13-10-22 – The Practise of Treating CVS Patients Flashcards
Learning outcomes
- To Gain Knowledge of the Guideline Recommended way to treat Essential Hypertension in practice
- To Gain Knowledge of the Guideline Recommended way to treat Chronic Heart Failure in practice
- To Gain Knowledge of the Guideline Recommended way to treat Chronic Stable Angina Pectoris in practice
- To Understand the new way to classify Acute Chest Pain and how to treat its various subtypes in practice
- To Gain Understanding of Atrial Fibrillation itself and how to treat it in practice
- To Gain Knowledge of the Guideline Recommended way to treat Strokes
What are 6 of the more common CVS diseases?
- 6 of the more common CVS diseases?
1) Hypertension
2) Heart failure
3) Angina Pectoris
4) MI
5) Atrial Fibrillation
6) Strokes
Clot strategies.
What are 3 Antithrombotic methods of treatment?
Where can they each be used?
What is Thromboprophylaxis?
What are 2 examples of anti-clotting factor drugs?
What are 4 examples of anti-platelet drugs?
- Clot strategies:
- 3 Antithrombotic methods of treatment:
1) Thrombectomy
* Sucking out the clot
* Only used in the brain vessels
2) Thrombolysis
* Dissolve the clot
* Use in the brain, heart, and kidney
3) Angioplasty (+/- clot)
* Blow up balloon to widen the narrowing, then plant a stent to keep it open
* Used in the heart
- Thromboprophylaxis ( aka Thrombosis prevention) is medical treatment to prevent the development of thrombosis in those considered at risk for developing thrombosis
- Thromboprophylaxis drugs:
1) Anticlotting factor drugs:
* Warfarin (less common now)
* NOAC (novel oral anticoagulants) e.g Rivaroxaban
2) Anti-platelet drugs:
* Aspirin (less used now)
* Clopidogrel
* Ticagrelor
* Prasugrel
Which drugs (ACE inhibitors, Beta Blockers, Calcium Antagonists, Diuretics) are used to treat hypertension, heart failure, and angina?
Which drugs (ACE inhibitors, Beta Blockers, Calcium Antagonists, Diuretics) are used to treat hypertension, heart failure, and angina?
Nice/British hypertension society guidelines. Who are the 2 different columns for?
What are medications A, C, D?
What alpha blocker can be used?
What K+ sparing diuretic might be used?
What is resistant hypertension?
What are the 4 steps of treatment for age column?
- Nice/British hypertension society guidelines.
- Column 1 is for patients with diabetes / <55 years old
- Column 2 is for patients of African/Caribbean descent / >55 years old
- Medications used:
1) A – ACE inhibitor / ARB
2) C – Ca2+ channel blocker
3) D – Thiazide diuretic
4) Alpha blocker e.g doxazosin
5) Spironolactone – K+ sparing diuretic - Resistant hypertension is when we need 3 blood pressure medications + a diuretic
What are 6 of the drugs given for chronic cardiac failure?
- 6 of the drugs given for chronic cardiac failure:
1) Diuretic
* Especially furosemide (loop diuretic)
* Used because body retains fluid after heart failure
2) ACE Inhibitor (ACEI) / ARB
3) Beta Blocker
4) Spironolactone/ eplerenone
* Spironolactone and eplerenone are K+ sparing diuretics (aldosterone – blocking agent)
* eplerenone can block androgens, leading to low sex drive on gynaecomastia
5) Change ACEI/ARB to Sacubitril-Valsartan
* Sacubitril is a Neprilysin inhibitor
* Valsartan is an ARB
6) SGLT2 Inhibitor e.g. Dapagliflozin
* Sodium glucose transporter – tells kidneys to retain glucose, so body will excrete glucose through urine
What group of people are alternative procedural treatments for cardiac failure used for?
What are 3 procedural treatments for cardiac failure?
- Alternative procedural treatments for cardiac failure are only used for a select group of people
- 3 procedural treatments for cardiac failure:
1) Cardiac Resynchronisation Therapy to long QRS patients (= Biventricular Pacing)
* Long QRS for prolonged ventricular depolarisation
* One of the ventricles is contracting milliseconds after the other
* This treatment corrects this
2) Implantable Cardiac Defibrillators to highly selected patients
* If this device detects an abnormal rhythm, it can shock the heart to correct it
3) Transplantation to a select few (normally young people)
Changing ACEI/ARB to Sacubitril-Valsartan. What types of drugs are Sacubitril and Valsartan?
What does neprilysin do?
What is BNP released by?
When Is BNP released?
What do both Sacubitril and ACEI cause?
What must we be careful of when changing from ACEI to Sacubitril?
- Changing ACEI/ARB to Sacubitril-Valsartan
- Valsartan is an ARB
- Sacubitril is a Neprilysin inhibitor
- Neprilysin degrades BNP and other vasoactive peptides
- BNP is produced by ventricular muscle
- It is released as a stress response protein that increases in heart failure
- Both Sacubitril and ACEI cause angioneurotic oedema
- Angioneurotic oedema presents as unpredictable frequent oedematous episodes of cutaneous and mucosal tissues such as lips, eyes, oral cavity, larynx, and gastrointestinal system
- When changing for ACEI to sacubitril, we have to make sure there is at least a couple days between the transition, as some ACEI could be left in the system, which would trigger angioneurotic oedema if they are both present in the system
What is Angina Pectoris?
How is it caused?
What are the 4 drugs taken for chronic Angina Pectoris to prolong survival?
What 3 drugs may be used sequentially to relieve symptoms?
What 2 other procedures may be done?
- Angina pectoris is a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck,
- It is due to an inadequate blood supply to the heart
- 4 drugs taken for chronic Angina Pectoris to prolong survival (SAAB):
1) Statin
* Reduces LDL cholesterol
2) Aspirin / Anti-platelet
* Anti-platelets more common.
* Use to stop clotting in coronary artery
3) ACE Inhibitor
4) Beta Blocker
* Also relieves symptoms, which is why it is used in the initial treatment
- 3 drugs may be used sequentially to relieve symptoms:
1) Beta Blocker
2) Calcium Channel Blockers or Nitrates
3) New antianginals e.g Ivabradine or Ranolazine
- 2 other procedures may be done:
1) Coronary angioplasty to relieve symptoms (blow up balloon)
2) Coronary artery surgery
Describe the flow chart we use to analyse acute chest pain.
Why is troponin measured more in the blood?
- Describe the flow chart we use to analyse acute chest pain
- Troponin is measured for in the blood because when heart muscle dies, it will release troponin into the blood
Is STEMI or NSTEMI more severe?
What are 3 emergency treatments used in the treatment of STEMI?
What are 5 medications those with STEMI might take long term?
- STEMI is more severe than NSTEMI
- 3 emergency treatments used in the treatment of STEMI:
1) Aspirin / anti-platelet medication under tongue
2) Angioplasty (if near hospital that offers it)
3) Thrombolysis (if far away)
- 5 medications those with STEMI might take long term (SAAAB):
1) Statin
2) ACE inhibitor
3) Aspirin / Anti-platelet
4) Low Molecular Weight Heparin (anti-clotting) or Fondaparinux (anti-clotting)
* Fondaparinux is synthetic pentasaccharide that inhibits activated factor x
5) Beta Blocker
What is the main difference between STEMI and NSTEMI treatment?
What are the 6 treatments in the treatment plan for NSTEMI / Unstable Angina / ACS treatment (acute coronary syndrome treatment?
- The main difference between STEMI and NSTEMI treatment is the timing of the angioplasty
- With STEMI, the angioplasty must be performed asap
- With NSTEMI, the angioplasty can be performed later e.g the day after
- Treatment plan for NSTEMI / Unstable Angina / ACS treatment (acute coronary syndrome treatment:
1) Statin
2) Aspirin (Anti-platelet)
3) May use anti-clotting agent such as fondaparinux
4) ACE inhibitor
5) Beta Blocker
6) Non emergent angioplasty
What is atrial fibrillation (AF)?
What are the 3 steps in the treatment of AF?
What 2 types of drugs may be used to prevent emboli?
What 2 drugs may be used control rate?
How do they work?
What 3 drugs and 2 procedures can we use to control rhythm?
Why is the rhythm rarely corrected in those with AF?
- Atrial fibrillation (AF) is a condition that causes an irregular and often fast heartbeat (sometimes 150bpm)
- 3 steps in the treatment of AF:
1) Prevent emboli
* May use:
* Warfarin
* NOAC (novel oral anticoagulants) e.g Rivaroxaban
2) Control rate (crucial)
* May use:
* Beta blocker
* Digoxin
* Both of these drugs cause a controlled degree of heart block
* They allow the ventricular rate to slow, so the heart can fill properly
* The heart can beat as as fast as 150bpm, and we want to use these drugs to get around 60 – 100bpm
3) Control rhythm (rarely done)
* Drugs used:
* Amiodarone (class III) if there is heart failure (very powerful antiarrhythmic, loads of side effects)
* Sotalol (class II or III)
* Flecainide (class Ic antiarrhythmic) ) only if heart structure/function normal
- Procedures used:
- DC cardioversion acutely – shock patient’s heart
- Radioablation – cardiologist goes into heart, identifies part responsible for AF, and burns it away
- Rhythm is rarely corrected in those with AF, because patients can function with the treatments, and it is very difficult to get back to sinuous rhythm
What is another name for a stroke?
What is a stroke?
What are 3 causes of strokes?
What must be do prior to treatment?
What 4 stages of treatment do we use if there is no haemorrhage on the CT scan?
- Another name for a stroke is CVA (cerebrovascular accident)
- A stroke is a very serious condition where the blood supply to part of your brain is cut off
- 3 causes of strokes:
1) Cerebral Thrombosis
2) Cerebral Embolus
3) Cerebral Haemorrhage - Prior to treatment, we must have CT scan to differentiate haemorrhage from clot
- If there is no haemorrhage on CT scan, treatment consists of:
1) Emergency thrombolysis or thrombectomy
* Surgical thrombectomy is a type of surgery to remove a blood clot from inside an artery or vein
* It is less widely available, but considered better
2) (SAAAD) - Statin (lower LDL cholesterol)
3) Aspirin - Usually taken for 2 weeks, then another antiplatelet forever
4) Anti-platelet drug - Prescribed forever
5) Ace inhibitor
6) Indapamide (diuretic drug)
What are common side effects of:
* ACE inhibitors (3)
* Angiotensin Receptor Blockers (ARBs) (1)
* Beta blockers (3)
* Calcium Channel Blockers (2)
* Diuretics (3)
Which 2 should never be used in pregnant women?
- Common side effects of:
1) ACE inhibitors
* Dry cough
* Renal dysfunction *(worsen or improve)
* Angioneurotic oedema
2) Angiotensin Receptor Blockers (ARBs)
* Renal dysfunction *(worsen or improve)
3) Beta blockers
* Bradycardia/Heart Block
* Tired
* Asthma (Dont use in asthmatics)
4) Calcium Channel Blockers
* Ankle oedema for Amlodipine
* Heart Block for Diltiazem & Verapamil
5) Diuretics
* Hypokalaemia
* Diabetes
* Gout
- ACE inhibitors and ARBs should never be used in pregnant women
