ACS Flashcards
ACE- I indications
- HTN in any context
- CCF
- IHD
- Diabetic nephropathy or CKD with proteinuria
MOA of ACE-i
- block the action of ACE to prevent the conversion of Ang I to II. This dilates efferent arteriole reducing progression of CKD. .
SE of ACE-i
- hypotension
- persistent dry cough
- hyperk+
- cause or worsen renal failure especially those with renal artery stenosis who need cosntricted efferent to maintain filtration.
- angioedema and anaphylaxis
who should you not give ace-i
- renal artery stenosis
- AKI
- women who are or want to become pregnant or breastfeeding
when should you lower the dose of ace-i
CKD
interactions of ace-i
- avoid giving with other potassium elevating drugs.
- if given with diuretics can cause first dose hypotension
- NSAID and ACE-I = nephrotoxic risk
name ace-is
ramipril, lisinopril, perindopril
common starting dose of ramipril
1.25mg in HF or neohropathy or 2.5mg iin others
max dose = 10
when should you take ace-i
with or without food. first doe before bed to limit hypotension
what over the counter meds those on ace-i should not take
ibuprofen
when should u check u and e after starting ace-i
1-2 weeks
when do you stop ace-i
if serum creatine rises more than 30% or egfr falls more than 25%.
if k+ above 5, stop other k+ sparing drugs then reduce dose of ace. if >6, stop ace-i
Indications for ARBS
where ACE-i are not tolerated due to cough. indications are the same as ACE-I
MOA of ARBS
Block action fo ang II on AT1 receptor.
ARBS SE
- First dose hypotension
- Hyperkalaemia
- Renal failure
when should ARBS be avoided
- Renal artery stenosis
- AKI
when should ARBS be used cautiously
Breastfeeding and Pregnancy and CKD - use lower dose in CKD
Name ARBS
Losartan, Candesartan, Irbesartan
Starting dose of losarten in HF
12.5mg
Common starting dose for losartan in anythign other than HF
50mg
Beta blockers indications
- IHD
- CCF
- AF
- SVT
- HTN
MOA BB
- B1r in heart, B2r in SM
- BB reduce force of contraction and speed of conduction in heart
- slow refractory period of AVN so helpful in AF
- HTN; BB reduce renin - as this is mediated by b1 receptors
SE of BB
- Cold extremities
- Fatigue
- headache
- GI distrubance
- sleep disturbance and nightmare
- Impotence in men
Who do you not give BB to
Asthma, those with Heart block
when to use BB at low dose
- HF - as at first they impair heart function
- Hepatic failure
- avoid in haemodynamic instability
interactions of BB
- Non-dihydropyridine ccb - verapamil, diltiazem. do not combine unless specialist advice.
name b1 selective BB
Bisoprolol, metoprolol
advice to patients as to when to take BB
At same time everyday roughly
Indications fo heparin and fondaparinux
- DVT, PE
- ACS - used with antiplatelet agents
MOA heparin/ fondaprinux
enhance anticoag effect of antithrombin.
- UFH = inavtivates F11a and Xa.
- MWH = FXa
- Fonda = Xa
SE of heparin/fondaprinux
- Haemorrhage (lower with fonda)
- bruising at injection site
- Hyperk+
- HIT/HITT - less with MWH
Use anticoags cautiously in which patients
- clotting disorders
- severe uncontrolled HTN
- Recent surgery or trauma
- Renal impairment - use lower dose and use UFH
when to withhold anticoags
- before and after surgery +LP and anaesthesia
protamine reverses which heparin
UFH
indications for nitrates
- angina and acs
- long acting for angina prophylaxis
- pulmonoary oedema rx with furosemide and o2
MOA of nitrates
- increases cGMP and refuces calcium in vascular smooth muscle cells = relax = reduce cardiac work and myocardial o2 demans
- relax systemic arteries - reduce afterload
SE Nitrates
- flushing
- headache - warn many initially
- light-headedness
- hypotension
can become tolerant - reduce by timing doses. always have a nitrate free period in day often before bed
CI of nitrates
- severe aortic stenosis - cause CVS collapse
- haemodynamic instability esp hypotension
Nitrate interactions
- PDE -i
- use carefully in those with HTN meds as can have opposite effect
plasma lif eof GTN
<5minutes
In ACS or HF - how do you prescribe GTN
= IV infusion
isosorbide mononitrate half life
4-5 hours BD or TDS use.
IV GTN dose
50mg in 50ml = 1mg = 1ml infusion rate. increase related to sx. so increase by 0.5ml/hr every 15-30mins till sx relieved. but systolic to stay abouve 90mmhg
strong opioid examples
morphine
oxycodone
indications for strogn opioids
- acute severe pain including post op and MI
- Relief of chronic pain if other methods on ladder havent worked
- relief of SOB in palliative care
- Relief of SOB and anxiety in acute pulmonary oedema along with o2, furosemide, nitrates
MOA strng opioids
mew receptor activation = GPCR on = reduced neuronal excitability and transmission.
- in medulla - blunt response to hypxia and hypercapmoea = low RR
- relieve pain as above = reduce Sympathetic NS response - reduce cardiac demand and o2 demand
SE strong opioids
- Resp depression
- Euphoria and detachment and neurologicald epression
- N and V
- pupil constriction as stimulate edinger westphal
- constipation as mew receptors increase SM tone and reduce motility
- skin - histamine release = itching, urticaria, vasodilatation and sweat
- dependance and tolerance - withdrawal reactions
When to reduce strong opioid doses
- hepatic and renal failure
- old
CI to strong opioids
- Resp failure untill senior approved
- biliary colic - spasms sphincter of odii = worse pain
- other sedating drugs
Acute pain what route do you give strong opioids
IV - initial 2-10mg but can give IM and SC
Chronic pain route for strong opioids
oral
statins indications
- Primary prevention CVD
- Secondary prevention CVD
- primary hyeprlipidaemia
MOA of Statins
- inhibit HMG CoA reductase which makes cholesterol
- reduce cholesterol production in liver and increase clearance of LDL
- reduce TG and increase HDL
SE statins
- Headahce
- GI disturbance
- myopathy
- rhabdomyolysis
- rise in ALT
- drug induced hepatitis - rare
reduce dose of statins for which patients
- hepatic impairment
- renal impairment
- pregnant females ir breastfeeding as need cholesterol for foetal development
Interactions with statins
CYP450 reduces metabolism e.g. amiodarone, diltiazem, itraconazole, macrolides. = accumulation = increased SE
- withold statin when necessary STM treatment on above drugs
when should patients take simvastatin
evening as cholesterol synthesis is most in early morning hours
warnings to patients taking sivmastatin or atorvastatin
dont drink too much alcohol, avoid grapefruit juice
what bloods need to be done before statin given
- ALT in LFT at base, 3 and 12 months. rise up to 3x UNL is acceptable but no more
- also check lipid profile before and 3 months after rx if priamry prevention
what disease should be ruled out before prescribing statin for hyperlipidaemia
- Hypothyroid
- note hypothyroid will give increaed risk of myositis with statins
