What agent is the first line treatment for all CHF?
If a patient is symptomatic despite optimal dosing with ACEI and a diuretic, what can you add to their Rx? What is the main side effect of this extra medication?
Spironolactone (aldosterone antagonist) risk of hyperkalaemia and decreased renal function;
Digoxin - risk of toxicity
When should you use beta blockers in chronic heart failure?
All patients once they have been stabilised with other medications.
Which drugs have the potential to excacerbate heart failure?
Non-dihydropyridine CCBs; TCAs; Anti-arrhythmics
NSAIDs; Thiazolidinediones/Glitazones; Corticosteroids; Cancer drugs; TNF antagonists;Clozapine
The Australian Cardiovascular Risk Calculator takes into account of .... to calculate ....
Gender, age, smoking status, diabetes, BP, total cholesterol:HDL; 5y risk of CV event.
What other factors put you (not taken into account by the calculator) at increased risk of CVD?
Symptomatic/ECG-diagnosed CV (automatically >20% 5y risk of CV event), FHx of CVD, ATSI, >60yo with DM, obesity, socioeconomic disadvantage
What is the diagnostic criteria of grade 3 hypertension?
Systolic >=180 or diastolic >=110 or isolated systolic HTN with widened pulse pressure (syst >=160, diast <=70)
What constitutes mild/grade 1 HTN?
Systolic 140-159; diastolic 90-99 (whichever is the highest).
When must you start patient on antihypertensives immediately?
5 year risk of CV event is >15%
Associated clinical conditions
End organ disease
Grade 3 HTN
A patient with A has a BP of B. Is there hypertension meeting the target?
Uncomplicated HTN - 135/85
HTN and diabetes mellitus - 135/85
HTN and hypercholesterolaemia - 128/78
HTN and proteinuria - 128/78
No - HTN with associated condition/complication < 130/80
No - HTN with proteinuria target <125/75
What is the recommended waist circumference for men and women?
<94cm M; <80cm for F
Jack, 50yo, was put on enalapril for his HTN 3 months ago. His BP is now 142/92. What should you do?
Add a CCB (e.g. amlodipine) or a low dose thiazide duiretic (e.g. frusemide)
Jack, 50yo, has a history of HTN and gout. He is currently on irbesartan but his BP control is still poor. What additional drug would you recommend?
Calcium channel blocker (e.g. amlodipine)
AVOID thiazide diuretic (frusemide) because it reduces uric acid clearance.
Jacque, 50yo, has HTN and AF. He has been on irbesartan for 3 months but his BP is still poorly controlled. What agent should you add?
Non-hydropyridine CCB (e.g. diltiazem) for rate control + BP control.
Debbie, 60, has HTN and type II DM with proteinuria. She has been on enalapril for 3 months but her BP is still 145/95. What can you add?
CCB (e.g. amlodipine) - thiazide diuretics should only be used with caution.
Who should be screened for hyperlipidaemia and how often?
>=45yo - every 5y
>=20yo with 1st degree relative of premature CHD (<55yo M/<65yo F) - every 5y
Established CHD/high risk - yearly
Duncan, a 46 year old male has total cholesterol levels of 8. Mx?
Trial dietary changes for 6 weeks, check fasting lipids afterwards and if TCL still >7.5 or triglycerides >4, start on a statin.
What are the lipid targets for a patient with established heart disease or at high absolute risk of CVD?
Total cholesterol <4
What drug can you add to statins or replace statins with? What is its MoA?
Ezetimide - reduces small intestinal absorption of cholesterol.
What is the most common presenting complaint in GP?
URTI symptoms (e.g. sore throat)
List 4 clinical features of a respiratory infection with group A beta haemolytic streptococcus.
Lack of cough
Anterior cervical lymphadenopathy
Jacqui, 19, presents with a sore throat. She has a temperature of 38.1C, her tonsils exude pus and on palpation she has enlarged anterior cervical nodes. Mx?
Treat as GABHS - penicillin. Do NOT administer amoxicillin in case she has EBV (age group risk).
Antibiotics in URTI should only be given to...
Bilateral OM in <2yos
Acute OM with otorrhea
Acute sore throat/tonsilitis with >3 Centor (GABHS) criteria
Populations with high rates of complications (remote ATSI communities)
When would you consider prescribing antibiotics for sinusitis? Which one?
>= 3 of: persistent (>7d) mucopurulent discharge; poor response to decongestants; facial pain, tenderness (esp unilateral) over sinuses, tenderness on percussion of maxillary molar/premolar teeth.
Amoxyillin or doxycycline
List 4 signs of community acquired pneumonia. What would be your management?
Fever, productive cough, SOB, chest pain
Amoxycillin & doxycycline for 7 days
List 3 atypical causative agents for CAP.
How do you diagnose acute bronchitis?
Clinically: acute (<14d) cough with one or more other respiratory tract symptom (rhinitis, sore throat, sputum, dyspnoea, wheeze, chest discomfort).
Jay, 22yo, presents with a 5 day Hx of a productive cough (yellow sputum) and rhinitis. What is your management?
Reassure patient this is self-limiting (2-3wks) - paracetamol, fluids and rest.
Jake, 62yo, is a smoker presenting with a 5 day Hx of a productive cough and wheeze. Mx?
Assess for community acquired pneumonia.
Jillian, 50yo, presents with a 4d Hx of cough accompanied by a sore throat and malaise. Her temperature is 38.5C. Next step?
Nose and throat swab for PCR.
What is the most common cause of community acquired pneumonia?
Who is entitled to free annual flu shots and 5 yearly pneumococcal vaccines?
>65 year olds
>55 year old ATSIs
Chronic disease sufferers
Outline the management plan of a severe exacerbation of astham in an adult.
Continuous nebulised bronchodilator (5mg salbutamol every few minutes)
500ug ipratropium stat
Oral steroid (50mg prednisolone) --> IV hydrocortisone (200mg)
In stable COPD, what would be your first drug of choice?
Intermittent use of SABA or ipratropium
What is the key difference in dosing between inhaled corticosteroids for persistent asthma versus COPD?
High dose (>500ug fluticasone/beclamethasone) does not provide additional benefits in asthma where as they do in COPD.
ICS is a first line Tx in persistent asthma whereas it is only introduced in later stages of COPD.
List 3 indicators of COPD severity.
Symptoms despite SABA use
Frequent exacerbations (>=2 per year)
FEV1 <= 50% of predicted
What is SMART asthma Tx and what benefits does it provide to patients? Who should you avoid prescribing SMART to?
Symbicort maintenance and reliever therapy (low dose budesonide and eformoterol dry powder inhaler) - eliminates need for SABA and decreases no. of severe asthma exacerbations. Do NOT give to habitual overusers, <12yos and COPD patients.
Gob, 60, has COPD and his dyspnoea has been worsening despite having been prescribed with an ICS and ipratropium. He gets breathless after walking for a few minuets on a flat. His dyspnoea Medical Research Council scale is .../5? What are your next steps?