Cardio treatment summaries Flashcards
Treatment for stable angine:
- GTN spray for future attacks
1. First line Beta blocker (bisoprolol) or CCB (diltiazem or verapamil) or combination
2. Second line long-acting nitrates (isosorbide mononitrate) or nicorandil (potassium channel opener) or ranolazine (late sodium current inhibitor) or ivabradine (SA channel blocker only if HR above 70) - Lifestyle changes
- Secondary prevention Anti-platelet (aspirin / clopidogrel), Statin and ACE inhibitor
- Stenting or bypass surgery or CABG surgery (open heart surgery)
ACS treatment
ACUTE MANAGEMENT:
- MONA at admission (morphine 5-10 g IV, Oxygen if saturation below 94, Nitrates - GTN, aspirin 300mg)
- Antiemetic such as cyclizine or metoclopramide
- Dual antiplatelet (aspirin 300 mg + clopidogrel 300mg/ticagrelor 180 mg)
- Anti-thrombin therapy (fondaparinux 2.5 mg or UH if there is angiography within 24 hours) in NSTEMI or unstable angina
- If GRACE score above 3 then give IV glycoprotein inhibitor (tirofiban/abciximab) or if angiography within 96 hours (not STEMI)
- Beta blocker (bisoprolol)
- For STEMI urgent PCI or thrombolysis
LONG-TERM MANAGEMENT:
- Life style changes
- ABAS: dual antiplatelet (aspirin 75 mg life long + clopidogrel 75 mg for 12 months), beta blocker, ACE inhibitor/ ARB and statin (atorvastatin 80mg)
- Heparins
GORD treatment
- Antacids neutralise acidity (sodium bicarbonate, calcium carbonate or Mg/Al salts)
- Alginates create a protective raft (sodium alginate/Gaviscon)
- H2RA’s antagonise histamine H2 receptor to prevent acid secretion (ranitidine 75mg BD) less commonly used as carcinogenic
- If the above do not work the GP will prescribe a PPI (lansoprazole 30mg od)
- If the above do not work then endoscopy (with 2 weeks of PPI before)
- Surgery (laparoscopic Nissen fundoplication)
Peptic ulcer treatment
TRIPLE THERAPY WITH:
- Lansoprazole 30 mg bd + clarithromycin 500 mg bd + amoxicillin 1 g tds (or metronidazole 400mg bd if allergic to penicillin)
Functional dyspepsia Treatment
- Lifestyle changes
- Acid reduction treatment (antacids, alginates and PPIs)
- Surgery if severe
Heart failure treatment
OFFER DIURETIC FOR VOLUME MANAGEMENT
1- Thiazide diuretic like indapamide
2- Potassium sparing like spironolactone and eplerenone
3- Loop diuretics like furosemide and bumetanide
FIRST LINE
- ACE inhibitors (Ramipril) or ARB (valsartan) and beta blocker (bisoprolol)
- If symptoms persist offer and MRA (spironolactone or eplerenone)
- Hydralazine and nitrate if intolerant to ACE or ARB
SECOND LINE (WITH SPECIALIST ASSESSMENT)
- Hydralazine and nitrate particularly if African or Caribbean
- Ivabradine (rhythm control agent) for sinus rhythm with heart rate above 75 bpm and ejection fraction below 35%
- Digoxin with sinus rhythm to improve symptoms
- Replace ACE or ARB with sacubitril valsartan if ejection fraction below 35%
*Dapagliflozin and novel agents (adenosine antagonists, calcium sensitizers and natriuretic peptides) not yet approved
DEVICES
- Cardiac resynchronisation therapy for ventricular desynchrony
- Implantable cardioverter defibrillator for patient with high risk of sudden cardiac death
AF treatment
ANTICOAGULATION ACCORDING TO STROKE RISK IF ABOVE 2 (OR SOMETIMES ABOVE 1 IN MEN)
- DOACs (dibagatran, apixaban, rivaroxaban or edoxban) first line
- If DOAC not tolerated or contraindicated give warfarin
- If anticoagulation not tolerated or contraindicated then consider left atrial appendage occlusion
RATE CONTROL:
- Beta blocker or rate limiting CCB (diltiazem or verapamil)
- Offer digoxin if the above not tolerated or contraindicated or patient is sedentary
- Amiodarone can be used only for short term rate control
- If monotherapy does not work give a combination of 2 (diltiazem, digoxin or beta blocker)
RHYTHM CONTROL FOR PAROXYSMAL AF:
- Beta blocker (not sotalol)
- Amiodarone if the patient has IHD, LV impairment or HF
- Flecainide if the patient has no IHD or structural heart disease
- If none work then do ablation
RHYTHM CONTROL FOR PERSISTENT AF FOR LONGER THAN 48 HOURS:
- If already taking anticoagulants, cardioversion and/or anticoagulant therapy for 3 weeks before cardioversion
- If already taking anticoagulants, cardioversion -/+ 4-week amiodarone before and up to 12 months after
ABLATION
- If drug treatment fails to control symptoms of AF or unsuitable/not tolerated
- Can consider left atrial ablation to destroy abnormal sources of electrical impulses that may be driving AF
- Consider pacing and atrioventricular node ablation for people with permanent AF with history of left ventricular dysfunction caused by high ventricular rates
Deep vein thrombosis/Pulmonary embolism Treatment
- Offer oxygen and analgesia to relief symptoms
ANTICOAGULATION THERAPY NORMAL: - Apixaban or rivaroxaban
- If not suitable give LMWF for at least 5 days then dabigatran or edoxban
- or warfarin and LMWH for 5 days (until INR at least 2.0 for 2 readings) then warfarin alone
ANTICOAGULATION THERAPY WITH HAEMODYNAMIC INSTABILITY: - offer UFH with thrombolytic therapy
ANTICOAGULATION THERAPY RENAL IMPAIRMENT/FAILURE: - 15-50 ml/min offer apixaban or rivaroxaban or at least 5 days LMWH then edoxaban or dabigatran (if above 30)
Or LMWH/UFH with warfarin for 5 days (until INR at least 2.0 for 2 readings) then warfarin alone
Less than 15 ml/min offer LMWH or UFH or LMWH/UFH with warfarin for 5 days (until INR at least 2.0 for 2 readings) then warfarin alone
ANTICOAGULATION THERAPY WITH ACTIVE CANCER: - Offer DOAC
If unsuitable LMWH alone or with warfarin for 5 days (until INR at least 2.0 for 2 readings) the warfarin alone
ANTICOAGULATION THERAPY WITH POSITIVE ANTIPHOSPHOLIPID SYNDROME:
warfarin and LMWH for 5 days (until INR at least 2.0 for 2 readings) then warfarin alone
OBSTRUCTIVE SLEEP APNOEA – HYPOPNEA SYNDROME
- Life style changes: weight reduction, smoking cessation, no alcohol/sedatives and treat nasal symptoms
CONTINOUS POSITIVE AIRWAYS PRESSURE (CPAP): - Gold standard a device that the patient wears to maintain pressure to keep airways open
- Stop if the patient loses weight and reassess after 2 weeks
MANDIBULAR ADVANCEMENT SPLINT: - If the patient is intolerant to/refuses CPAP
- Only if over 18 and have optimal dental health
SURGERY: - Tonsillectomy (BMI <35), polypectomy or septoplasty
- Uvulopalatopharyngoplasty (UPPP)
- Bariatric surgery
OTHERS: - Position modifiers
- Treat rhinitis (refer to ENT)
- Notify DVLA
NARCOLEPSY
- Life style changes: weight reduction, regular sleep cycle, supportive measures, avoid certain foods, regular mealtimes and naps FOR EXCESSIVE DAYTIME SLEEPINESS: -modafinil Methylphenidate/ amphetamines FOR CATAPLEXY (REM SUPPRESSION): - Tricyclic antidepressants - SSRIs FOR IMPROVED SLEEP / CATAPLEXY: - Sodium oxybate
Asthma
SABA (PRN) - Salbutamol or terbutaline INHALED CORTICOSTEROID: - Beclomethasone, budesonide, fluticasone, mometasone and ciclosenide - Can cause oral thrush, sore throat, croaky voice LEUKUTRIENE RECEPTOR ANTAGONIST LTRA: - Montelukast, zileuton and zafirlukast LABA: - Salmeterol and formoterol MART (COMBINATION OF RELIVER AND PREVENTER) LAMA: - Tiotropium THEOPHYLLINE VACCINES: - Influenza and pneumococcal Life style changes: smoking cessation, avoid allergens, good breathing technique and asthma action plan
ACUTE ASTHMA ATTACKS
MODERATE (PEF 50-70%, WORSE SYMPTOMS)
- Give SABA with a large volume spacer (up to 10 puffs and repeat every 10 – 20 mins)
- Increase ICS dose if required
SEVERE (PEF 33-50%, RR>25, HR>110 AND SLURRED SPEECH)
- Give SABA with a large volume spacer (up to 10 puffs and repeat every 10 – 20 mins)
- If there is no response admit to hospital
LIFE-THREATINING (PEF<33%, CONFUSION, CYNOSIS, SILENT CHEST,SPO2<92% AND HIGH PCO2)
- Hospital admission
- Oxygen gives (target 94-98%)
- Nebulized salbutamol and ipratropium (oxygen or air driven)
- Prednisolone 40mg or IV hydrocortisone 200mg
- If there is poor response give magnesium sulphate
- If there is poor response IV aminophylline
- If the PEF kept dropping/ hypoxia/ high or normal PCO2/ lower pH/ drowsy or exhausted then refer to ITU
DISCHARGE:
- Once the SABA dose is reduced
- Off the nebulizer > 24 hours
- PEF>75% with variability below 25%
REVIEW WITHIN 4 WEEKS AND SEE GP WITHIN 2 DAYS AFTER DISCHARGE
COPD
1) SABA
1) SAMA:
- Ipratropium
2) LAMA+LABA
- If there are no asthmatic features or steroid response
3) LABA+LAMA+ICS OR LABA+LAMA
2) LABA+ICS:
- If there are asthmatic features or steroid response
3) LAMA+LABA+ICS
COPD EXCACERBATION
- Give 24-28% oxygen (target 88-92%)
- Nebulized bronchodilators
- Prednisolone 30mg or IV hydrocortisone
- If there is poor response IV aminophylline
- Antibiotics for infection (amoxicillin 500mg tds/ clarithromycin 500mg bd/ doxycycline 200mg on the 1st day then 100mg od for 5 days)
- Monitor fluids
- Give heparin if needed
COMMUNITY ACQUIRED PNEUMONIA
CURB 0-1:
- Amoxicillin 500 mg tds for 5 days
- If allergic to penicillin give doxycycline 200mg on the first day the 100mg od for 4 days
- Clarithromycin 500mg bd for 5 days
- If pregnant give erythromycin 500 mg qds for 5 days
CURB 2-5:
- Amoxicillin PO /benzylpenicillin IV + doxycycline PO/ clarithromycin IV/ erythromycin
- If allergic to penicillin give levofloxacin 500mg bd IV for 5 days alone
HOSPITAL ACQUIRED PNEUMONIA
1ST LINE:
- Doxycycline PO
- If severe give benzylpenicillin IV/ amoxicillin PO with IV gentamicin or levofloxacin IV/PO if allergic to penicillin
ASPIRATION PNEUMONIA
1ST LINE:
- Doxycycline PO + metronidazole PO
- If severe give benzylpenicillin IV/ amoxicillin PO with IV metronidazole or if allergic to penicillin give levofloxacin IV with IV metronidazole
ISCHAEMIC STROKE
THROMBOLYSIS:
- Using IV alteplase within 4-5 hours of stroke (no more than 9 hours) after confirming there is no intracranial haemorrhage with CTA and MRI
- Maximum is 90mg
THROMBOCTOMY:
- The clot is retrieved (surgery)
ACUTE MANAGEMENT:
- Aspirin 300mg within 24 hours for acute stroke until 2 weeks after onset stroke symptoms + PPI
- Offer clopidogrel 300mg then 75mg daily if intolerant to aspirin
- Offer atorvastatin
SECONDARY PREVENTION:
- Antiplatelet therapy: 1st line is 75mg clopidogrel od or MR dipyridamole 200mg bd with/out aspirin 75mg with
- Anticoagulation therapy (according to bleeding risk) – exception AF: warfarin (INR 2-3) if there is mechanical heart valve otherwise give DOAC
- Statin: atorvastatin 80mg od (target cholesterol <4 and LDL<2)
- Diabetes management
- Hypertension management (target BP <130/80)
- Lifestyle changes: low salt, weight reduction, alcohol limit, smoking cessation and exercise
- Avoid combined contraceptive pill in pre-menopausal women with a history of stroke
- Avoid HRT for post-menopausal women with a history of stroke
HAEMORHAGIC STROKE/ PRIMARY INTRACEREBRAL HAEMORRHAGE (PICH)
URGENT BRAIN SURGERY
- Decompressive hemicraniectomy where a bone flap is removed to relief pressure
REVERSE ANTICOAGULATION THERAPY
- Using vitamin K and PCC for warfarin
- Idarucizumab for dabigatran
- Adexanet alfa for rivaroxaban and apixaban
SECONDARY PREVENTION:
- Antiplatelet therapy: 1st line is 75mg clopidogrel od or MR dipyridamole 200mg bd with/out aspirin 75mg with
- Anticoagulation therapy (according to bleeding risk) – exception AF: warfarin (INR 2-3) if there is mechanical heart valve otherwise give DOAC
- Statin: atorvastatin 80mg od (target cholesterol <4 and LDL<2)
- Diabetes management
- Hypertension management (target BP <130/80)
- Lifestyle changes: low salt, weight reduction, alcohol limit, smoking cessation and exercise
- Avoid combined contraceptive pill in pre-menopausal women with a history of stroke
- Avoid HRT for post-menopausal women with a history of stroke
HYPERLIPIDEMIA
STATINS 1ST LINE
- Maximum tolerated dose of a high intensity statin such as atorvastatin 80 mg
EZETIMIBE
- Can be given as monotherapy if statins are contraindicated or not tolerated
- Can also be given with a statin
FIBRATES
- Such as bezafibrate, ciprofibrate and gemfibrozil
- Given if ezetimibe and statins are contraindicated or not tolerated
- Also given for severe hypertriglyceridemia
PCSK9 INHIBITORS
- Such as alirocumab and evolocumab
- Used if all the above treatments fail
Lifestyle changes: weight reduction, exercise, lower alcohol intake, smoking cessation, manging diabetes and hypertension
OBESITY
ORLISTAT 120MG TDS:
- With a weight management plan
- Taken with meals only
- BMI at least 30 or28 (if there are other comorbidities)
- Continue if there is at least 5% weight reduction after 3 months
- Maximum 12 months
- Only for 18 and over with BMI at least 28 can be given OTC 60mg tds for no longer than 6 months
LIRAGLUTIDE:
- If BMI at least 35, non-diabetic hyperglycaemia and high CVD risk
SURGERY:
- Bariatric surgery if BMI at least 35 and the patient has a significant disease that could be improved by weight loss
Lifestyle changes: exercise, be on a calorie deficit, Eatwell guide, reduce sugar intake, increase vegetables and fruits in diet
HYPERTENSION
IF THE PATIENT HAS DIABETES / <55 AND NOT AFRICAN OR CARIBBEAN
1- ACE inhibitor or ARB
2- ACE inhibitor or ARB + CCB or thiazide diuretic
3- ACE inhibitor or ARB + CCB + thiazide diuretic
4- Seek expert advice or add low dose spironolactone (if K < 4.5) or alpha/beta blocker (if K > 4.5)
IF THE PATIENT IS 55 OR OVER / AFRICAN OR CARIBBEAN
1- CCB
2- CCB + ACE/ARB or thiazide diuretic
3- CCB + ACE/ARB + thiazide diuretic
4- Seek expert advice or add low dose spironolactone (if K < 4.5) or alpha/beta blocker (if K > 4.5)
CYSTIC FIBROSIS
MUCOACTIVE AGENTS FOR AIRWAY CLEARANCE
- 1st choice is dornase alfa
- If there is no adequate response give hypertonic sodium chloride with/out dornase alfa
- If the above are no tolerated or effective, give mannitol dry powder
CFTR MODULATORS
- Ivacaftor (Kalydeco®) CFTR potentiator – makes CFTR open longer
- Lumacaftor CFTR corrector - corrects trafficking of ΔF508 CFTR
- Ivacaftor/Lumacaftor (Orkambi®)
- Ivacaftor/Tezacaftor (Symkevi® / Symdeko®)
- Ivacaftor/Elexacaftor/Tezacaftor (Kaftrio® / Trikafta
ANTIBIOTICS FOR PULMONARY INFECTIONS
Lifestyle changes: increase caloric intake, hydration, avoid alcohol, beware of cystic fibrosis related diabetes and exercise
Carbocisteine given as a reliever - makes mucus less viscous
LUNG CANCER
NON-SMALL CELL
- Surgery, radiotherapy and chemotherapy
SMALL CELL
- Chemotherapy alone
MIGRAINE
ACUTE (DURING ATTACKS)
- Triptan (oral/nasal) with/out paracetamol or NSAID (or 900mg aspirin) with/out metoclopramide or prochlorperazine (antiemetic)
PROPHYLAXIS
- Topiramate (if pregnant/ taking contraceptives) or beta blockers or TCA (amitriptyline)
- Riboflavin can be effective sometimes
- Acupuncture
CLUSTER HEADACHE
ACUTE - 100% oxygen - SC/nasal triptan PROPHYLAXIS - Verapamil 1st line - Topiramate, steroids and melatonin
HYPERKALEMIA
DRUGS THAT INCREASE INTRACELLULAR REABSORPTION OF K
- Dextrose/insulin, sodium carbonate and salbutamol inhalers
CARDIO PROTECTIVE DRUGS THAT ELIMINATE K
- Calcium and its derivatives and loop diuretics
LIFESTYLE CHANGES
- Decrease dietary K
- Stop potassium sparing diuretic, ACE/ARB and heparin
- Dialysis if severe
HYPOKALEMIA
- IV potassium or supplements
- Switch to potassium sparing diuretics
- Correct Mg levels
- Potassium rich diet
HYPERMAGNESEMIA
- IV calcium if severe
- Diuretics
- Decrease Mg intake
HYPOMAGNESEMIA
- IV Mg
- Monitor blood pressure and renal function
HYPERCALACEMIA
- Fluids
- Loop diuretics
- Bisphosphonates and calcitonin
- Dialysis in severe cases
HYPOCALACEMIA
- Correct Mg level if low
- Oral or IV calcium with vitamin D
HYPERPHOSPHATEMIA
- Decrease phosphate intake
- Phosphate binders such as sevelamer, lanthanum (dialysis) and sucroferric oxyhydroxide
- Volume repletion
- Dialysis if severe
HYPOPHOSPHATEMIA
- Oral replacement
- IV phosphate if severe
- Stop phosphate binders
PROTEINURIA
- Treat underlying disease/condition
- Reduce salt and protein intake
- Manage diabetes
- 1st line is ACE/ARB
- Give loop with/out thiazide diuretics + albumin
- Verapamil or diltiazem also work
- If the patient is diabetic of suffers from CKD, offer SGLT2 inhibitor (dapagliflozin)
ACUTE KIDNEY INJURY
- Antibiotics
- Fluids
- Catheter
- Stop inducing drugs (gentamicin, cisplatin, penicillin, rifampicin, NSAIDs and ACEi)
- Monitor urinary output to see if dialysis is required
- If vitals and blood pressure drop ITU
- Abnormal ECG and high K level offer Calcium/ dextrose +insulin or dialysis in severe cases
- If there is SOB/ abnormal arterial gases/acidosis dialysis
RENAL STONES
- Thiazide diuretics if calcium is high
- Calcium carbonate if oxalate is high
- Potassium citrate if citrate is high
- Allopurinol if uric acid is high
- Increase fluid intake
BEHIGN POSTATIC HYPERPLASIA
ALPHA ADRENERGIC BLOCKERS
- Tamsulosin and alfuzosin
- Might decrease blood pressure
- Tamsulosin is given for males aged 45-75 as a single 400mcg od after the same meal everyday
- Tamsulosin is initially supplied for 2 weeks (refer if no improvement or contraindications) and only supplied for 4 more weeks if there is improvement. The patient should see the doctor within 6 weeks of therapy to decide on continuation (visit doctor every year for review)
- Refer patient if the symptoms are less than 3 months, the patient had prostate surgery, undiagnosed diabetes suspected, signs of postural hypotension, cataract surgery planned, blurry/cloudy vision, tried another BPH treatment before, taking doxazosin (zosins)/indoramin/verapamil, fever (UTI), bloody/cloudy urine or urinary incontinence
5 ALPHA REDUCTASE INHIBITORS
- Finasteride and dutasteride
- Cause hormonal imbalance
- Cause sexual dysfunction and gynecomastia
- Can be given in combination with alpha blockers
SURGERY
- Transutheral resection of prostate gland (TURP)
- Open prostatectomy
RETROPERITONEAL FIBROSIS (RPF)
IMMUNOSUPRESSION
- Steroids and mycophenolate mofetil (MMF)
STOP INDUCING DRUGS
- Such as L-Dopa and ergot derivatives (methysergide and bromocriptine)
SURGERY
OVERACTIVE BLADDER
ANTICHOLINERGICS - Non-M3 selective like oxybutynin - M3 selective like solifenacin and darifenacin BETA 3 ADRENORECEPTOR AGONISTS - Mirabegron
SYNCOPE
- Avoidance of the trigger factors
- Increase fluid intake
- Increasing the salt intake may help in certain patients who have low risk of heart disease
- Physical counterpressure manoeuvre (PCM) useful in younger patients
PHARMACOLOGICAL TREATMENT - Fludrocortisone 50mcg initially monitor potassium levels and not used for long duration
- Midodrine is the most effective but must be avoided in older males with urological problems (pill in pocket for some patients)
- New drugs such as droxidopa helped in reducing falls (useful in OH and orthostatic syncope)
