BNF Chapter 2: The Cardiovascular System Flashcards
Which thiazide diurectic is first-line for hypertension?
Bendroflumethiazide 2.5mg
Why are thiazide-like diuretics second-line when compared to thiazide diurectics?
More expensive
What loop diuretic is first-line for hypertension?
Furosemide
What is the ONLY indication for spironolactone?
Heart failure (it is first-line for heart failure with reduced ejection fraction)
What type of diuretic is spironolactone?
Potassium-sparing
Which diuretics can cause a fall in potassium during the first few weeks of treatment?
Thiazide
Loop
What three types of drugs should not be combined when treating heart failure due to potentially fatal hyperkalaemia?
ACE inhibitor
ARB
Mineralocorticoid receptor antagonist (spironolactone)
What three drugs are anti-arrythmics, and when would they be used?
Amiodarone- initiated with a loading dose, require monitoring up to 12-months after discontinuing
Dronedarone- maintaining sinus rhythm after successful cardioversion
Mexiletine for life-threatening ventricular arrhythmias
What are some examples of beta blockers?
Atenolol
Bisoprolol
Carvedilol
Labetalol
Target doses of beta-blockers in heart failure (if tolerated):
- Bisoprolol- 10mg OD
-Carvedilol- 25-50mg BD
What type of drug is doxazosin, and when would it be used for hypertension and heart failure?
Alpha-adrenoceptor blocking drug, as a fourth line add on therapy
ACEi (Ramipril, Lisinopril)
- Not for use in pregnancy
-Black/african american patients should use an ARB over an ACEi as first-line for hypertension
-Perindopril can only be used on advice from a stroke physician for secondary stroke or cardiovascular incident prevention
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ARBs (Losartan, Candesartan)
-Losartan is the first-choice ARB for all indications except heart failure
- Candesartan is the first-choice ARB for heart failure.
-Not recommended in pregnancy
-Should be reserved for patients that are completely intolerant to ACEis.
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When would losartan be a first-choice ARB as a medication?
For all cardiovascular indications except HF
When would candesartan be a first choice ARB?
HF
When would sacubitril/valsartan be used?
For treating symptomatic chronic heart failure with reduced ejection fraction
REMEMBER: The use of ACEis and ARBs in combination is NOT recommended- they are both renin-angiotensin hormone system blocking agents.
In HF, a few patients may medically require both an ACEi and ARB; candesartan and valsartan are licensed as add on therapy to ACEi for symptomatic heart failure if needed.
When would the use of an ACEi and an ARB in combination be licensed?
Symptomatic heart failure (only if necessary)
Target Doses of ACEis and ARBs in HEART FAILURE (if tolerated)
Lisinopril: 20-35mg OD
Ramipril: 10mg OD or 5mg BD
Enalapril: 10-20mg BD
Losartan: 150mg OD
Candesartan: 32mg OD
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SGLT2i in HF
- Includes dapagliflozin and empagliflozin
- Add on treatment option for HF- not to be used for T1 diabetic patients
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NITRATES FOR ANGINA
- GTN spray/tabs
-Isosorbide mononitrate
-Initiated at a low dose, gradually increase
-Isosorbide mononitrate- BD regimen (OD preparations not cost-effective), second dose after 8hr rather than 12hr to allow a nitrate-free period (avoids tolerance developing)
Why should the second daily dose of isosorbide mononitrate be taken 8hr after the first?
Allows for a nitrate-free period to prevent tolerance from developing
What are some examples of CCBs?
Amlodipine
Diltiazam
Nifedipine
Verapamil
Why should verapamil not be prescribed to patients taking beta-blockers?
Together they may precipitate profound bradycardia or hypotension
What are the two types of oral anti-coagulants?
Non-vitamin K antagonist oral anti-coagulant (NOAC)
Vitamin K antagonist (warfarin)
What are some examples of NOACs?
Edoxaban
Rivaroxaban
Apixaban
Dabigatran
What is the first-line NOAC for AF patients when anticoagulation is necessary?
Edoxaban
NOACs
-Not recommended for patients who have antiphospholipid syndrome
-Interacts with erythromycin and clarithromycin potentially
Warfarin- initiated with a loading dose
Which oral
anticoagulant is first choice in breastfeeding women?
Warfarin
What are some examples of antiplatelet agents?
Aspirin 75mg disp
Clopidogrel 75mg
Prasugrel
Ticagrelor
What is the recommended first-choice antiplatelet therapy for the secondary prevention of CVD?
Aspirin (aspirin and clopidogrel are NOT recommended for primary prevention of CV events)
Why should enteric coated aspirin not be routinely used?
No evidence to suggest that EC aspirin has a lower DI bleed risk than dispersible, also is more expensive
What three things can you do if a patient experiences dyspepsia whilst on low dose aspirin?
- Take aspirin with food
-Reduce dose to the minimum effective dose
-Conisder co-prescribing antacid or low dose PPI
When would clopidogrel be recommended as the first choice antiplatelet therapy?
In patients who have had an ischaemic stroke, TIA or have peripheral arterial disease.
Which PPIs are preferred if given alongisde clopidogrel?
Lanzoprazole or pantoprazole
What can tranexamic acid 500mg tablets be used to treat?
Menorrhagia
What statin can be used in patients with swallowing difficulties?
Atorvastatin chewable tablets
When may rosuvastatin be used as a second-line to atorvastatin?
If a patient has a complete intolerance to atorvastatin or a partial tolerance to other statins but is not achieving target lipid reduction
When would ezetimibe be a treatment option for cholesterol reduction?
When a patient is truly intolerant to statins
Pharmacological treatment of angina
- Short-acting nitrate (e.g. GTN) to prevent and treat episodes
1st line: either a beta-blocker (e.g. atenolol 100mg OD) or CCB (diltiazam or verapamil 80-120mg TDS)
2nd line: combination of the previous two
3rd line: Isosorbide mononitrate with asymmetrical dosing.
Pharmacological treatment of angina
- Short-acting nitrate (e.g. GTN) to prevent and treat episodes
1st line: either a beta-blocker (e.g. atenolol) or CCB (diltiazam or verapamil)- decide which based on pt preference, comorbidities and contraindications.
2nd line: combination of the previous two
3rd line: Isosorbide mononitrate with asymmetrical dosing.
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Why are rate-limiting CCBs such as diltiazam and verapamil preferred to a dihydropyridine CCB (e.g. amlodipine) when treating angina using monotherapy?
RL CCBs have the additional act of decreasing myocardial contractility and HR
Dihydropyridine CCBs can sometimes cause reflex tachycardia, which can worsen angina symptoms
COMBINATION THERAPY:
-Pt on a beta-blocker: prescribe dihydropyridine CCB such as amlodipine
-Pt not taking a beta-blocker: prescribe a rate-limiting CCB such as verapamil or diltiazam.
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Blood Pressure Targets:
Under 80= below 140/90
Over 80= below 150/90
Type 1 diabetics with hypertension with CKD and ACR (albumin:creatinine ratio) below 70mg/mmol: below 140/90
^^^ but with ACR above 70: below 130/80
T1 diabetic aged 80 or over: below 150/90
xx
What is the first-choice medication type to treat a diabetic patient that has just been diagnosed with hypertension?
An ACEi or ARB
What would be added after an ACEi/ARB if BP was still unsatisfactory (T2 diabetic patient)?
Thiazide-like diuretic (would add a CCB if this was still ineffective)
What would be the first-line antihypertensive treatment for someone under 55 that was not black african?
ACEi or ARB (would then progress the same as if the pt was type 2 diabetic)
What would be the first line antihypertensive for a patient over 55 or a black african patient?
CCB
For a patient over 55 or black african, what would be the next step if a CCB did not work?
Add in an ACEi or ARB or Thiazide-like diuretic
Hypertension treatment in patients with CKD
Diabetes:
-ACR >3mg/mmol with or without hypertension or
CKD stage1 = Offer ACEi or ARB
-Type 2 diabetes and ACR >30 mg/mmol = offer an SGLT2 inhibitor, in addition to the ACEi or ARB
-Type 2 diabetes and ACR >3 mg/mmol
(NICE NG28)= same as above
Non-diabetic:
-Hypertension and ACR <30mg/mmol = offer choice of antihypertensive treatment according to NICE
Hypertension and ACR ≥30mg/mmol1= offer ACEi or ARB
Summary- treat with ACEi first and move to ARB if the ACEi is not tolerated. Must titrate the drug to the maximum tolerated therapeutic dose before adding a second-line agent.
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Which CCBs can potentially cause ankle swelling (oedema)?
Dihydropyridine CCBs, such as amlodipine and felodipine
Antiplatelet therapy for the prevention of occlusive vascular events
Had an ischaemic stroke/TIA: Clopidogrel —> Aspirin + Dipyridamole MR (if one of these two is CI or not tolerated then just use the other one by itself)
Had an MI: Aspirin —> Clopidogrel
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Which antiplatelet agent should be used first-line following a stroke or TIA?
Clopidogrel
Which antiplatelet agent should be used first-line following a heart attack?
Aspirin
When is the long-term use of low-dose aspirin recommended?
In patients with established CVD (secondary prevention)
When is the long-term use of low-dose aspirin recommended?
In patients with established CVD (secondary prevention)
What is clopidogrel used for?
Prevention of atherothrombotic events in patients with a history of symptomatic ischaemic disease, e.g. ischaemic stroke
Can also be used in combination with low-dose aspirin for the prevention of atherothombotic and thromboembolic events in patients with AF, and for whom warfarin is unsuitable
Antiplatelets for Secondary CVD Prevention
-Antiplatelet treatment for secondary CVD prevention should be offered to people with ACS, angina, AF, peripheral arterial disease. Also to people following a stroke or TIA, MI or stent implantation.
-Angina- Aspirin 75mg, clopidogrel 75mg is aspirin unsuitable
-AF- Aspirin 75mg daily plus clopidogrel 75mg daily (dual antiplatelet therapy)- usually anticoagulants are used (apixaban, edoxaban, etc) BUT ANTIPLATELETS CAN BE USED IN PATIENTS WHO DO NOT WANT TO TAKE ANTICOAGULANTS.
PCI in patients with stable coronary artery disease- DAPT of aspirin+clopidgrel
-ACS which is medically managed OR PCI for people with ACS OR ACS patients undergoing coronary artery bypass grafting- aspirin 75mg daily plus ticagrelor 90mg BD for 12 months
-Stroke or TIA- clopidogrel 75mg daily, or MR dipyridamole 200mg BD with aspirin 75mg if clopidogrel is unsuitable.
What is acute coronary syndrome (ACS)?
Encompasses a spectrum of conditions such as MI with or without ST-segment elevation (STEMI or NSTEMI), and unstable angina. Results from the formation of a thrombus on an atheromatous plaque in a coronary artery. Definitive diagnosis is based on clinical presentation, ECG changes and measurement of biochemical caridac markers.
What usually causes a STEMI?
A complete and persistent blockage of an artery resulting in myocardial necrosis with ST-segment elevation seen on the ECG.
What usually causes an NSTEMI and unstable agina?
A partial or intermittent blockage of the artery, usually resulting in myocardial necrosis in NSTEMI but not in unstable angina.
Non-Drug Treatment of ACS
-Revascularisation procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) are often appropriate, alongside drug treatment, for patients with an ACS. The decision regarding choice of these management options depends on multiple factors such as the type of ACS, time since symptom onset, the patient’s clinical condition, comorbidities, and their formally-assessed risk of future cardiovascular events
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Initial ACS Management
-Support and pain relief (GTN, morphine), and prevention of progression of the cardiac injury.
-Aspirin loading dose ASAP
-Closely monitor for _, and insulin administered if BG is above 11mmol.litre.
Hyperglycaemia
STEMI Management
-Aim is to restore cornonary blood flow asap
-Coronary reperfusion therapy (primary PCI or fibrinolysis) should be deliverd asap. Primary PCI is preferred for most patients.
-In addition to aspirin, most patients should be offered a second antiplatelet (prasugrel, ticagrelor, clopidogrel)- depends on planned intervention and bleed risk. Prasugrel preferred for most patients undergoing a primary PCI.
-Fibrinolysis will require patients to receive an antithrombin agent at the same time.
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What are the two coronary reperfusion therapy options for a STEMI?
Primary PCI
Fibrinolysis
NSTEMI and Unstable Angina Management
-May be managed with reperfusion therapy, similar to STEMI management
-Should be offered a second antiplatelet agent in addition to aspirin, choice is dependent on planned intervention.
-Antithrombin therapy with fondaparinux should also be offered, heparin used in patients with significant _ impairment.
Renal
Secondary Prevention of Cardiovascular Events
-Offer all patients that have had an ACS a cardiac rehabilitation programme- lifestyle advice, stress management ect.
-Secondary prevention should involve an ACE inhibitor, a beta-blocker, dual antiplatelet therapy and a statin.
-ACE inhibitor should be started asap and continued indefinitely, an ARB can be used if they are intolerance to the ACEi.
-Beta-blocker started asap and continued indefinitely for patients with a reduced left ventricular ejection fraction (LVEF). Without LVEF, may be appropirate to discontinue after 12 months.
-Aspirin should be continued indefinitely. Dual antiplatelet therapy (aspirin + second antiplatelet) should be continued for up to 12 months unless CI. Clopidogrel monotherapy is an alternative in patients where aspirin is unsuitable.
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What medication should a patient be started on following an ACS?
ACEi (or ARB is not tolerated)- continued indefinitely
Beta-blocker- stopped after 12 months if no LVEF
Dual antiplatelet therapy (aspirin continued indefinitely, DAT stopped by 12 months)
Statin
What are the two ways that atrial fibrillation can be managed?
Controlling the ventricular rate (‘rate control’)
OR
Attempting to restore and maintain sinus rhythm (‘rhythm control’)
If a patient presents with arrhythmias, rate OR rhythm control can be offered if the onset was less than 48 hours. Rate control is preferred if the arrhythmia onset is over 48 hours or uncertain.
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Cardioversion
-Sinus rhythm can be restored by electrical cardioversion or by pharmacological cardioversion with an anti-arrhythmic drug (flecainide acetate or amiodarone hydrochloride)
-If AF has been present for over 48 hours, cardioversion is preferred over drugs, but delay until pt has been fully anticoagulated for at least 3 weeks.
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What are some examples of anti-arrhythmic drugs?
Flecainide acetate
Amiodarone hydrochloride
Is ‘rate control’ or ‘rhythm control’ the preferred first-line treatment strategy for AF?
Rate control (except in patients with new onset AF, AF with a reversible cause or heart failure primarily caused by AF)
What drugs can be used for ‘rate control’ associated with arrhythmias?
Ventricular rate can be controlled with a standard beta-blocker (not sotalol)
OR
a rate-limiting CCB such as diltiazem or verapamil as monotherapy
Choice of drug should depend on individual symptoms, HR, comorbidities and patient preference
Drug Treatment for ‘Rate Control’ of Arrhythmias
-Standard beta-blocker or rate-limiting CCB such as diltiazem or verapamil. Atenolol may be preferred as it is taken OD.
-Digoxin monotherapy can be considered for initial rate control in patients with non-paroxysmal AF who are predominantly sedentary
-If monotherapy fails to accurately control ventricular rate, consider combination therapy with any of the two: beta-blocker, digoxin or diltiazem.
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If monotherapy fails to control ventricular rate in arrhythmia, what drugs can be used in combination?
Any two from:
-A beta-blocker
-Diltiazem
-Digoxin
A beta-blocker and digoxin combination tends to be preferred.
Drug Treatment for ‘Rhythm Control’ in Arrhythmia
-Drug treatment first-line is a standard beta-blocker (NOT sotalol)
-If a beta-blocker is not appropriate/ineffective the consider an anti-arrhythmic drug: amiodarone, flecainide, propafenone or sotalol.
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What drugs can be used for rhythm control in arrhythmia if standard beta-blockers are appropriate?
Amiodarone
Flecainide
Propafenone
Sotalol
Anticoagulation and Stroke Prevention
-Patients with AF should be assessed individually for their risk of stroke vs risk of bleeding.
-Offer anticoagulation to all patients with a CHA2DS2-VASc of 2 or above.
-Heparin should be offered to patients with new-onset AF who are receiving subtherapeutic or no anticoagulation therapy, untill assessment is made and appropriate anticoagulation is started.
Oral anticoagulation should be offered to patients with a confirmed AF diagnosis where stable sinus rhythm has not be successfully restored within 48h of onset.
-DOACs such as apixaban, dabigatran, edoxaban or rivaroxaban for non-valuvular AF.
-Offer warfarin if DOAC unsuitable
-Aspirin as monotherapy not recommended for stroke prevention in AF patients
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What is the first-line anticoagulation option for patients with AF if anticoagulation is supported?
DOACs such as apixaban, dabigatran, edoxaban or rivaroxaban.
Atrial Flutter
-Same as atrial fibrillation for treatment options, but generally responds less well to drug treatment
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