ACS and Heart Failure Flashcards
MOA of Aspirin
NB: anti platelet effect occurs at low doses and lasts for lifetime of platelet
Irreversibly inhibits cox reducing platelet aggregation
Give 3 SEs of Aspirin
- GI irritation, ulcer, haemorrhage
- bronchospasm
- tinnitus
2 contraindications of aspirin?
- children <16
- aspirin sensitivity
- 3rd trimester pregnancy
What conditions should you have a caution about giving aspirin in?
- peptic ulcer disease
- gout
In ACS prescribe a loading dose of aspirin ___mg, followed by a regular daily dose of ___mg
300mg
75mg
Warfarin MOA
-inhibits vitamin K epoxide reductase (responsible for synthesis of clotting factors)
2 indications for the use of statins and 3 examples of names of statins
- primary prevention of CV events (MI/stroke) w QRISK >10% 40yrs+
- secondary prevention of CV events (+lifestyle changes, to prevent events in pts with established CV disease)
- primary hyperlipidaemia treatment
- e.g. rosuvastatin, parvastatin, simvastatin, atorvastatin
MOA of statins
- inhibits HMG Co-A reductase decreasing serum cholesterol levels
- also increases clearance of LDL cholesterol from blood
- indirectly reduces triglyceride levels, and increase HDL
3 statin SEs?
- headache
- GI disturbance
- muscle aches, myopathy
- rhabdomyalisis (rare)
- elevated liver enzymes (e.g ALT)
Statin cautions
- hepatic impairment
- renal impairment - reduce dose
- avoid pregnancy/breastfeeding
Statins are metabolised by
Cytochrome p450 enzymes (so inhibitors of this enzyme reduce the effect of statins)
Give 1 SEs of warfarin use?
- bleeding
- increased risk w trauma and peptic ulcers
- OD can —> spontaneous bleeding
2 Warfarin contraindications:
- pt at immediate risk of haemorrhage (trauma, surgery)
- liver disease
- 1st trimester pregnancy
What type of medications increase warfarin metabolism therefore lower the therapeutic effect and leave pt at risk of clots?
CYP inducers
3 SEs of heparin
- haemorrhage
- bruising at injection site
- hyperkalaemia (effects on adrenal aldosterone secretion)
- heparin induced thrombocytopenia (HIT) - rare immune reaction, low platelet count and thrombosis (!) - more with UFH
Give 2 indications for Heparin (e.g. enoxaparin, dalteparin, UFH, fondaparinux)
- VTE prophylaxis for in-pts, or initial VTE rx until oral anticoagulation is established
- ACS: LMWH/fondaparinux used with antiplatelets to reduce clot progression/maintain revascularisation
Heparin MOA
- antithrombin inactivates clotting factors IIa and Xa
- heparin enhances this anticoagulant effect of the antithrombin
We know that heparins act by (antithrombin inactivates clotting factors IIa and Xa), heparin enhances this anticoagulant effect of the antithrombin, how does the size of the heparin relate to the specificity UFH vs LMWH?
- UFH: large and small molecules, these promote inactivation of both factor IIa and Xa
- LMWH: smaller molecules, is more specific for factor Xa
NB: Fondaparinux is a synthetic polysaccharide that mimics the sequence of the binding site of heparin to AT and is very specific for factor Xa
When should you exercise caution in prescribing heparin?
- increased bleeding risk (clotting disorder, severe uncontrolled HT, recent trauma/surgery)
- withhold before and after an invasive procedure
- renal impairment
What type of heparin should be used in renal impairment and why? /reduce dose
- UFH should be used
- as LMWH and fondapariux will accumulate so requires a much lower dose/don’t use
In major bleeding, what 2 agents can reverse UFH action but is less effective for LMWH (and no effect on fondaparinux)
Protamine
Andexanet
A typical VTE prophylaxis dose is dalteparin ___ UNITS daily, mode of administration is ___, in renal impairment can give ___ ““UNITS “” mode 12-hrly
- 5000 UNITS
- Subcutaneous (into abdo wall not arm as can –> uncomfortable/disabling bruising)
- Unfractionated Heparin 5000 UNITS
LMWH and fondaparinux effect is predictable enough to not need monitoring, but UFH when used therepeutically must have the dose titrated against the activated ___ ____ ratio (APTR) with a usual target of ___. FBC, clotting and renal profiles must be checked pre-rx, what 2 blood tests must be monitored in case of HIT?
- Activated partial Thromboplastin Ratio (target 1.5-2.5)
- Platelet count and serum K+
3 indications for the use of ACEi
- HT
- Chronic HF
- Ischaemic Heart Disease
- Diabetic Nephropathy and CKD w proteinuria
MOA ACEi (relate to effect on BP, intra-glomerular effect and benefit for HF)
- block ACE so prevent ang I –> ang II conversion
- ang II is a v.constrictor and stimulates aldosterone secretion
- blocking ang II reduces TPR (afterload) and lowers BP, also dilates the efferent arteriole so reduces intraglomerular pressure and slows CKD progression
- lower aldosterone = more sodium and water excreted so lower CVP (preload) good for HF
Give 2 examples of ACEi, and 3 common side effects
-ramipril
-lisinopril
-perindopil
SEs: hypotension (esp after 1st dose), persistent dry cough, high K+, worsen renal failure
Explain the following SEs of ACEi:
- persistent dry cough,
- high K+,
- worsen renal failure-esp with renal artery stenosis
- cough: due to increased bradykinin levels-usually inactivated by ACE
- high K+: as aldosterone levels are lower, potassium retention is promoted
- worsen renal failure: pt may rely on constriction of efferent glomerular arteriole to maintain GFR
Name 2 contraindications and 2 cautions for the administration of ACE inhibitors:
advice regarding K+?
CI: RENAL ARTERY STENOSIS, AKI
Caution: pregnant, breastfeeding, CKD - although can help some, use lower doses and monitor carefully
-avoid prescribing with other potassium elevating drugs unless under specialist
The combination of ACEi with which medication class is associated with a marked increase in risk of nephrotoxicity?
NSAIDs
Ramipril daily dose in HF is __mg, for other indications start dose is ___mg.
These are titrated up to a max of __mg daily over weeks according to pts response, SEs and renal function
- 1.25mg HF
- 2.5mg other indications
- up to 10mg
Give 3 examples of ADP-receptor antagonist antiplatelet drugs used with aspirin for ACS treatment with aim to prevent/limit __ ___ and reduce subsequent ___
- clopidogrel, ticagrelor, prasugrel
- limit arterial thrombosis
- reduce mortality
Other than ACS treatment, give 2 indications for ADP-receptor antagonist antiplatelet drugs.
- prevent coronary artery stent occlusion (+aspirin)
- long term 2dry prevention of thrombotic arterial events in CVD, cerebro-vasc disease and PVD