe the signs and symptoms of dissecting thoracic aneurysm?
A
- Symptoms: sudden tearing chest pain radiating to the back & inter-scapular region
- Signs: high BP, BP differentials (different in both arms), inequality in pulses (carotid, radial, femoral), a new diastolic murmur (aortic value regurgitation) & occasionally a pericardial friction rub, neuro deficits may be present (hemiplegia)
9
Q
Describe the signs and symptoms of pericarditis/cardiac tamponade?
A
- Symptoms: sharp, constant sternal pain relieved by sitting forward, may radiate to the L shoulder and/or L arm into the abdomen, worse when lying on the L side and on inspiration, swallowing, and coughing. Fever, cough, and arthralgia. Tamponade may have breathlessness, dysphagia, cough, and hoarseness
- Signs: pericardial friction rub. Tamponade pulsus paradoxus (decrease in palpable pulse and arterial systolic blood pressure of 10 mmHg on inspiration), Beck’s Triad
10
Q
What is Beck’s triad for a cardiac tamponade?
A
- Hypotension
- Muffled heart sounds
- Jugular venous distension
11
Q
Describe the signs and symptoms of acute congestive HF?
A
- Symptoms: ankle swelling, tiredness, severe breathlessness, orthopnea, and coughing (rarely producing frothy, blood-stained sputum)
- Signs: elevated JVP, gallop rhythm, inspiratory crackles at lung bases, and wheeze
12
Q
Describe the signs and symptoms of arrhythmias?
A
- Symptoms: chest pain associated with palpitations, breathlessness, and syncope/near syncope
- Signs: bradycardia / tachycardia
13
Q
When would you suspect an ACS?
A
- Pain in the chest or other areas (for example the arms, back, or jaw) lasts >15mins
- Associated N/V, sweating or breathlessness, or a combo
- Associated with haemodynamic instability (SBP <90 mmHg)
- New-onset / result of an abrupt deterioration of stable angina, with pain occurring frequently with little or no exertion, and often lasting >15mins
14
Q
How do you diagnose ACS?
A
- Resting 12-lead ECG: pathological Q waves, LBBB, ST elevation, T flattening/inversion
- Troponin I/T: increased indicates myocardial damage
15
Q
List 4 causes, other than ACS, which can raised your Troponin?
A
- Arrhythmias
- Pericarditis
- PE
- Myocarditis
16
Q
Describe the signs and symptoms of a PE?
A
- Symptoms: acute-onset breathlessness, pleuritic chest pain (worse on inspiration), cough, haemoptysis and/or syncope. Recurrent acute episodes may lead to chronic breathlessness
- Signs: tachypnoea >20BPM
17
Q
Describe the signs & symptoms of pneumothorax?
A
- Symptoms: sudden-onset pleuritic pain and breathlessness in people with/ without pallor/tachycardia
- Signs: reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side. Tension pneumothorax can result in a rapid development of severe symptoms, tracheal deviation away from the pneumothorax, tachycardia, and hypotension
18
Q
Describe the signs & symptoms of CAP?
A
- Symptoms: cough and at least 1 other symptom of sputum, wheeze, dyspnoea, or pleuritic chest pain
- Signs: any focal chest sign (dull percussion note, bronchial breathing, coarse crackles, or increased vocal fremitus or resonance) plus at least 1 systemic feature (fever or sweating, myalgia), with/ without temp >38°C
19
Q
What may there be additionally signs of with a CAP?
A
Associated pleural effusion
20
Q
Describe the signs & symptoms of asthma?
A
- Symptoms: wheeze, breathlessness, cough. Variable (worse at night, first thing in the morning, exercise or exposure to cold or allergens)
- Signs: there may be none when the person is feeling well. Acute episode, the RR increased, and wheeze present
21
Q
Describe the signs & symptoms of lung/lobar collapse?
A
- Symptoms: localized chest pain, breathlessness, cough
- Signs: reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds
22
Q
Describe the signs & symptoms of lung cancer?
A
- Symptoms: chest / shoulder pain, haemoptysis, dyspnoea, weight loss, appetite loss, hoarseness, and cough
- Signs: finger clubbing, cervical or supraclavicular lymphadenopathy, thrombocytosis
23
Q
Describe the signs & symptoms of pleural effusion?
A
- Symptoms: localised chest pain and progressive breathlessness
- Signs: reduced chest wall movements on affected side, stony dull percussion note, diminished or absent breath sounds, and (in heart / renal failure) signs of fluid overload
24
Q
Describe the typical history of someone with acute pancreatitis?
A
May have a history of gallstones or excessive alcohol consumption
25
Describe the signs & symptoms of acute pancreatitis?
- Symptoms: sudden-onset pain typically severe, continuous, and boring in nature. Usually epigastric region, may be generalised. Radiate to the right upper quadrant, chest, flanks, and lower abdomen, relieved by sitting upright and leaning forward, and is worse in supine. Increases in severity to a peak during the first few hours, before reaching a plateau that may last for several days. N&V
- Signs: abdo tenderness, abdominal distension, Cullen's sign (bluish discolouration around umbilicus), or Grey Turner's sign (bluish discolouration around flank), and low BP. May be low-grade fever
26
Describe the typical history of someone with oesophageal rupture?
Recent history of a medical procedure, foreign body ingestion, or oesophageal cancer
27
Describe the signs & symptoms of oesophageal rupture?
- Symptoms: thoracic oesophageal perforation leads to chest pain, dyspnoea, and odynophagia
- Signs: fever and subcutaneous emphysema (around the neck & upper chest wall)
28
Describe the typical symptoms of peptic ulcer disease/GORD/ oesophageal spasm/ oesophagitis?
- Sub-sternal pain, which commonly occurs at night or after consumption of a large meal
- Epigastric pain often radiates to the throat and is worse when bending or lying flat
- Regurg of acid & food into the mouth
29
Describe the typical history of someone with acute cholecystitis?
History of gallstones (cholelithiasis). Cholecystitis without biliary colic usually has a gradual onset
30
Describe the signs & symptoms of acute cholecystitis?
- Symptoms: sudden-onset, constant, severe pain in the upper right quadrant, possibly anorexia, N&V, sweating. Low-grade fever
- Signs: tenderness in the upper right quadrant, with/without Murphy's sign (inspiration is inhibited by pain on palpation). May also be fever (sepsis) and jaundice (stone in the bile duct / external compression of biliary ducts)
31
Describe the signs & symptoms of rib fracture?
- Symptoms: unilateral, sharp chest pain, worse with inspiration
- Signs: bruising and tenderness on palpation over the affected rib
32
Describe the signs & symptoms of costochondritis?
- Symptoms: unilateral, sharp, anterior chest-wall pain, exaggerated by breathing, activity, posture. Usually preceded by exercise or URTI, can last for months
- Signs: tenderness over costochondral junction and pain in the affected area when palpating the chest wall. Tietze's syndrome, there is a tender, fusiform swelling of the costal cartilage
33
Describe the signs & symptoms of chest pain associated with spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction)?
- Symptoms: dull, aching pain aggravated by particular movements of neck. Exercise makes pain worse and rest relieves, the opposite may also be true. Pain radiates in a non-segmental distribution down the arm, up the head, into shoulder, or across scapulae. Headache/dizziness/ spine pain
- Signs: paraesthesia or hyperaesthesia, no objective loss of sensation / muscle strength
34
Describe the typical history of someone with psychogenic/non-specific chest pain?
- No identifiable risk factors for a physical cause
- Anxiety disorders common, especially panic disorders
- The episode is often preceded by a stressful event
35
Describe the symptoms of psychogenic/non-specific chest pain?
- Usually in the left sub-mammary position (without radiation)
- Sharp and continuous
- Aggravated by tiredness and stress, and may be associated with symptoms of hyperventilation (incl tingling of extremities) and palpitations
36
Describe the signs & symptoms of Herpes Zoster?
- Symptoms: prodrome (1-5d before development of rash), abnormal sensation (burning, tingling, or itch) in affected skin, may also be headache, malaise, and photophobia
- Signs: painful maculopapular rash in a unilateral, dermatomal distribution, which develops into vesicular lesions, which become cloudy within 3-5d, then crust over and health within 2-4wks
37
Describe the signs & symptoms of Bornholm's disorder (Coxsackie B virus infection)?
- Symptoms: unilateral, knife-like chest or upper abdominal pain, following an URTI
- Signs: normal examination.
38
Describe the signs & symptoms of precordial catch (Texidor twinge)?
- Symptoms: brief, episodic left-sided chest pain commonly associated with bending or posture, relieved by a single deep depth or straight posture. No radiation
- Signs: normal examination.
39
Describe how to manage a person with chest pain while they are waiting to be admitted to hospital?
- Sit person up
- Only offer O2 if sats <94% and are not at risk of hypercapnic resp failure
- If suspected ACS: GTN &/or opioid (diamorphine), aspirin 300mg, resting 12-lead ECG
- If suspected pulmonary oedema: IV diuretic (furosemide), IV opioid (diamorphine), IV anti-emetic (metoclopramide), nitrate subling/buccal (GTN)
- If suspected tension pneumothorax: consider large-bore cannula through 2nd IC space mid-clav line on side of pneumothorax if life threatening
- Monitor: Pulse, BP, HR, O2 sats, resting 12-lead ECG, pain relief affectivity
40
What are the 2 types of MI's?
1. ST-segment elevation myocardial infarction (STEMI), caused by complete and persisting blockage
2. Non-ST-segment elevation myocardial infarction (NSTEMI), partial/intermittent blockage
41
List 6 possible complications of an MI?
1. Heart failure (acute or chronic)
2. Angina
3. Depression/anxiety
4. Sudden death due to another MI/fatal arrhythmia
5. Stroke
6. Dressler's syndrome (pericarditis post-MI- febrile with pericardial/pleural pain)
42
List 5 lifestyle changes that can reduce the risk of having further MI/other CV events following an MI?
1. Smoking cessation
2. Healthy diet
3. Moderate physical activity for at least 150mins/week
4. Losing weight if overweight or obese
5. Keeping alcohol consumption within recommended limits
43
List the 3 secondary preventions given to patients after they've had an MI?
1. Cardiac rehabilitation
2. Relevant lifestyle risk-factors
3. Drug treatment
44
List 4 drugs offered to patients post-MI (providing there are no contraindications) to reduce risk of further MI/CV events?
1. Angiotensin converting enzyme (ACE) inhibitor (or angiotensin-II receptor antagonist)
2. Dual antiplatelet therapy (aspirin + clopidogrel/ticagrelor)
3. Beta-blocker
4. Statin
45
List the 8 common concerns that may beed to be discussed with a person following an MI?
1. Returning to work & normal activities
2. Driving (don't need to inform DVLA but should have a break from driving to recover, and inform insurer)
3. Sexual activity (when comfortable to do so, usually ~4wk)
4. Erectile dysfunction (Tx with phosphodiesterase type 5 (PDE5) inhibitor, avoid if on nitrates &/or nicorandil or if the patient has low BP/severe HF/refractory angina)
5. Air travel
6. Stress
7. Anxiety
8. Competitive sport (stop until recovery complete)
46
List the 3 routine further assessment post-MI that should normally be arranged by secondary care?
1. Assessment of left ventricular function
2. Assessment of bleeding risk (usually at a 1st follow-up hospital appointment)
3. Cardiological assessment to consider whether coronary revascularization is appropriate
47
List 5 contraindications for ACEi drugs?
1. Hx of angioedema associated with previous ACEi
2. Hereditary/recurrent angioedema
3. Diabetes mellitus/eGFR <60, who are also taking aliskiren
4. Pregnant women and those planning a pregnancy, due to risks to the fetus
5. Breastfeeding women
48
List 7 side effects of ACEi drugs?
1. Renal impairment
2. Hyperkalaemia
3. Cough- can occur at any time after starting, if troublesome (disturbs sleep) consider changing to ARB
4. Angioedema- due to causing a non-allergic drug reaction
5. Dizziness and headaches- hypovolaemic/hyponatraemic
6. Hepato-biliary disorders
7. Other common: abdominal pain, dyspepsia, D&V, N&V, rash (maculo-papular), myalgia, muscle spasms, dyspnoea, chest pain and fatigue
49
List 9 drug interactions with ACEi drugs?
1. ARBs and Aliskerin- combined use increases risk of side effects of renal impairment etc.
2. Diuretics- hypotension risk
3. Allopurinol- increased risk leucopenia and hypersensitivity reactions esp in people with renal impairment
4. Bee/wasp venom- severe anaphylaxis
5. NSAIDS- increased renal impairment risk
6. Antacids- decreased absorption of ACEi
7. Insulin, metformin and sulfonylureas- increased hypoglycaemic effect
8. Lithium- ACEi increases plasma levels of lithium, needs monitoring for toxicity
9. Spironolactone- increased risk of severe hyperkalaemia
50
Describe the recommended beta-blocker prescription for post-MI?
- Continued for at least 12m post-MI in people without left ventricular systolic dysfunction/HF
- Continued indefinitely if the person has LVSD
51
List 8 contraindications for beta-blocker drugs?
1. Obstructive airway disease (asthma, COPD, bronchospasm)
2. Cardiogenic shock/phaeochromocytoma
3. 2nd/3rd-degree heart block
4. Sick sinus syndrome
5. Sinus bradycardia (HR <60bpm)
6. Severe hypotension (SBP <100mmHg)
7. Severe PAD (pain at rest & sometimes intermittent claudication)
8. Uncontrolled HF
52
List 10 side effects of beta-blocker drugs?
1. Bradycardia
2. Bronchospasm
3. Cold extremities, paraesthesiae, and numbness- more common in people with peripheral vascular disease
4. Conduction disorders
5. Dizziness
6. Dyspnoea
7. Exacerbation of psoriasis
8. Exacerbation of Raynaud's phenomenon
9. Fatigue
10. GI disturbances
53
List 9 drugs interactions for beta-blocker drugs?
1. Alpha-blockers/ACEi/ARB/anxioltyics/diuretics/levodopa/nitrates- increase hypotensive effect
2. Antidepressants- increase risk of postural hypotension
3. Antidiabetics- ACEi mask warning signs of hypoglycaemia (tremor)
4. Calcium channel blockers- bradycardia, asystole, severe hypotension, HF
5. Class I anti-arrhythmics (quinidine/flecainide)- bradycardia, myocardial depression
6. Class III anti-arrhythmics (amiodarone)- bradycardia, AV block, myocardial depression
7. Corticosteroids, oestrogen- hypotensive
8. Digoxin- bradycardia, AV block
9. NSAIDS- hypotension
54
What is atrial fibrillation and list the 4 common causes of it?
- Irregular disorganised electrical activity in atria, leading to irregular ventricular rhythm (160-180bpm). It's a SVT.
1. Ischaemic heart disease
2. HTN
3. Valvular heart disease
4. Hyperthyroidism
55
List the 4 complications of AF?
1. Stroke & thromboembolism
2. HF- disorganised atrial conduction leading to ineffective ventricular filling
3. Tachycardia-induced cardiomyopathy & critical cardiac ischaemia- due to persistently elevated ventricular rate
4. Reduced quality of life- reduced exercise tolerance, impaired cognitive function
56
Describe the management of AF?
- Admitting people who have severe Sx/complication
- Identifying and managing any underlying causes
- Tx arrhythmia: rate-control (beta-blocker, rate-limiting calcium channel blocker, digoxin) recommended for most people. Referral for rhythm-control (cardioversion), in addition to rate-control, may be appropriate if the person has a reversible cause (chest infection)
- Assess stroke risk using CHA2DS2VASc tool
- Assessing risks and benefits of anticoag. HAS-BLED tool used to assess risk of major bleeding & identify modifiable risk factors, such as uncontrolled HTN, harmful alcohol consumption, and concurrent use of aspirin/NSAID
- Follow-up advice and info on AF, its treatment, and where to find support groups
57
In a patient with AF, list the 4 situations when referral to a cardiologist is appropriate?
1. Rhythm control needed
2. Rate-control treatment fails to control the symptoms of AF (prompt referral within 4 weeks)
3. Valvular disease/left ventricular systolic dysfunction on echocardiography
4. Wolff–Parkinson–White syndrome / prolonged QT interval suggested by electrocardiogram
58
Describe the 3 classifications of AF?
1. Paroxysmal AF- episodes lasting >30secs but <7 days (often <48 hours) that are self-terminating and recurrent
2. Persistent AF- episodes lasting >7 days (spontaneous termination is unlikely to occur after this time) or <7days but requiring pharmacological or electrical cardioversion
3. Permanent AF- fails to terminate using cardioversion, AF that is terminated but relapses within 24 hours, or longstanding AF (usually >1 year) which cardioversion has not been indicated or attempted
59
Describe the diagnosis of AF?
- Clinically: irregular pulse, with/without - breathlessness/palpitations/chest discomfort/syncope/dizziness/reduced exercise tolerance/malaise/polyuria/stroke/TIA/HF
- PMHx: cardiac disease &/or recent cardiothoracic surgery. Diabetes, thyroid disease, cancer, alcohol misuse.
- Suspect Paroxysmal AF if Sx are episodic and last <48hrs
- ECG: no P-waves, chaotic baseline, irregular ventricular rate (160-180bpm)
- If paroxysmal AF is suspected & AF is not seen on ECG: 24hr ambulatory ECG monitor or 7-day Holter monitor
60
How would you manage AF if the onset was within the last 48hrs?
- Urgently admit for emergency cardioversion if the person has signs and Sx of haemodynamic instability, such as a rapid pulse (>150bpm) and/or low BP (SBP <90 mmHg), loss of consciousness, severe dizziness/syncope, ongoing chest pain, or increasing breathlessness
- If not exhibiting signs of haemodynamic instability, consider management in primary care (if appropriate) or refer the person to an acute medical unit for immediate cardioversion, depending on preferences and clinical judgement
61
Describe the CHA2DC2VASx score tool?
- Used to assess stroke risk
- Congestive HF/LVSD = 1
- HTN (resting SBP >140mmHg/DBP >90mmHg on at least 2 occasions or current antihypertensive Tx) = 1
- Age =/> 75yrs = 2
- Diabetes mellitus (fasting plasma glucose =/>7mmol/L or oral hypoglycaemic drugs or insulin) = 1
- Stroke/TIA = 2
- Vascular disease (MI, PAD, aortic plaque) = 1
- Age 65-74yrs = 1
- Sex (female) = 1
62
Describe the HAS-BLED scoring tool?
- Identifies people at high risk of bleeding, a score of 1 point should be given to the following risk factors:
- HTN (uncontrolled, >160mmHg SBP)
- Abnormal liver function
- Abnormal renal function
- Stroke (prev Hx, esp lacunar)
- Bleeding (Hx or predisposition)
- Labile international normalised ratios (INR)
- Elderly (>65yrs)
- Drugs (antiplatelets/NSAIDS)
- Harmful alcohol consumption
63
Describe the follow up care for AF?
- Within 1wk of starting rate-control (or any dose alteration), check tolerating the drug, and review Sx (palpitations, breathlessness, fatigue), HR, and BP
- For people taking warfarin anticoag assess INR initially daily until within therapeutic range on 2 occasions (2-3), then monitor 2x weekly for 1-2weeks, then weekly, thereafter if stable monitor at longer intervals
- Calculate time in therapeutic range (TTR) at each subsequent visit to ensure maintenance of international normalized ratio (INR) between 2-3 over a longer period of time
- Poor anticoag control= TTR <65%, 2 INRs >5 or 1 INR >8 within past 6m, 2 INRs <1.5 within past 6m
- If poor anticoag control cannot be improved, consider switching to DOAC (apixaban, edoxaban, dabigatran or rivaroxaban)
- Review at least annually once Sx controlled
64
List 10 contraindications for calcium channel blockers (Diltiazem, Verapamil)?
1. LVF with pulmonary congestion
2. Severe bradycardia (<40/50bpm)
3. 2nd/3rd degree AV block except with functioning ventricular pacemaker - as Ca-channel blockers may induce AV block
4. Severe hypotension (SBP <90bpm)
5. Severe aortic stenosis
6. Cardiogenic shock
7. Congestive HF
8. Sick sinus syndrome
9. People taking ivabradine
10. Pregnancy
65
List the 5 indications when you wouldn't prescribe digoxin?
1. Some supraventricular arrhythmias (Wolff–Parkinson–White syndrome)
2. Arrhythmias caused by previous digoxin/another cardiac glycoside
3. Heart conduction problems (intermittent complete heart block/AV heart block)
4. Ventricular tachycardia/ventricular fibrillation
5. Hypertrophic obstructive cardiomyopathy, unless concomitant AF and HF
66
List the 3 types of adverse effects of digoxin?
1. Cardiac: sinoatrial and atrioventricular block, premature ventricular contractions, PR prolongation and ST-segment depression
2. Non-cardiac: N&V, visual abnormalities, CNS effects, thrombocytopenia, gynaecomastia
3. Narrow therapeutic window of Digoxin
67
List the 5 advantages and disadvantages of warfarin and DOACs?
1. Stroke risk reduction: DOACs & warfarin the same
2. Risks: DOACs associated with a reduced risk of haemorrhagic stroke & intracerebral haemorrhage
3. Adherence: adherence is vital, more important with the NOACs. Because DOACs have a relatively short half-life & anticoag effect fades rapidly after 12-24hrs. With warfarin, some benefit is retained for 48-72 hours after missing a dose
4. Monitoring: DOACs have predictable pharmacokinetics, so coag control does not need to be monitored. Warfarin, needs regular blood tests
5. Reversibility: unlike warfarin, there are, as yet, no specific antidotes for DOACs
68
What would you prescribe for follow up treatment of AF if anticoagulation was contraindicated?
Combination of aspirin and clopidogrel
69
Describe how amiodarone would be given and monitored?
- Always initiated in secondary care
| - Baseline assessments are performed beforehand: TFTs, LFTs, serum U&Es, chest radiography and electrocardiography
70
List the 6 complications of chronic heart failure?
1. Arrhythmia
2. Depression
3. Cachexia
4. Chronic kidney disease
5. Sexual dysfunction
6. Sudden cardiac death
71
What should you do in GP if chronic heart failure is suspected?
- Serum natriuretic peptide level (NT-proBNP) measured
- If level is normal, HF is unlikely
- If levels are raised, referral for specialist assessment & echocardiography
- 12-lead ECG to exclude aggravating factors
- Loop diuretic may be prescribed for Sx relief while awaiting specialist assessment
72
What should you do for confirmed HF with reduced ejection fraction?
- Diuretic: relieve Sx of fluid overload
- Angiotensin-converting enzyme (ACE) inhibitor & a beta-blocker should be prescribed: reduce morbidity and mortality
- If still symptomatic despite optimal treatment with an ACEi & beta-blocker, a referral for specialist management
73
List the 9 things that you should do for all people with confirmed HF?
1. Prescribe an antiplatelet & statin should be considered
2. Comorbidities & precipitating factors should be managed
3. Screening for depression/anxiety
4. A supervised exercise-based rehabilitation programme offered
5. Appropriate vaccinations offered
6. Self-care advice
7. Nutritional status assessed
8. Follow-up & advanced care planning offered, if appropriate
9. Women of child-bearing age should be given advice about contraception & pregnancy
74
What is the definition of heart failure?
The ability of the heart to maintain the circulation of blood is impaired as a result of a structural/functional impairment of ventricular filling/ejection
75
Describe the 3 different ways chronic heart failure can be classified according to?
1. Ejection Fraction: reduced LVEF =/< 35-40% (HF-REF). Or there is preserved EJ (HF-PEF)
2. Time-course: acute HF may be a new presentation/deterioration or decompensation of chronic HF. Or chronic HF which there is no agreed definition of timescale
3. Symptomatic severity: New York heart association (NYHA)
76
Describe the 4 functional classification of HF according to the New York heart association (NYHA)?
1. Class I: no limitation of physical activity. No undue fatigue, breathlessness, or palpitations
2. Class II: slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue, or palpitations
3. Class III: marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations
4. Class IV: unable to carry out any physical activity without discomfort. Sx at rest can be present
77
Describe the other types of HF?
- Right heart failure & left heart failure were used to reflect whether the predominant symptoms reflected congestion in the systemic (right) or pulmonary (left) veins
- Congestive heart failure describes evidence of sodium & water retention
78
List the 9 types of causes for chronic heart failure?
1. Myocardial disease: CAD (most common), HTN, cardiomyopathies
2. Valvular heart disease: AS
3. Pericardial disease: constrictive pericarditis, pericardial effusion
4. Congenital heart disease
5. Arrhythmias: AF
6. High output states: anaemia, thyrotoxicosis, phaeochromocytoma, septicaemia, liver failure,
AV-shunts, Paget's disease, Thiamine (vitamin B1) deficiency
7. Volume overload: end-stage chronic kidney disease, nephrotic syndrome
8. Obesity
9. Drugs: alcohol, cocaine, NSAIDS, beta-blockers and calcium-channel blockers
