ACS, Stroke and HF Flashcards
What are the common causes of HF?
Coronary artery disease and hypertension
Symptoms of HF?
- 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
Patient groups at an increased risk of developing HF?
Men
Smokers
Diabetic
Elderly
How is heart failure diagnosed?
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
Lifestyle advice for a patient with HF?
- 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)
What medications should be stopped when diagnosed with HF?
All drugs that worsen HF must be stopped:
CCB (except amlodipine),
Drugs causing hypernatremia e.g., NSAIDs.
Drugs that cause fluid retention
what are the 4 pillars of HF?
- 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)
Specialist treatment for HF
- Sacubitril/valsartan (Entresto)
- Ivabradine (Procoralan)
- Hydralazine & Nitrate (long-acting nitrate).
- Digoxin (mainly used if patient is sedentary or has
HF&AF. - Amiodarone hydrochloride
ACE/ARB and MRA monitoring
- 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
Types of ACS
NSEMI
STEMI
Angina (stable and unstable)
Management of acute attacks for stable angina
GTN spray
GTN spray counselling
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
Expiry of GTN tablets after opening
8 weeks
Long term prevention of stable angina?
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
Nicorandil MHRA
Skin, Mucosa & eye ulceration
Nitrate dose counselling
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
Nitrate side effects
Flushing
Throbbing headache
Postural Hypotension due to vasodilation.
Nitrate interactions
!! Sildenafil (phosphodiesterase- Type 5 inhibitor
Antihypertensives (hypo)
Antidepressant (amitriptyline)
Anti-parkinsonian drugs
Antipsychotics
Diuretic
SGLT2 Inhibitor
Initial management of unstable angina and Myocardial infarction
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.
Long-term management of unstable angina and Myocardial infarction
STEMI and NSTEMI, most patients with unstable Angina= DAPT therapy
STEMI and NSTEMI
BB, ACE inhibitor, DAPT (12 months), high intensity statin
Types of stroke
Ischaemic, TIA and Haemorrhagic
Symptoms of stroke
FAST
Facial weakness
Arm weakness
Speech problems
Time- call 999
Initial management of a TIA and ischaemic stroke
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
Long term management of a TIA and ischaemic stroke
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
Treatment of haemorrhagic stroke
Antihypertensive
Surgery
(Avoid aspirin, statin and anticoagulants due to high risk of bleeding)
Dipyridamole counselling
IM- take 30-60 minutes before food
MR- after food
MR caps= ‘special containers’ - discard 30 days after opening
What antihypertensives should be avoided in HF?
CCB (except amlodipine)
What antihypertensives should be avoided in stroke?
Beta blockers
What marker is elevated in MI
Troponin
