cardio Flashcards
What are the two main focusses when treating arrhythmia’s?
Rate control and rhthym control
what does “rate control” control?
Ventricular rate
What does “rhythm control” control?
the sinus rhythm
how do you control rhythm in arrthymias?
Cardioversion
Two types: Electrical and pharmacological
If AF symptoms are present for more than 48 hours what type of cardio version do you give?
-Electrical cardioversion is preferred but should not be attempted until the patient is fully coagulated for three weeks as a clot could come loose and cause a stroke.
-
If you want to treat a new onset arrhytmia (AF), and it has life threatening haemodynamic instability (emergency) , how do you treat it?
- emergency electrical cardioversion
- give parenteral anticoagulant and rule out left atrial thrombus immediately before procedure
In acute new-onset presentation of AF how do you treat it if symptoms have presented for less than 48 hours?
- Rate or rhythm control - electrical cardioversion or amiodarone/flecanidie
In acute new-onset presentation of AF how do you treat it if symptoms have presented for more than 48 hours?
- RATE CONTROL
- verapamil, beta blocker
What is the first-line maintenance drug treatment for AF?
first line: RATE CONTROL
- Beta blocker (not sotalol)
- Rate limiting CCB - verapamil or diltaziam
- Digoxin ( only be considered in patients with non-paroxysmal AF who are predominantly sedentary)
if monotherapy doesn’t work, move on to dual therapy then rhythm control
what is the second-line maintanance drug treatment of AF?
- RHYTHM CONTROL
- Beta blocker or oral anti-arrythmic drug amiodarone, flecanide
How do you treat paroxysmal AF?
- Ventricular or rhythm control - standard Beta blocker or oral-antiarrhythmic drug. Dronedarone
All patients with AF should be assessed for their risk of stroke and need for thromboprophylaxis (anticoagulant). what scores are used to assess this?
CHADVASC Score - Assesses risk of stroke
ORBIT bleeding risk tool (HASBLED) - Risk of bleeding score
what risk factors does the CHADVASC score take into account and what score must someone have to be on anticoagulant?
- Age
- Gender - Female (scores 1)
- History of VTE , congestive heart failure
- hypertension
- diabetes
- Anticoagulation should be offered for stroke prevention to all patients with a CHA2DS2-VASc score of 2 or above.
How often should CHADVASC scores be reviewed in a patient?
Annually
Why is an anticoagulant given to patients who have AF?
Stroke prevention
If a patient with AF has a CHADVASC score of 2 and is going to be given an anticoagulant, what anticoagulant is given and what does the choice of anticoagulant depend on?
NEW ONSET AF:
- parenteral anticoagulant is given like heparin
Diagnosed AF:
- Warfarin or NOAC
In treatment of AF, when should flecainide and propafenone be avoided?
In patients with known inschaemic or structural heart disease.
How do you treat patients with symptomatic paroxysmal AF with infrequent episodes?
“PILL IN POCKET” - if patient has infrequent episodes they can treat themselves when they get symptoms with flecainide or propafenone.
How do you treat pulseless ventricular tachycardia ?
immediate defibrillation and CPR.
How do you treat unstable ventricular tachycardia?
direct current cardioversion
if this doesn’t work IV amiodarone and repeat direct current
How do you treat stable sustained ventricular tachycardia?
IV anti-arrhymic drug ( amiodarone, flecainide, propafenone)
What is given as maintenance therapy after a ventricular tachycardia?
- implantable cardioverter defibrillator
- B-blocker or combined with amiodarone
What is torsade de pointes and what can cause it?
Form of ventricular tachycardia associated with a long QT interval
- caused by drugs, hypokalaemia, severe bradycardia etc
How do you treat torsade de pointes?
IV magnesium sulfate
B-blocker can be considered (not sotalol)
What is paroxysmal supra ventricular tachycardia and how can you non-pharmalogically treat it?
- tachycardia that spontaneously terminates
- another way to terminate it is through the valsalva manouvre, immersing the face in cold water or carotid sinus massage.
how do you treat paroxysmal supraventricular tachycardia and what are the contraindications of the drug? what is the second line treatment
- IV adenosine
- contraindicated in asthma and COPD,
SECOND LINE:
verapamil
contraindicated in patients recently treated with b-blockers
what are the directions for administration for adenosine?
Rapid IV - give over 2 seconds into central or large peripheral vein followed by rapid sodium chloride 0.9% flush.
how do you treat paroxysmal supraventricular tachycardia in haemodynaically unstable patients?
Direct current cardioversion
how do you treat patients with recurrent episodes of paroxysmal supraventricular tachycardia?
- catheter ablation
- diltiazem, verapamil
- beta blockers including sotalol
- anti-arrhytmics like flecainide or propafenone
What type of anti-arrhythmic drug is amiodaron, the indication for amiodarone ?
Class III anti-arrhythmic
treatment of arrhythmias - supraventricular and ventricular
what is the initial loading dose of amiodarone?
- 200mg TDS for 7 days
- 200mg BD for 7 days
- 200mg OD as maintanance
What kind of side effects can amioadone cause ? (special side effects)
EYES
- Corneal microdeposits
- counsel patients on driving at night-time as there could be a glare due to blurred vision.
- optic neuropathy can occur so patients should stop taking if Vision is impaired as can cause blindness.
SKIN
- phototoxicity
- patients should be advised to shield skin from light during treatment and for several months after discontinuing amiodarone. use wide-spectrum sun cream.
NERVES
- peripheral neuropathy
LUNGS
- If new or progressive shortness of breath or cough develops in patients , pulmonary toxicity should be suspected. Pulmonary toxicity is usually reversible following early withdrawal of amiodarone.
LIVER
- hepatotoxicity
- stop treatment if severe liver function abnormalities or clinical signs of liver disease develops
THYROID DYSFUNCTION
- it contains iodine which can cause hypo and hyperthyroidism.
- hypothyroidism can be treated with levothyroxine without stopped amiodarone.
What is the MHRA alert for amiodarone?
- use of amiodarone with sofosbuvir and daclatasvir, simeprevir and sofosbuvir, or sofosbuvir and ledipasvir can cause bradycardia and heart block
- amiodarone can cause eyes, skin, liver, thyroid and lung problems.
What are the monitoring requirements for amiodarone?
- Liver function tests before treatment and every 6 months
- thyroid function tests before treatment and every 6 months : T3,T4 and TSH
- serum potassium levels
- Chest X Ray
- Patients taking sofosbuvir and daclatasvir, simeprevir and sofosbuvir, or sofosbuvir and ledipasvir should be closely monitored during first weeks of treatment. pt’s at high risk of bradycardia should be monitored for 48 hours in clinical setting.
- blood pressure and ECG - in IV use
Does amioadarone have a long half-life?
Yes 50 days so it can interact with drugs several months after stopping
What drugs does amiodarone interact with?
- Grapefruit Juice - Increased plasma amiodarone concentrations
- Warfarin, phenytoin, digoxin - it is an enzyme inhibitor
- Statins - risk of myopathy
- BBlockers, rate limiting CCBs - can cause bradycardia, AV block and myocardial depression
- Quinolones, macrolides, TCAs, SSRIs, lithium, quinine, anti-malarial, antipsychotics - QT prolongation - increased risk of ventricular arrhythmias
What drug class is digoxin and how does it work?
cardiac glycoside
What drug class is digoxn and how does it work?
cardiac glycoside and it increases the force of myocardial contraction and reduces conductivity within the AV node.
Digoxin is a narrow therapeutic drug. what is its therapeutic level?
1-2micrograms/L
After giving digoxin loading dose, when should its therapeutic levels be monitored?
6 hours after dose.
Regalar monitoring is not require during maintanance treatment unless toxicity suspected or in renal impairment (renally cleared)
What doses of digoxin do you give for maintanance of arrthymias and heart failure?
arrhytmias: 125-250 microgram
heart failure: 62.5-125 microgram
What are the signs of digoxin toxicity?
- SLOW AND SICK
- bradycardia and heart block
- nausea and vomiting and diarrhoea and abdominal pain
- blurred or yellow vision
- confusion, delirium
- rash
what is the treatment of digoxin?
withdraw
correct elelctrolyte imbalance
What are the main interactions with digoxin?
- HYPOkalaemia is a risk factor for digoxin toxicity -so dont give it with meds that cause hypokalaemia like diuretics, B2 agonists, steroids.
- Increased plasma digoxin concentration = amiodarone, rate limiting CCB, macrolides,=
- Decreased plasma digoxin concentrations = St John’s wort, rifampicin
- Reduced renal excretion - NSAIDs, ACE inhibitors
What are the two types of venous thromboembolism?
- Deep vein thrombosis
2. Pulmonary embolism
In what patients are anti-embolism stockings unsuitable?
- acute stroke
In VTE prophylaxis , when would you use unfractionated heparin?
in renal impairment
In VTE prophylaxis , when would you use fondaprinux?
patients undergoing abdominal, bariatric, thoracic or cardiac surgery, or for patients with lower limb immobilisation or fragility fractures of the pelvis, hip or proximal femur.
how long would u give VTE prophylaxis for general surgery, major cancer surgery and spinal surgery?
general: 7 days post surgery
major cancer surgery: 28 days
spinal surgery: 30 days
why can heparins be used to treat VTE in pregnancy?
it does not cross placenta
which heparin is preferred in VTE in pregnancy?
LWMH
-
Which heparin has the shorter duration of action?
unfractionated heparin
what is the antidote for heparin?
protamine
What are the main side effects of heparin?
- HAEMORRHAGE
- withdraw heparin.
- if rapid reversal needed, give antidote protamine (only partially reverses effects of LMWH) - HEPARIN-INDUCED THROMBOCYTOPENIA
- 30% lower platelet count, thrombosis or skin allergy. - HYPERKALAEMIA
- heparin inhibits aldesterone secretion
- risk increased in patients with diabetes, renal failure, raised plasma potassium
What monitoring is needed for heparin?
- Heparin-induced thrombocytopenia
- platelet count before treatment. regular monitoring of treatment if given for more than 4 days. - Hyperkalaemia
- monitor plasma potassium levels in pts at risk of hyperkalaemia, escp if treatment is longer than 7 days.
what colour is wafarin 0.5mg, 1mg, 3mg and 5mg?
0.5mg - white
1mg - brown
3mg - blue
5mg - pink
How long does it take warfain to work?
48-72 hours
What dose do you give to patients starting warfarin and what is the maintanance dose?
5mg initially and monitor INR every 1-2 days.
maintanance dose is 3-9mg.
How long should patients be on warfarin for the treatment of isolated calf-vein deep-vein thrombosis?
6 weeks.
How long should patients be on warfarin in provoked VTE?
3 months
What is duration of treatment for provoked VTE (when caused by pregnancy, taking combined oral contraceptive or leg plaster) and unprovoked VTE (AF) ?
provoked: 3 months
unprovoked: at least 3 months
What is the target INR for VTE and recurrent VTE?
VTE (AF, PE, mitral stenosis, Myocarial infarction, cardioversion—target INR should be achieved at least 3 weeks before cardioversion and anticoagulation should continue for at least 4 weeks after the procedure (higher target values, such as an INR of 3, can be used for up to 4 weeks before the procedure to avoid cancellations due to low INR): 2.5
Recurrent VTE: 3.5
What are the three MHRA alerts for warfarin?
- Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin K antagonists and changes in INR. INR should be closely monitored in patients taking both.
- Monitor patients during the covid-19 pandemic. Acute illness may exaggerate effect of warfarin. monitor INR continually. warfarin may interact with other medicines .
- Calciphylaxis - warfarin can cause calciphylaxis. pt’s should consult doctor if they develop a painful skin rash. most commonly found in patients with known risk factors like end-stage Renal disease.
What is the caution of prescribing warfarin in elderly people?
prescription potentially innappropriate if:
- significant bleeding risk - uncontrolled severe hypertension
- part of dual therapy with antiplatelet agent in patients with stable coronary, cerebrovascular or peripheral arterial disease,
- DVT without continuing provoking factors for longer than 6 months
- 1st PE without continuing provoking factors for longer than 12 months
What food interactions are there with warfarin?
- Changes in diet (involving salads and legs) and alcohol consumption can affect anticoagulant control.
- Pomegranate juice increases INR.
What side effects does warfarin cause?
- BLEEDING. in major bleeding, stop warfarin, antidote: IV phytomenadione (vitamin K) and dried prothrombin complex or fresh frozen plasma.
- Calciphylaxis - painful skin rash.
Is warfarin safe in women of child bearing age?§
they should be warned of the danger of teratogenicity
what are the types of vitamin k antagonists?
warfarin, phenindione, acenocoumarol -
can vitamin k antagonists be given in pregnancy?
- do not give in 1st trimester of pregnancy
- avoid in 1st and 3rd trimester
- they cross the placenta so risk congenital malformations.
Stopping these drugs before the sixth week of gestation may largely avoid the risk of fetal abnormality.
Babies of mothers taking warfarin at the time of delivery need to be offered immediate prophylaxis with intramuscular phytomenadione (vitamin K1).
what are the monitoring requirements of warfarin?
- prothrombin time should be determined before initial dose. but do not delay the initial dose.
- early days of treatment - monitor INR daily or on alternate days in early days of treatment. then up to every 12 weeks.
What do you know when the INR is high and there is bleeding? In what INR would you omit warfarin and give the antidote?
- when there is a high INR of 5 and above along with bleeding, give IV phytomenadione
- when the INR is above 8, stop warfarin and restart it when INR is back to 5.
- When there is bleeding, IV phytomenandione is always given, regardless of the INR.
- when the INR is high but there is no bleeding, you give oral phytomenadione.
- when INR is above 8 always stop warfarin
How many days before surgery should warfarin be stopped and when can it be resumed?
5 days before surgery and restarted on the evening of surgery or the next day.
What do you give patients before surgery who normally take warfarin if they have a high risk of thromboembolism?
- brigding therapy
- switch to a LMWH and stop it 24 hours before surgery
- if the surgery has a high risk of bleeding, restart the LMWH at least 48 hours after surgery
What do you give patients on warfarin who need emergency surgery?
- if it can be delayed for 6-12 hours, give IV phytomenadione to reverse anticoagulant effect.
- if surgery cannot be delayed, dried prothrombin complex + IV phytomenadione and check INR before surgery
What do you give patients on warfarin who need emergency surgery?
- if it can be delayed for 6-12 hours, give IV phytomenadione to reverse anticoagulant effect.
- if surgery cannot be delayed, dried prothrombin complex + IV phytomenadione and check INR before surgery
What do you give patients on warfarin who need emergency surgery?
- if it can be delayed for 6-12 hours, give IV phytomenadione to reverse anticoagulant effect.
- if surgery cannot be delayed, dried prothrombin complex + IV phytomenadione and check INR before surgery
How do NOACs work?
- inhibit clotting factors like thrombin and factorXa
Which NOAC inhibits thrombin and which NOACs inhibit factor Xa ?
Dabigatran - thrombin inhibitor
Apixaban, edoxaban, rivaroxaban. - factor Xa inhibitor
Why are NOACs better than warfarin?1
- rarely causes bleeding and no monitoring required
What are the different types of strokes?
- Ischaemic = blood clot obstructs blood supply to brain.
- Haemorrrhagic = weak blood vessel in brain bursts. bleeding in brain tissue which deprives it of oxygen and nutrients.
what is the antidote for dabigtran and what is the antidote for apixaban and rivaroxaban?
- Dabigatran - Idrarucizumab
- Apix and riva - Andexanet Alfa
What is the long-term management of transient ischaemic attack (mini strokes) and ischaemic strokes ?
1st line: Clopidogrel (unlicensed)
2nd line: MR dipyramidole and aspirin
3rd line: dipyramidole
4th line: aspirin
PLUS high intensity statin. started 48 hours after stroke onset.
What is the long-term management of AF-related strokes?
be reviewed for long term anticoagulation treatment.
What is the target BP for patients who had a stroke and should B-blockers be given?
<130/80mmHg
Beta-blockers should not be used in the management of hypertension following a stroke, unless they are indicated for a co-existing condition.
What is the long-term treatment of intracerebral haemorrhage and what should not be given?
- Treat hypertension , taking care to avoid hypo perfusion.
- AVOID aspirin, statin and anticoagulants.
What is the initial management for an ischaemic stroke?
- Alteplase within 4.5 hours of symptom onset and if intracranial haemorrhage has been excluded.
- Aspirin - ASAP within 24 hours of symptom onset
- PPI - considered for pt’s w history of dispepsia.
Extras:
- Parenteral anticoagulants- in pts at high risk of developing VTE
- treatment of hypertension should only be done in hypertensive emergency.
What is the initial management for intracerebral haemorrhage?
- BP LOWERING THERAPY - if systolic blood pressure between 150 and 220 mmHg and within 6 hours of symptom onset
- Patients taking anticoagulants should have this treatment stopped and reversed.
- should not be given to patients who have an underlying structural cause, have a score on the Glasgow Coma Scale of below 6, are going to have early neurosurgery to evacuate the haematoma or have a massive haematoma with a poor expected prognosis.
What are the MHRA alerts for NOACs?
- ANTIPHOSPHOLIPID SYNDROME - DOACs are not recommended in patients with antiphospholipid syndrome.
- Look out for signs of bleeding complications.
- Warfarin and other anticoagulants - Warfarin treatment should be stopped before apixaban treatment is started to reduce the risk of over-anticoagulation and bleeding.
Whats are the two contraindications for NOACS?
- Significant risk of major bleeding -
2. Use of any other Anticoagulant
When can you not give apixaban in renal impairment?
manufacturer advises use with caution if creatinine clearance 15–29 mL/minute.
When can you not give apixaban in renal impairment?
caution in mild to moderate impairment (or if hepatic transaminases greater than 2 times the upper limit of normal, or if bilirubin is equal or greater than 1.5 times the upper limit of normal);
What is the first line treatment for hypertension?
AB: if pt is under 55 and white = ACEI or ARB - not tolerated they take B-Blocker
CD: If patient over 55 and afro-carribean = CCB - if high risk of heart failure or CCB not tolerated, thiazide like diuretic like indapamide or cortalidone.
What is the second-line treatment for hypertension?
in patients under 55: Add CCB - if high risk of heart failure or CCB not tolerated - thiazide-like diuretic
In patients over 55+ : Add ACEI / ARB - ARB is preferred in afro-carribean patients.
What is the third-line treatment for hypertension?
ACEi/ARB + CCB + TLD
What is the fourth-line treatment for hypertension?
Resistant hypertension:
Diuretics: low dose spironolactone OR high dose TLD (preferred if K+ >4.5)
- if not tolerated add Alpha blocker or Beta blocker.
What is the BP of stage 1 hypertension?
140/90mmhG
How do you treat stage 1 hypertension?
Lifestyle changes
- reduced salt intake
- exercise
- smoking cessation
What age range do you treat stage 1 hypertension with meds?
Only treat if under 80 with
- target organ damage
- CVD or CVD risk >20%, renal disease, diabetes
What is the BP of stage 2 hypertension and what age range do you treat?
160/200mmHg
TREAT ALL AGES
What is the BP of stage 3 hypertension?
180> systolic or diastolic 110>
Why should you reduce hypertension slowly in hypertensive emergency? (stage 3 hypertension)
- can cause reduced organ perfusion = blindness, MI, cerebral infarction , severe renal impairment
What advise should you give to patients and carers to look out for when taking dabigatran?
GI symptoms - Dyspepsia
how many hours can you miss taking dabigatran for it to be considered a missed dose?
6 hours.
for apixaban, edoxaban, rivaroxaban and dabigatran, what clclearance would you avoid it and change the dose?
APIXABAN and RIVAROXABAN : caution if 15-39ml/min, avoid if less than 15
EDOXABAN: Use a dose of 30 mg once daily if creatinine clearance 15–50 mL/minute.
DABIGATRAN: Avoid if creatinine clearance less than 30 mL/minute.
What are the doses and frequency of all four NOACS being given for prophylaxis of stroke?
RIVAROXABAN: 20mg OD
EDOXABAN: 30-60mg OD (30mg if body weight up to 61kg) (60mg if body weight over
APIXABAN: 5mg BD. reduced to 2.5mg if aged 80 or over, body weight 60kg or less, or serum creatinine 133micromol/litre and over.
DABIGATRAN - 110mg-150mg BD.
when should you reduce the apixaban dose from 5mg BD to 2.5mg BD?
if aged 80 or over, body weight 60kg or less, or serum creatinine 133micromol/litre and over.
Who do you treat for stage 1 hypertension?
Patients aged 80 and under who have one or more of the following:
- target organ damage
- CKD
- CVD
- Renal disease
- Diabetes
- 10 year CVD risk of 10%>
What is the BP target for patients under 80?
under 140/90
Under 135/85mmHg - Patients with high CVD and target organ damage
