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1
Q

What is angina pectoris?

A

Central chest tightness or heaviness, brought on by exertion and relieved by rest

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2
Q

Cause of angina? (6)

A

Myocardial ischaemia - mostly atheroma (atherosclerosis)
Anaemia
Aortic stenosis
Tachyarrhythmias
Hypertrophic cardiomyopathy
Small vessel disease - microvascular angina

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3
Q

Symptoms of angina? (7)

A 
Chest pain - tight/heavy
Worse on exertion
Radiation to arms, neck, jaw, teeth
Dyspnoea
Nausea
Sweatiness
Syncope
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4
Q

What can trigger angina?

A

Exercise
Emotion
Cold weather
Heavy meal

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5
Q

Types of angina?

A

Stable angina - relieved by rest
Unstable - increasing frequency/severity, on minimal exertion or at rest, high risk of MI
Decubitus - precipitated by lying flat
Variant (Prinzmetals) angina - caused by coronary artery spasm, no usual CAD RFs

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6
Q

Risk factors for angina? (6)

A 
Smoking
Lack of exercise
Obesity
Hypertension
Diabetes
Hypercholesterolaemia
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7
Q

Tests for angina?

A

ECG - may show signs of past MI, ST depression, flat/inverted T waves
Stratify likelihood of CAD:
If >90% likelihood of CAD treat as known CAD
60-90 angiography
30-60 functional imaging
10-39 artery calcification score with CT

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8
Q

Management of modifiable risk factors of angina?

A

Modify risk factors - stop smoking, exercise, lose weight
Control hypertension, diabetes
Statin!

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9
Q

Secondary prevention of angina?

A

ASPIRIN 75mg or clopidogrel
Statin
ACEi

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10
Q

Medical management of angina?

A 
Sublingual glyceryl trinitrate (GTN) spray
Beta blocker (atenolol) OR calcium channel blocker (amlodipine)
2nd line - long acting nitrate (isosorbide mononitrate), or nicorandil, or ivabradine, or ranolazine
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11
Q

Contraindications to beta blockers?

A

Asthma, COPD
2nd/3rd degree heart block
Worsening unstable heart failure

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12
Q

Mechanism of beta blockers? 3 side effects

A

Reduce heart rate and force of ventricular contraction by blocking beta-adrenoreceptors
Bronchospasm, cold peripheries, sleep disturbance

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13
Q

Mechanism of nitrates? 3 side effects

A

Dilates arteries - relaxes vascular smooth muscle

headache, postural hypotension, tachycardia

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14
Q

Mechanism of calcium channel blockers? 3 side effects

A

Reduce calcium influx to reduce force of contraction of heart
Flushing, ankle oedema, headache

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15
Q

What type of beta adrenergic receptors are in the heart? Where are the other type?

A

Type 1

Type 2 are in the lung bronchioles

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16
Q

When is surgery indicated in angina?

A

Poor response or intolerance to medical therapy

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17
Q

What surgery is indicated in angina?

A

Percutaneous transluminal coronary angioplasty PTCA - balloon dilation of stenotic vessels

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18
Q

What is ACS?

A

Acute coronary syndrome, comprising of unstable angina and MI (STEMI/NSTEMI)

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19
Q

What is the pathology of ACS?

A

Atherosclerotic plaque in coronary artery
Forms a thrombus
Breaks off and occludes artery
Leads to ischaemia of heart, eventual infarction

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20
Q

Types of ACS?

A

ACS with ST elevation

ACS without ST elevation (ST depression, T wave inversion)

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21
Q

Risk factors for ACS?

A

Non-mod: age, male, family history

Mod: smoking, hypertension, diabetes, hyperlipidaemia, obesity, lack of exercise

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22
Q

Diagnosis of ACS?

A 
Increase then decrease in cardiac markers i.e. troponin
Symptoms of ischaemia
ECG changes of ischaemia
Pathological Q waves
Loss of myocardium on imaging
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23
Q

Symptoms of MI?

A 
Central chest pain lasting >20min, radiating to arm
Nausea
Sweatiness
Dyspnoea
Palpitations
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24
Q

When may a silent infarct be more likely and what are the symptoms?

A 
The elderly, diabetics
No pain
Syncope
Pulmonary oedema
Abdo pain, vomiting
Confusion
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25
Signs of MI?
``` Distress Anxiety Pallor Sweatiness Fast/slow pulse Hyper/hypotension ```
26
Heart sounds in MI?
3rd/4th heart sounds | Pansystolic murmur
27
Tests for suspected MI?
ECG Bloods Cardiac enzymes CXR
28
What is seen on ECG in STEMI initially?
ST elevation | Tall T waves
29
What is seen on ECG in STEMI after hours/days?
T wave inversion | Pathological Q wave
30
What is seen on ECG in other ACS?
ST depression T wave inversion May be non specific/normal
31
What is seen on CXR in ACS?
Cardiomegaly Pulmonary oedema Widened mediastinum
32
What bloods do you do in ACS?
FBC U+E Glucose Lipids
33
What cardiac enzymes would you test for in ACS?
Cardiac troponin T and I - increased within 3-12 hours peak at 24-48 then fall Creatine kinase - increased within 3-12 hour, peak within 24 then fall Myoglobin - rise within 1-4
34
Changes in which ECG leads suggest anterior MI?
V1-V4
35
What is an anterior MI?
Blockage of left anterior descending LAD artery
36
Changes in what ECG leads suggest inferior MI?
II, III, aVF
37
What is an inferior MI?
Blockage of the right coronary artery
38
Changes in which ECG leads would suggest a lateral MI?
I, V5-V6
39
What is a lateral MI?
Blockage of the left circumflex artery
40
Initial management of STEMI?
Morphine Oxygen if <95% Nitrates Aspirin 300mg
41
How is reperfusion done in STEMI?
Percutaneous coronary intervention if within 2hrs | If not, fibrinolysis
42
Other medications given in STEMI?
Clopidogrel Beta blockers/CCB ACEi LMWH
43
What is the difference between NSTEMI and unstable angina?
NSTEMI has a rise in cardiac enzymes
44
Initial management for NSTEMI?
``` Morphine Oxygen Nitrates Aspirin Clopidogrel ```
45
Other medications given in NSTEMI?
``` Beta blocker/CCB LMWH IV nitrate Glycoprotein IIb/IIIa inhibitors ACEi ```
46
Long term management (secondary prevention) of ACS?
Aspirin and clopidogrel Beta blocker or CCB ACEi Statin
47
What is PCI?
Balloon dilatation of stenotic vessels and stent insertion usually
48
What is CABG?
Coronary artery bypass graft | Internal mammary artery or saphenous vein grafted on the bypass stenosed coronary artery
49
Indications for CABG?
Left main stem disease Triple vessel disease Unresponsive to PCI or medical management
50
Complications after MI?
``` Bradycardias/heart block Tachyarrhythmias Right ventricular failure Pericarditis VTE Cardiac tamponade Mitral regurg ```
51
How does a statin work? 3 side effects
HMG-CoA reductase inhibitor - stops the enzyme that is needed to produce cholesterol, so reduces cholesterol Muscle pain, hyperglycaemia/increased diabetes risk, memory loss
52
Contraindications for statins?
Liver disease High alcohol intake Previous history of muscle toxicity
53
Contraindications for beta blockers?
Asthma 2nd/3rd degree heart block Worsening unstable heart failure
54
Contraindications of nitrates?
Aortic stenosis Cardiac tamponade/constrictive pericarditis Hypotension
55
Types of calcium channel blockers? Examples
Dihydropyridines (amlodipine, nifedipine) | Non-dihydropyridines (dilitiazem, verapamil)
56
How do the two classes of calcium channel blockers differ?
Both relax/widen arteries | Dilitiazem/verapamil also affect heart conduction i.e. for arrhythmias
57
Contraindications of calcium channel blockers?
Dilitiazem/verapamil avoid in heart failure, avoid concurrent use with beta blockers!
58
How does clopidogrel work? 3 side effects
Irreversibly inhibits platelet aggregation Haemorrhage, GI upset, dizziness ANTIPLATELET
59
Contraindications of clopidogrel?
Active bleeding | Caution with increased risk of bleeding i.e. surgery, conditions
60
Mechanism of ace inhibitors? 3 side effects
Inhibit conversion of angiotensin I to angiotensin II by ace to relax blood vessels, lower blood pressure Cough (accumulation of bradykinin), chest pain, dizziness
61
Contraindications of ace inhibitors?
Use with aliskiren - direct renin inhibitor | Concomitant diuretics
62
Examples of and mechanism of glycoprotein IIb/IIIa inhibitors?
Tirofiban, bivalirudin | Inhibition of GPIIb/IIIa receptor on platelets so prevent platelet formation
63
Side effects of GPIIb/IIIA inhibitors? Contraindications
SE: haemorrhage, headache, nausea CI: abnormal bleeding in last month, aneurysm history, history of haemorrhagic stroke
64
Mechanism of aspirin?
Irreversibly inhibits cyclooxygenase enzyme, stopping prostaglandin and thromboxane synthesis, reducing platelet aggregation ANTIPLATELET
65
Side effects of aspirin? Contraindications
SE: dyspepsia, haemorrhage, skin reactions CI: children under 16 (Reye's syndrome), active peptic ulcer, bleeding disorders
66
When are alternative drug treatments used in angina?
As monotherapy if BBs or CCBs aren't used In combination with 1 1st line agent if symptoms are not controlled and other 1st line agent isn't used As a 3rd agent if symptoms aren't controlled with 2 drugs and unsuitable/awaiting CABG/PCI Ivabradine - symptomatic relief of angina in patients with a heart rate >70, as an alternative to first line therapies
67
What is isosorbide mononitrate?
Long acting nitrate
68
What is nicorandil? SE, CI
Potassium channel activator SE: headache CI: left ventricular failure, hypotension
69
What is ivabradine? SE, CI
Acts on sinoatrial node to lower heart rate SE: dizzy, vision changes CI: bradycardia, heart block, heart failure
70
What is ranolazine? SE, CI
Affects sodium dependent calcium channels SE: dizzy, headache, nausea CI: renal/liver failure
71
What is hypertension?
Persistently elevated blood pressure in vessels - symptomless until causes organ damage, risk factor for other CV disease/diabetes/stroke/kidney disease/PAD
72
What are the stages of hypertension?
1 - 140/90, ambulatory 135/85 2 - 160/100, ambulatory 150/95 Severe - systolic >180 or diastolic >110
73
Causes of hypertension?
Essential (unknown) - may be alcohol, obesity Renal disease Endocrine disease - Cushings, Conns, acromegaly Coarctation of aorta Pregnancy
74
Lifestyle advice for hypertension?
``` Stop smoking Lose weight, exercise Reduce alcohol Reduce salt intake, healthy diet Decrease caffeine intake Encourage relaxation ```
75
When are statins given in hypertension?
STATIN if CVD or everyone over 40 and 10yr CV risk >20%
76
When to treat stage 1 hypertension?
``` <80 yrs and 1 of: Target organ damage Renal disease CVD Diabetes 10yr CVD risk >20% ```
77
When to treat stage 2 hypertension?
All patients
78
What if <40 with stage 1 hypertension and no associated features?
Refer for evaluation of secondary causes of hypertension and detailed assessment of CV risk
79
Step 1 hypertension treatment?
If under 55 years - ACEi (ramipril) or ARB if not tolerated | If over 55, or black African/Caribbean any age - CCB (amlodipine) or thiazide like diuretic if not tolerated
80
Step 2 hypertension treatment?
Offer ACE inhibitor (or ARB if not tolerated or of AfroCaribbean origin) PLUS CCB (or thiazide like diuretic if not tolerated)
81
Step 3 hypertension treatment?
``` Ensurestep 2 is at optimal doses Offer ACEi (ARB if not tolerated) PLUS CCB PLUS thiazide like diuretic ```
82
Step 4 hypertension treatment? If BP still >140/90
4th drug: Spironolactone OR higher dose thiazide like diuretic If diuretic CI, add alpha or beta blocker
83
When is a beta blocker used as step 1 treatment for hypertension?
Younger people if intolerant to ACEi/ARB Women of childbearing potential People with increased sympathetic drive NB: add CCB if second drug required
84
What are the target BP for non diabetic patients with no CKD?
<140/90, ambulatory <135/85 | <150/90 if over 80, ambulatory <145/85
85
What are the target BP for diabetic patients?
<140/80 uncomplicated type 2 <135/85 uncomplicated type 1 <130/80 if complications
86
What is the target BP for paitents with CKD?
<130/80
87
How is hypertension treated in patients with diabetes?
1 - ACEi (ARB if not tolerated), if AfroCaribbean ACEi+CCB 2 - add CCB 3 - add diuretic 4 - alpha/beta blocker, spironolactone
88
What is an ARB? Mechanism, give 2
Angiotensin II receptor antagonist Block angiotensin II by preventing binding, blood vessels dilate reducing BP Candesartan, irbesartan
89
ARB SEs, CI?
SE: abdo pain, cough, dizzy CI: Combo with aliskiren, caution with afrocaribbean, people with LV hypertrophy, valve stenosis
90
How do alpha blockers work? Give 2
Alpha adrenergic antagonists - bind to alpha receptors in arteries/smooth muscle, relaxing vessels Doxazosin, terazosin
91
Alpha blockers SE, CI?
SE: arrhythmias, chest pain, dizzy CI: postural hypotension, careful in heart failure, pulmonary oedema
92
What thiazide like diuretics are used in hypertension and how do they work?
Chlortalidone, indapamide | Decrease cardiac output, reduce extracellular fluid volume, reduce peripheral vascular resistance - vasodilate
93
Thiazide like diuretics CI, SEs?
CI: addisons, hypercalcaemia, hyponatraemia, hypokalaemia, hyperuricaemia SE: constipation, electrolyte imbalance, headache, hypotension
94
What is AF?
Atrial fibrillation, common disturbance of cardiac rhythm that may be episodic, associated with risk of stroke
95
What is seen on ECG in AF?
Rapid irregularly irregular narrow QRS complex tachycardia with the absence of P waves
96
Causes of AF?
``` No cause Coronary heart disease Hypertension Cardiomyopathy Valvular heart disease - esp. mitral ```
97
Causes of acute AF?
Infection High alcohol Surgery MI, PE
98
Symptoms of AF?
``` Often asymptomatic Palpitations Chest pain Stroke/TIA Dyspnoea Light headedness/syncope Fatigue ```
99
Investigations of AF?
``` ECG CXR Bloods - TFTs, FBC, U+E Ambulatory ECG echo if <50 ```
100
Management of recent onset AF?
Treat precipitating cause - infection Direct current cardioversion or chemical cardioversion Admit if fast rate/patient compromise
101
Management of not recent onset AF?
Address RFs i.e. alcohol, caffeine, hypertension, thyroid disease Refer for echo and cardio assessment
102
Treatment of paroxysmal not recent onset AF?
No drugs if can avoid triggers Pill in pocket - beta blocker as needed Anticoagulate - low risk give aspirin, high risk give warfarin or NOAC
103
Treatment of chronic not recent onset AF?
Rhythm control - DC/chemical cardioversion Beta blocker to maintain rhythm or rate limiting CCB i.e. verapamil If ineffective, beta blocker + digoxin If ineffective, verapamil + digoxin If ineffective, refer Anticoagulate - low risk give aspirin, high risk give warfarin or NOAC
104
Mechanism of atrial fibrillation?
Irregular atrial rhythm 300-600bpm which leads to an irregular ventricular rate due to AV node only sometimes responding
105
What system is used to measure stroke risk in AF?
CHA2D2-VASc
106
Risk assessment tool for someone starting anticoagulation?
HASBLED
107
What is atrial flutter?
ECG shows regular sawtooth baseline at 300bpm, with narrow complex QRS tachycardia superimposed at 150bpm
108
What is used for rate control in AF?
Beta blocker or rate limiting CCB | Can add digoxin
109
What is used for rhythm control in AF?
Electrical cardioversion Dronedarone (with beta blocker) Amiodarone if LV impairment/heart failure
110
How is acute medical cardioversion done in AF?
Fleicainide | Amiodarone if structural heart disease
111
How does digoxin work?
Increases the force of contraction of the heart muscle but reduces heart rate - inhibits Na/K ATPase
112
Side effects of digoxin? CIs?
SE: arrhythmias, dizzy, vision disorders CI: intermittent complete heart block, myocarditis, 2nd degree AV block, V fib
113
How does amiodarone work?
Class III antiarrhythmic - prolongs the refractory period of SA and AV nodes, slowing conduction rate
114
Side effects of amiodarone? CIs?
SE: arrhythmias, liver damage, hyperthyroid CI: severe conduction disturbances, sinus node disease, thyroid dysfunction
115
What are guidelines on returning to normal life after MI?
Sedentary work 4-6 weeks, light 6-8, heavy 12 Sex after 6 weeks Fly - after 2 weeks if can climb stairs Driving - car angioplasty 1 week, other 1 month, lorry licence revoked assess at 6 weeks
116
What is heart failure?
Output of the heart is inadequate to meet the needs of the body, end stage of all diseases of the heart
117
Causes of chronic heart failure?
High output - needs of the body are more than what heart can give Low output - increased preload, pump failure, chronic excessive afterload
118
Causes of high output heart failure?
Hyperthyroidism Anaemia Paget's disease
119
Causes of increased preload?
Mitral regurgitation | Fluid overload
120
Causes of pump failure?
IHD Cardiomyopathy Restrictive cardiomyopathy, constrictive pericarditis Inadequate rate - beta blockers, heart block Arrhythmia - AF Negatively inotropic drugs - verapamil
121
Causes of chronic excessive afterload?
Hypertension | Aortic stenosis
122
Classification of heart failure?
Left ventricular systolic dysfunction - decreased left ventricular ejection fraction (LVEF) on echo Heart failure with preserved ejection fracture - normal LVEF but signs/symptoms of heart failure
123
Tests for heart failure?
``` Echo Blood - FBC, U+E, TFT, eGFR, creatinine, HbA1C, glucose ECG CXR PEFR/spirometry Serum natriuretic peptides ```
124
What is the NY heart association grading of heart failure severity?
I - no limitation II - slight limitation, ordinary activity causes fatigue/palpitations/dyspnoea III - marked limitation, less than ordinary activities causes symptoms IV - unable to carry out any physical activity without discomfort, symptoms present at rest
125
Symptoms of heart failure? (8)
``` SoB - on exertion, orthopnoea, paroxysmal nocturnal dyspnoea Decreased exercise tolerance Nocturnal cough Ankle oedema Abdo discomfort - liver distension Confusion, dizziness Gain or lose weight Wheeze ```
126
Signs of heart failure? (11)
``` Increased RR Cyanosis Increased pulse Increased JVP Displaced apex beat - cardiomegaly 3rd heart sound Hepatomegaly Right ventricular heave Crepitations, pleural effusions Pitting oedema ankles Ascites Cachexia, wasting ```
127
Features of PMH that may indicate heart failure?
MI, AF, hypertension
128
What serum natriuretic peptides are tested for in heart failure?
BNP - B-type natriuretic peptide | NTproBNP - N-terminal prohormone of BNP
129
If high SNPs, or previous MI what is next management?
Refer in <2wks for specialist and doppler echo
130
If low SNPs what is next management?
If medium, refer in 6wks for doppler echo | If low, heart failure unlikely
131
How often is review needed in heart failure? What is checked?
``` 6 months - check functional capacity, fluid status, heart rhythm, cognition and nutrition Depression Co-morbidities Medication compliance/SEs Bloods - U+E, creatinine, eGFR ```
132
Non medical management of heart failure? (6)
``` Educate - discuss prognosis Ease - benefits, mobility, blue badge Diet - low salt, lose weight if obese, low alcohol Lifestyle - smoking, exercise Restrict fluid intake if severe Vaccination - pneumococcal and influenza ```
133
What is given in all types of heart failure?
Diuretics. 1st - loop i.e. furosemide 2nd - thiazide i.e. bendroflumethiazide if oedema/hypertension continue
134
What is first line treatment in LV systolic dysfunction?
(Diuretics) ACE inhibitor (or ARB) and beta blocker If ACEi/ARB not tolerated, use hydralazine with a nitrate Add mineralocorticoid receptor antagonist (spironolactone)
135
What is treatment of heart failure with preserved ejection fraction?
(Diuretics) No specific treatment Treat diabetes, hypertension, IHD...
136
When is anticoagulation given in heart failure?
If AF or history of thromboembolism, LV aneurysm, intrathoracic thrombus
137
When is aspirin used in heart failure?
If concurrent with atherosclerotic arterial disease
138
When to refer heart failure?
Severe failure, not controlled by first line medication, concurrent with angina/arrhythmia
139
What 2nd line treatments for heart failure are given?
``` Digoxin Ivabradine Amiodarone Implantable cardioverter defibrillator Surgery - valve replacement, coronary angioplasty ```
140
How does spironolactone work?
Aldosterone antagonist - increases sodium and water excretion in DCT, spares potassium (aldosterone normally increases resorption of sodium and water)
141
CI and SE of spironolactone?
CI: addisons, anuria, high potassium SE: AKI, dizzy, electrolyte imbalance
142
How do loop diuretics (furosemide) work?
Inhibit reabsorption of sodium and water from the ascending loop of loop of Henle, increasing excretion
143
CI and SE of furosemide?
CI: anuria, renal failure, severe hypokalaemia or hyponatraemia SE: Dehydration, dizzy, electrolyte imbalance
144
How do thiazide diuretics (bendroflumethiazide) work?
Inhibits sodium reabsorption at beginning of the distal convoluted tubule, increasing excretion
145
CI and SE of bendroflumethiazide:
CI: addisons, hypercalcaemia, hyponatraemia, hypokalaemia SE: constipation, electrolyte imbalance, headache
146
What causes systolic failure?
MI, IHD, cardiomyopathy
147
What causes diastolic heart failure?
Inability of ventricle to relax and fill - constrictive pericarditis, tamponade, restrictive cardiomyopathy
148
Compensatory mechanisms when cardiac output compromised?
Sinus tachycardia Increased venous pressure Myocardial dilation/hypertrophy
149
Why does decreased CO lead to fluid retention?
Poor renal perfusion activates RAAS
150
What is positive inotropism and chronotropism?
Inotrope - Increase in force of contractility | Chronotrope - Increase in rate of contractions
151
3 cardinal symptoms of heart failure?
SOB Ankle swelling Fatigue
152
What are 3 major and 4 minor criteria in Framingham criteria?
Major - nocturnal SOB, crepitations, S3 gallop third heart sound Minor - ankle oedema, SOB, tachycardia, nocturnal cough
153
Which 2 investigations if normal exclude heart failure?
ECG, BNP
154
Features on CXR in heart failure? (5)
``` Alveolar oedema (batwing) Kerley B lines (interstitial oedema) Cardiomegaly Dilated pulmonary vessels Pleural effusion ```
155
Features on echo of heart failure?
Dilated chambers, valve incompetence, cardiomyopathy,LV dysfunction
156
What is cor pulmonale?
Right sided heart failure due to chronic pulmonary hypertension - COPD, asthma, fibrosis
157
What is preload and afterload?
Preload - initial stretching of cardiac myocytes prior to contraction Afterload - load against which the heart has to contract to eject blood
158
What is CKD?
Chronic kidney disease | Impaired renal function for >3months based on abnormal structure or function, or GFR <60mL persistently
159
What are the stages of CKD?
1 - eGFR>90, kidney damage normal GFR 2 - eGFR 60-89, kidney damage mildly low GFR 3a - 45-49, 3b - 30-44, moderately low GFR 4 - 15-29 severely low GFR 5 - <15 renal failure
160
Causes of CKD?
``` Diabetes Hypertension Urinary tract obstruction Polycystic kidneys Glomerulonephtritis Renovascular disease SLE ```
161
Who should be screened for CKD?
``` Diabetics Hypertension CV disease Chronic stones BPH Recurrent UTI Multisystem i.e. SLE FHx ```
162
How may CKD present?
``` Often asymptomatic until ~stage 4 Nausea Anorexia/lethargy Itch Nocturia Impotence Oedema Dyspnoea ```
163
Signs of CKD?
``` Pallor Lemon tinge to skin - uraemic Pulm/peripheral oedema Pericarditis Pleural effusions Metabolic flap Retinopathy Hypertension ```
164
Investigations of CKD?
Bloods - U+E, creatinine, eGFR, glucose, protein, FBC Urinalysis - MC+S, albumin:creatinine Renal tract USS - usually small kidneys
165
What would be on bloods in CKD?
Anaemia High calcium High phosphate Raised alkaline phosphatase
166
General management of CKD?
Treat reversible cause i.e. nephrotoxic drugs (NSAIDs) Manage CVD risk i.e. statin, antihypertensives, antiplatelet Treat diabetes Stop smoking Treat anaemia, renal bone disease
167
When to refer?
``` Stage 4 or 5 Significant proteinuria Sudden drop in eGFR Persistent haematuria if under 50yo Bone disease, anaemia ```
168
How to treat CKD?
``` ACEi (lisinopril) or ARB (losartan) Statin Loop diuretics for oedema, restrict fluid/salt VitD/calcium supplements Sodium bicarb supplements Replace iron/B12/folate/EPO if anaemia Gabapentin for restless legs ```
169
When to start dialysis?
eGFR 8-10
170
What are types of RRT?
Haemodialysis, haemofiltration (if critically ill), peritoneal dialysis (ambulatory)
171
How does haemodialysis work?
Blood flows opposite dialysis fluid and substances cleared along a concentration gradient across semi permeable membrane
172
Complications of dialysis?
Pulmonary oedema Infection Hypotension
173
End stage treatment of CKD?
Transplant
174
What is COPD?
Chronic obstructive pulmonary disease Progressive disorder characterised by airway obstruction with little or no reversibility Includes emphysema and chronic bronchitis
175
What is the FEV1 and FEV1/FVC needed to diagnose COPD?
FEV1 <80% | FEV1/FVC <0.7
176
Difference between obstructive and restrictive airways disease?
Obstructive - conditions that hinder ability to exhale all the air from lungs Restrictive - difficulty fully expanding lungs
177
What are the obstructive lung diseases?
Chronic bronchitis Emphysema Asthma Bronchiectasis
178
What would indicate COPD instead of asthma? (6)
``` Increasing age History of smoking/smoke Chronic sob Sputum Little diurnal FEV1 variation Irreversible ```
179
What is chronic bronchitis?
CLINICAL diagnosis | Cough, sputum production on most days for 3 months of 2 successive years
180
What is emphysema?
HISTOLOGICAL diagnosis | Enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls
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What causes COPD?
Smoking
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What inherited trait can cause COPD?
Alpha1 antitrypsin deficiency on chromosome 14 | Inhibits neutrophil elastase - enzyme that disrupts connective tissue, so develop emphysema at young age
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Pathological features seen in COPD? (4)
``` Goblet cell hyperplasia Inflammatory infiltration Squamous epithelium replaced with columnar Fibrosis Loss of elasticity - emphysema ```
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What is a pink puffer?
Breathless NOT cyanosed Normal Co2 from increased ventilation Pursed lips and barrel chest From emphysema
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What is a blue bloater?
Cyanosed NOT breathless High Co2 due to insensitivity, rely on hypoxic drive Bloat due to right heart failure From chronic bronchitis
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Symptoms of COPD? (4)
Cough Sputum Dyspnoea Wheeze
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Signs of COPD? (8)
``` Tachypnoea Use of accessory muscles Hyperinflation Decreased chest expansion Hyperresonant percussion Quiet breath sounds Cyanosis Cor pulmonale ```
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Complications of COPD? (4)
Acute exacerbations/infections Polycythaemia - more RBCs Resp failure Cor pulmonale - oedema
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Triggers for COPD exacerbations? (3)
Cold weather Pollution/smoke Exertion
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Investigations for COPD? (6)
``` FBC - high circulating RBCs ABG - hypoxia, possible hypercapnia Lung function CXR ECG Steroid trial ```
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What is seen on CXR in COPD? (4)
Bullae - air filled spaces Hyperinflation (>6 ribs above diaphragm), flat hemidiaphragms, large pulmonary arteries, decreased peripheral vascular markings
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What is seen on ECG in COPD?
Right atrial and ventricular hypertrophy
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What is FEV1 and FVC?
Forced expiratory volume in 1 second into a spirometer | Forced vital capacity into a spirometer - until no more can be exhaled
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Steroid trial in COPD?
Oral prednisolone for 2 weeks If FEV1 > by 15% COPD is steroid responsive Not done much
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How is severity of COPD tested?
1 mild - FEV1 >80% predicted 2 moderate - 50-79% predicted 3 severe - 30-49% predicted 4 very severe - <30% predicted
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General management of COPD? (7)
``` Stop smoking Exercise Nutrition/lose weight Flu and pneumoccocal vaccine Pulmonary rehabilitation Mucolytics Diuretics for oedema ```
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What is first line for COPD?
Short acting beta 2 agonist as needed - salbutamol | OR short acting muscarinic antagonist as needed - ipatropium bromide
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What is second line for COPD if persistent sob?
FEV1 >50%: Long acting beta 2 agonist - formoterol OR Long acting muscarinic antagonist - tiotropium (discontinue ipatropium) FEV <50%: Long acting beta 2 agonist - formoterol AND inhaled corticosteroid - budesonide OR Long acting muscarinic antagonist - tiotropium (discontinue ipatropium)
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What is third line for COPD if remain symptomatic?
Long acting beta 2 agonist - formoterol PLUS inhaled corticosteroid - budesonide PLUS long acting muscarinic antagonist (tiotropium)
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Treatments for more advanced COPD?
Theophylline PLUS inhaled corticosteroid - budesonide PLUS long acting beta 2 agonist - formoterol Pulmonary rehabilitation LTOT if oxygen <7.3kPa
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What is ipatropium and tiotropium, how do they work?
Short and long acting antimuscarinics | Decrease bronchial secretions by antagonising M3 muscarinic receptors, cause bronchodilation
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SE/CI for antimuscarinics
SE: arrhythmias, cough, dizziness CI: parodoxical bronchospasm, susceptible to angle closure glaucoma
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What is salbutamol and formoterol, how do they work?
Short and long acting beta 2 agonists | Activates beta 2 receptors which relax bronchial smooth muscle
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SE/CI for S/LABAs
SE: fine tremor, headache, hypokalaemia CI: severe pre-eclampsia
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How does budesonide work? SE, CI
Glucocorticoid agonist, prevents inflammation SE: headache, oral candidiasis, taste change CI: acute exacerbations
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How does theophylline work? SE, CI
Phosphodiesterase inhibitor causing bronchodilation of airway smooth muscle SE: anxiety, arrhytmias, dizzy CI: arrhythmias, hypokalaemia risk
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Surgery available for COPD?
Bullectomy, lung transplant
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Treatment of acute COPD exacerbations? (4)
Nebulised salbutamol and ipratropium Oxygen Steroids - prednisolone Antibiotics - amoxicillin
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What is asthma?
Recurrent episodes of dyspnoea, cough, wheeze caused by REVERSIBLE airways obstruction
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What factors contribute to asthma pathogenesis?
Bronchial muscle contraction Mucosal inflammation - mast cell and basophil degranulation Increased mucous production
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Symptoms of asthma?
``` Intermittent dyspnoea Wheeze Cough - often nocturnal Sputum Disturbed sleep - indicates severe Acid reflux Eczema, hayfever ```
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Precipitants of asthma?
``` Cold air Exercise emotion Allergens - dust, pollen, fur Infection Smoke inhalation/pollution Job - if better at weekends ```
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What drugs can precipitate asthma?
NSAIDs | Beta blockers
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What is diurnal variation seen in asthma?
In symptoms OR peak flow - worse in morning
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Signs of asthma?
``` Tachypnoea Audible wheeze - widespread, polyphonic Hyperinflated chest Hyperresonant percussion Decreased air entry ```
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Signs of a severe asthma attack?
Inability to complete sentences Pulse >110bpm Resp rate >25 PEF 33-50% expected
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Signs of a life threatening asthma attack?
``` Silent chest Confusion Exhaustion Cyanosis - oxygen <8kPa (low), <92%, co2 4.6-6 (normal) Bradycardia PEF <33% predicted ```
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Sign of a near fatal asthma attack?
Increased PaCO2 - shows failing respiratory effort
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Tests for asthma? (4)
Peak expiratory flow monitoring - diurnal variation >20% for 3 days a week for 2 weeks Spirometry - obstructive, FEV1/FVC <0.7 FEV1 <80% Steroid/b2 agonist trial - 15% increase in FEV1 CXR - hyperinflation
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General management of asthma?
Stop smoking Avoid precipitants CHECK INHALER TECHNIQUE Teach peak flow technique for 2x daily monitoring
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Step 1 of asthma treatment?
Inhaled short acting beta 2 agonist - salbutamol
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Step 2 of asthma treatment?
If using SABA/having symptoms more than 3 times a week or woken at night ADD inhaled corticosteroid - beclometasone
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Step 3 of asthma treatment?
Offer leukotriene receptor antagonist (montelukast) in addition to SABA and ICS
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Step 4 of asthma treatment?
Add a long acting beta 2 agonist (formoterol) with the SABA, ICS, LTRA
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What if uncontrolled asthma on SABA, ICS, LABA, LTRA?
Change ICS and LABA therapy to maintenance and reliever (MART) with fast acting LABA Then increase ICS to moderate
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What if uncontrolled with moderate ICS dose?
Trial of high ICS OR theophylline OR muscarinic receptor antagonist (ipratropium)
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What are leukotriene receptor antagonists?
Block the effects of cysteinyl leukotrienes in the airways which normally cause narrowing/swelling of the airways
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SE/CI of LTRAs
SE: diarrhoea, GI upset, headache, URTI CI: pregnancy. none really - may be linked to depression/suicide

3A REVISION (17 decks)

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