ACS, Stroke and HF

Question 1

What are the common causes of HF?

Answer 1

Coronary artery disease and hypertension

Question 2

Symptoms of HF?

Answer 2

• Oedema
  - Pulmonary oedema- SOB, and persistent cough,
  bloodstained sputum. (cracking chest)
  - Peripheral- swollen ankles/legs
• Fatigue, reduced exercise tolerance (due to inability of
  heart to supply major organs with
  blood and oxygen that it needs)
• Chest pains, palpitations

Question 3

Patient groups at an increased risk of developing HF?

Answer 3

Men
Smokers
Diabetic
Elderly

Question 4

How is heart failure diagnosed?

Answer 4

Physical examination: faster than normal pulse, swelling in legs, pulmonary oedema (cracking) abdominal examination- larger liver

BNP or NT-proBNP blood test

echocardiogram to determine type of heart failure

Question 5

Lifestyle advice for a patient with HF?

Answer 5

• Smoking cessation and reduce alcohol intake
  Exercise
• Weigh regularly- report if large increase over 2 days (e.g., 1.5-2kg)
• Balanced diet, Restrict salt in diet (<6g daily= recommended dose)

Question 6

What medications should be stopped when diagnosed with HF?

Answer 6

All drugs that worsen HF must be stopped:
CCB (except amlodipine),
Drugs causing hypernatremia e.g., NSAIDs.
Drugs that cause fluid retention

Question 7

what are the 4 pillars of HF?

Answer 7

• ACE (perindopril, ramipril, captopril, enalapril maleate, lisinopril, quinapril or fosinopril sodium)
  or ARB (candesartan cilexetil, losartan potassium, or valsartan)
• BB (bisoprolol, nebivolol, carvidelol)
• MRA (spironolactone, Eplerenone)
• SGLT2 (dapagliflozin, empagliflozin)

Question 8

Specialist treatment for HF

Answer 8

• Sacubitril/valsartan (Entresto)
• Ivabradine (Procoralan)
• Hydralazine & Nitrate (long-acting nitrate).
• Digoxin (mainly used if patient is sedentary or has
  HF&AF.
• Amiodarone hydrochloride

Question 9

ACE/ARB and MRA monitoring

Answer 9

• U&Es (K and Na), and blood pressure should be checked prior to starting treatment, 1-2 weeks after starting treatment, and at each dose increment.
• reached target/max dose= monitored monthly for 3 months and then at least every 6 months

Question 10

Types of ACS

Answer 10

NSEMI
STEMI
Angina (stable and unstable)

Question 11

Management of acute attacks for stable angina

Answer 11

GTN spray

Question 12

GTN spray counselling

Answer 12

1 tablet/spray, dose may be repeated at 5 minute intervals if required; seek urgent medical attention if symptoms have not resolved 5 minutes after the second dose, or earlier if the pain is intensifying or the person is unwell.
max 3 doses

Question 13

Expiry of GTN tablets after opening

Answer 13

8 weeks

Question 14

Long term prevention of stable angina?

Answer 14

GTN/LA acting
1) Beta-Blocker
If unsuitable use a rate limiting CCB
2) Beta-Blocker + Calcium channel blocker
Dual therapy if BB alone is ineffective then add
CCB. (DO NOT USE VERAPAMIL and BB as they can
cause severe cardio depression)
3) IF BB and CCB contraindicated= Vasodilator as monotherapy
Long-acting nitrate- ivabradine, ranolazine, nicorandil

Question 15

Nicorandil MHRA

Answer 15

Skin, Mucosa & eye ulceration

Question 16

Nitrate dose counselling

Answer 16

Leave patches off for 8-12 hours (overnight)

LONG- ACTING NITRATE- take after 8 hours instead of 12 (covers a 16-hour period vs 24 hours = 8-hour free period)

OD nitrates take each morning

Question 17

Nitrate side effects

Answer 17

Flushing
Throbbing headache
Postural Hypotension due to vasodilation.

Question 18

Nitrate interactions

Answer 18

!! Sildenafil (phosphodiesterase- Type 5 inhibitor

Antihypertensives (hypo)

Antidepressant (amitriptyline)

Anti-parkinsonian drugs

Antipsychotics

Diuretic

SGLT2 Inhibitor

Question 19

Initial management of unstable angina and Myocardial infarction

Answer 19

Pain relief- GTN and IV opioids (Morphine or diamorphine)
N&V- metoclopramide
300mg aspirin
Monitor: oxygen saturations and glucose concentration (above 11mmol= treat asap with insulin.

Question 20

Long-term management of unstable angina and Myocardial infarction

Answer 20

STEMI and NSTEMI, most patients with unstable Angina= DAPT therapy
STEMI and NSTEMI
BB, ACE inhibitor, DAPT (12 months), high intensity statin

Question 21

Types of stroke

Answer 21

Ischaemic, TIA and Haemorrhagic

Question 22

Symptoms of stroke

Answer 22

FAST
Facial weakness
Arm weakness
Speech problems
Time- call 999

Question 23

Initial management of a TIA and ischaemic stroke

Answer 23

Initial management of ischaemic: If within 4.5 hours then alteplase

Both:
300mg aspirin for 14 days (PPI if history of dyspepsia)
if alteplase has been given then wait 24 hours for
aspirin

Question 24

Long term management of a TIA and ischaemic stroke

Answer 24

Clopidogrel,
if CI then MR dipyridamole + aspirin.
(Dipyridamol and aspirin can be used alone if CI)

• High intensity statin
• Anti-hypertensive (at least
  NOT BB

Question 25

Treatment of haemorrhagic stroke

Answer 25

Antihypertensive
Surgery

(Avoid aspirin, statin and anticoagulants due to high risk of bleeding)

Question 26

Dipyridamole counselling

Answer 26

IM- take 30-60 minutes before food
MR- after food
MR caps= ‘special containers’ - discard 30 days after opening

Question 27

What antihypertensives should be avoided in HF?

Answer 27

CCB (except amlodipine)

Question 28

What antihypertensives should be avoided in stroke?

Answer 28

Beta blockers

Question 29

What marker is elevated in MI

Answer 29

Troponin