GP

Question 1

AF risk factors

Answer 1

HTN
CCF 
Coronary artery disease 
Valvular disease 
Arrhythmias 

Age 
DM 
Alcohol 
Male 
Smoking

Question 2

AF presenting features

Answer 2

Palpitations 
Tachycardia 
Irregular pulse 
Stroke 
Dyspnoea 
Fatigue 
Chest pain 
Dizziness

Question 3

AF investigations

Answer 3

ECG
TFTs
Echo

Before starting medication:
U+Es
CHA2DS2-VASc

Question 4

AF ECG findings

Answer 4

Absent P waves

Irregularly irregular rate

Question 5

AF echo findings

Answer 5

Valvular regurgitation or stenosis
LV or LA enlargement
PHTN
LV thickening and dysfunction

Question 6

CHA2DS2-VASc

Answer 6

CHF - 1 
HTN - 1 
Age > 75 - 2 
DM - 1
Stroke/TIA - 2 
Vascular disease - 1 
Age 65-74 - 1 
Sex - Female

Question 7

AF management

Answer 7

Anticoagulation - DOAC

• Factor 10a inhibitor
• CI in mitral stenosis or prosthetic valves
• Maintain INR 2-3

?Warfarin - HASBLED

Rate control - B-blocker

Question 8

HASBLED

Answer 8

HTN - 1 
Abnormal renal/liver function - 2 
Stroke - 1 
Bleeding history - 1 
Labile INRs - 1 
Elderly > 65 - 1 
Drugs predisposing bleeding - 1

Question 9

HTN definition

Answer 9

Clinical reading > 140/90

Ambulatory reading > 135/85

Primary hypertension = 90-95% of cases

Question 10

Secondary HTN causes

Answer 10

Renal

• Glomerulonephritis
• Chronic pyelonephritis
• PKD
• Renal artery stenosis

Endocrine

• Primary hyperaldosteronism
• Phaeochromocytoma
• Cushing’s
• CAH
• Acromegaly

Other causes

• Glucocorticoids
• NSAIDs
• Pregnancy
• CoA
• COCP

Question 11

HTN features

Answer 11

Usually asymptomatic

Headaches
Visual disturbances
Seizures

Question 12

HTN investigations

Answer 12

24-hour BP monitoring

U+E - Check for cause or consequence 
HbA1c 
Lipids 
ECG 
Urine dip

Question 13

HTN management

< 55 or DM2

Answer 13

1. A
2. A + D
3. A + C + D

K+ < 4.5 - Spironolactone
K+ > 4.5 - A/B-blocker

Question 14

HTN management

> 55 or Afro-Caribbean

Answer 14

1. C
2. C + A
3. C + A + D

K+ < 4.5 - Spironolactone
K+ > 4.5 - A/B-blocker

Question 15

ACE

Answer 15

Inhibits conversion of AT1 to AT2

Side effects

• Cough
• Angioedema
• Hyperkalaemia

Considerations

• CI in pregnancy
• Check renal function 2/3 weeks after starting

Question 16

CCB

Answer 16

Block voltage-gated Ca channels

• Causes smooth muscle relaxation
• Reduces force of myocardial contraction

Side effects

• Flushing
• Ankle swelling
• Headache

Question 17

Thiazide diuretics

Answer 17

Inhibit sodium absorption at the beginning of the DCT

Side effects

• Hyponatraemia
• Hypokalaemia
• Dehydration

Question 18

A2RB

Answer 18

Block the effects of AT2 at the AT1 receptor

Side effects - Hyperkalaemia

Used if ACE is not tolerated

Question 19

Adrenal cortex layers

Answer 19

Great Friday routines
Salt, sugar, sex
The deeper you go, the sweeter it gets

GFR-ACD

Glomerulosa - Mineralocorticoids - Aldosterone
Fasciculata - Glucocorticoids - Cortisol
Reticularis - Androgens - DHEA

Question 20

R-A-S

Answer 20

Low BP detected by baroreceptors in aortic arch…

Stimulates SNS…

• Vasoconstriction
• Increased water and sodium reabsorption
• Increased potassium excretion

Question 21

Renin

Answer 21

Released by renal juxtaglomerular cells…

In response to…

• Reduced renal perfusion
• Hyponatraemia
• SNS

Hydrolyses angiotensinogen to AT1

Question 22

AT2

Answer 22

ACE converts AT1 to AT2

AT2 acts to increase BP…

• Vasoconstriction of efferent arteriole
• Increased filtration fraction to preserve GFR
• Stimulates thirst via hypothalamus
• Stimulates aldosterone and ADH release
• Increases proximal tubule Na+/H+ activity

Question 23

Aldosterone

Answer 23

Released by zona glomerulosa in response to raised AT2, K+ and ACTH

Acts on DCT and collecting ducts

Stimulates…

• Na+ reabsorption
• K+ excretion
• H2O reabsorption

Question 24

ADH

Answer 24

Increases BP

• Synthesised by hypothalamus
• Secreted by PP in response to decreased BP
• Acts on collecting ducts
• Increases water reabsorption

Question 25

ANP

Answer 25

Atrial natriuretic peptide Decreases BP Released by atrial myocytes in response to... - Cardiac distension - SNS stimulation - AT2 Inhibits RAS and causes vasodilation

Question 26

CKD definition and staging

Answer 26

GFR < 60 ``` Stage 1 - GFR > 90 + Evidence of kidney damage on investigation Stage 2 - GFR 60-89 Stage 3a - GFR 45-59 Stage 3b - GFR 30-44 Stage 4 - GFR 15-29 Stage 5 - GFR < 15 ```

Question 27

CKD risk factors

Answer 27

Age > 50 DM HTN Childhood kidney disease ``` Long-term steroid use Male Black/Hispanic FH Smoking Obesity AI disorders ```

Question 28

CKD signs and symptoms

Answer 28

``` Anaemia Oedema Nausea Pruritus Arthralgia Enlarged prostate ```

Question 29

CKD investigations

Answer 29

``` Creatinine-based estimate of GFR Albumin:Creatinine ratio Creatinine ^ Urinalysis - Haematuria and proteinuria Microalbuminaemia Renal USS Biopsy ```

Question 30

Complications

Answer 30

Anaemia Renal osteodystrophy CVD Protein malnutrition Metabolic acidosis Hyperkalaemia Pulmonary oedema

Question 31

CKD stage 1-2 | Management

Answer 31

1. ACE-I or ARB Measure serum K+ and GFR before starting and 1/2 weeks after K+ > 5 - Do not offer RAS inhibitor 2. CCB - Verapamil +++ Statin

Question 32

CKD stage 3-4 | Management

Answer 32

1. ACE-I or ARB Measure serum K+ before starting and 1/2 weeks after K+ > 5 - Do not offer RAS inhibitor 2. CCB - Verapamil +++ Statin +++ B-blocker

Question 33

CKD additional treatments

Answer 33

CONSIDER ANTICOAGULATION ``` EPO stimulating agent Ferrous sulphate Calcium carbonate Ergocalciferol Calcitriol Sodium bicarbonate ```

Question 34

CKD stage 5 | Management

Answer 34

Dialysis Kidney transplant Calcium carbonate Calcitriol Ergocalciferol

Question 35

HF risk factors

Answer 35

``` MI DM Dyslipidaemia Age ^ Male HTN Valvular heart disease FH AF Thyroid disease ```

Question 36

HF symptoms

Answer 36

``` Dyspnoea Chest pain Fatigue Orthopnoea Tachycardia ```

Question 37

HF signs

Answer 37

``` Raised JVP S3 gallop Cardiomegaly Hepatojugular reflux Rales Hepatosplenomegaly Pitting oedema ```

Question 38

HF diagnosis

Answer 38

Framingham criteria 1 major + 2 minor

Question 39

Framingham criteria

Answer 39

Major - Acute pulmonary oedema, cardiomegaly, hepatojugular reflux, neck vein distension , orthopnoea, pulmonary rales, S3 gallop Minor - Ankle oedema, dyspnoea on exertion, hepatomegaly, nocturnal cough, pleural effusion, tachycardia > 120

Question 40

HF investigations

Answer 40

``` Echo CXR BNP ^^^ FBC Serum electrolytes - Sodium LOW Creatinine and urea ^ BM - Check for DM LFTs ^ TFTs Lipids ^ Ferritin or transferrin saturation ```

Question 41

HF management

Answer 41

``` ACE-I or ARB B-blocker Loop diuretic or thiazide diuretic Digoxin Aldosterone antagonist - Spironolactone ```